1. 30 for 30: According to the NCQA, patients with a new onset low back pain diagnosis normally should not receive imaging within the first 30 days of diagnosis but there may be instances when imaging should be considered. You can access an evaluation chart to use with patients presenting low back pain: click here
2. Fall Risk: In our poll of Medicare Advantage plan care managers and medical directors, 91 of 153 said this was the number one ‘avoidable outcome’ issue that their networks are struggling to reduce. My dad fell down stairs two years ago and, though he luckily survived, continues to struggle with vertigo and other issues ever since. ‘There are a host of root causes,’ Mary Flanders, RN, says, including dehydration or lack of physical activity, orthostatic balance issues, and often untreated PTSD that often can lead to substance abuse. It’s a hint to MA focused home care or physician groups to focus on fall risk, particularly since CMS has noted it as an issue they are honing in on over the coming months.
3. Drug Testing Change: Anthem has changed its policy for drug testing. When definitive drug testing is submitted on the same date of service as presumptive drug testing by instrumented chemistry analyzers for the same member by an independent clinical laboratory, Anthem will allow separate reimbursement for definitive drug testing of 1-7 drug classes, but won’t separately reimburse for definitive testing for 8 or more drug classes when performed on the same date of service as the presumptive testing.
4. Play Time: A physician in Nevada told us last week that he now ‘prescribes’ play to kids and teens – and seniors - during annual physicals and sick visits. Phil Smith, MD, said about 7 out of 10 parents ‘love the script’ but several parents still just tell him ‘can you prescribe a medicine’? A small software company, Advex, said they have asked their insurer (Aetna) to help develop a benefit that gives discounts for physical activity and includes coverage for applied behavioral analysis for kids on the autism spectrum, but they want ‘only certain programs’ in the network, including an ABA Sports model ‘that we think can be really helpful to our families … many are having to pull kids out of sports and bring them to a clinic for therapy at their own cost,’ Marge Youmens, an HR director, says.
5. Behavioral Roundtable Chatter: During our behavioral health roundtable in Chicago Tuesday, there were moments when we may have learned more from the silence in the room than the chatter. In one discussion, a debate centered around how to manage the rising cost of autism – a 40% increase in the number of providers in one insurer’s network, a 45% increase in total costs, more self-insured employers ‘being pushed’ to cover ABA therapy and a total lack of services for older teens and young adults…and yet at times Tuesday uncertainty manifested in stares and long pauses on how in the world managed care can handle what seems more like Tsunami than high tide. Payers here say they are trying to raise the bar on quality of care and outcomes for those on the spectrum but this is difficult given the supply and demand challenges. Efforts to cover more kids earlier and perhaps ‘reduce costs down the line’ have potential but ‘50% of those early autism diagnoses self correct’ one roundtable guest opined. The answer, at least for the next 2-3 years, seems to likely be increased scrutiny around the billing and compliance operations of ABA providers – doing the wrong thing, pushing the needle on hours or medical need, face an audit. In another moment, a school counselor talked about the importance of prevention and physical activity as underappreciated still in school curriculums, but few could wrap their head around how to invest in the solution when so much of the business of healthcare is focused on treatment.
6. Extra Point: We are nearing release of a 20-year study of parent behavior and the impact of sports on families. In full disclosure, both my wife and I participated but I don’t think we skewed the results, nor could we have envisioned how much we have changed our views in this time. The study began post Columbine and has tracked the views and outcomes of 362 families over 20 years. For a snapshot of the findings click here