1. New MA Plan 2020: Montifiore Health System and Oscar Health will create a joint Medicare Advantage plan in NYC starting in 2020 featuring individual and small groups plans for New Yorkers. It will be interesting to see two things – adoption of the plan as well as how well these models fare on a total cost of care basis vs. purely independent providers.
2. NW Blue Inks Deal With TalkSpace: Premara, the Blue plan in the upper northwest, wins in early votes as among the most favorable insurers for behavioral health. Case in point, it just signed a contract with the virtual counseling service Talkspace, which promises initial sessions within 3 days and counseling within a week. A spokesman said ‘we are encouraging’ physicians and others to refer to Talkspace.
3. Cliff For Autism, Psych: In a surprise move, our managed care index of priorities continues to look increasingly like a list of social services. Coming in at #16 for the first time in the now 15-year study, commercial and Medicaid insurers say they are beginning to discuss how to create a better system for older teens and young adults with significant psychiatric conditions as well as severe autism. This includes benefits, care coordinators and in-home counseling, as well vocational and housing support. In 2018, we covered this issue in a feature story.
4. Sloan Enters Value: Cigna and Memorial Sloan Kettering dipped their toe in the value-based contract arena this week. Patients get one RN to coordinate their treatment and one Cigna contact to help navigate benefit issues The cancer center gets a share of savings if reducing total cost of cancer care.
5. Chief Complaint: TennCare Kids screening guidelines now allow reimbursement for both sick and well visits on the same day so physicians don’t need to schedule other appointments. Managed Medicaid plans are encouraging this in other markets and in some cases primary care groups and even oral health groups are using this as an opportunity to hire specialists to address the common complaints they typically have to refer (respiratory, bladder, pain, psych).
6. Air Intercept: Patriots fans remember the greatest surprise interception in Super Bowl history vs. Seattle in 2015. Well, hospitals and skilled nursing facilities have been dealing with their own surprise interception too as payers use the prior authorization process to change the next level of care order for patients needing air transport out of state. 82% of non-emergent air ambulance transports, up from 67% last year, will require pre-approval starting in 2020, based on our tracking poll of 62 different health plans. Besides the obvious issue that many of these inter-facility transports run through OON operators costing 3-5x in-network transports, there’s a hidden benefit: payers using the authorization process to intercept the next level of care (i.e., hospital or SNF) and diverting to a different option, if lower cost and better quality.
7. In-Home Assessments: In 2020, a company called Matrix Medical will handle in-home assessments for a handful of Midwestern and southeastern Medicare Advantage plans, including FIT testing for colorectal cancer, A1C diabetic measurements and diabetic retinal eye exams. All results are supposed to be sent to each patient’s PCP.
8. Midwife Win, Loss & Tie: A Wisconsin state law changed in 2018 to allow licensed midwives to enroll as ‘providers’ for the state’s Medicaid programs but Anthem decided at the time not to contract with these type of providers, so they won’t cover services midwives perform. The plan covers nurse practitioner services if the NP is certified with the nurse midwife specialty, but a source said Anthem is re-evaluating.
9. Retail Health: A string of multi-cultural health and retail facilities continue to open through partnerships between managed care and providers, like Sanitas and Horizon BCBS’s retail, grocery and healthcare set-up in northern Jersey. Sanitas, which opened in 2018, has a presence in 6 other countries and most notably in Florida – it primarily helps Horizon manage health for the large Hispanic population here. Other models exist such as Community Health Services in Hartford that include adolescent, pediatric, women’s health, lab, behavioral and physical therapy, among other services for Husky Medicaid patients. The center is located next to a newly revamped YMCA center. The center’s number one health issue it sees – asthma, due to smoking but also very poor housing conditions in the area. An educational effort is underway to help families understand how to use inhalers and the different types of asthma ‘but things won’t get better until the housing improves’. Physicians often prescribe exercise to moms, dads and kids and are working on a training program for students interested in careers as PAs and NPs. The innovation in care delivery has been in the shadows here. In early 2018, there was a Homicide one block away during a community event.
10. Psych Up and Down: Primary care providers who collaborate with psychiatric professionals on a patient’s care can get paid for this collaboration but the rules for billing have changed and recently Anthem started using a new audit vendor, Alliant, to ensure appropriate services and billing. Licensed clinical social workers or psychiatrists were mentioned as the likely collaborators for PCPs. Billing a series of CPT codes like 99492 to 99494 is allowed, as of 2018. Anthem hopes this encourages information sharing. Alliant, meanwhile, examines Anthem’s outpatient behavioral health claims data and conduct provider audits.
11. Extra Point: So 83-year-old Uncle Mike, the tenured political science professor at Gonzaga and the Jesuit priest who married Janine and me, is in town this week – bringing all his peccadillos with him. This morning he managed to put three or four shakes of sugar on his cinnamon LIFE cereal. ‘A little heavy handed there?' my wife said with a smile….'you do know it’s ‘cinnamon flavored’ 'Well, um, it just needs a little something,' he said coughing a bit while using the bowl as a cup to drink up the last bits of sugary milk. 'It’s a wonder you don’t have diabetes' my mother-in-law quipped. 'Well, I do take this pill every day to control my blood sugar….my regular endocrinologist gave it to me…but I’m not diabetic.' I’m pretty sure you are but say this for Uncle Mike, he has his idiosyncrasies but he can eat what he wants as far as I’m concerned because, nearest I can tell, he’s blessing all the food and he’s the one who may be a key vote for me when it’s my time. I quip, but having the old guy here with my mother-in-law reminds me how challenging the healthcare system is. Neither of them can walk up or down any stairs without help and a lap around the block is like digging a hole to China. Both them have fallen asleep at least a dozen times mid-sentence since arriving. 'What’s wrong with Uncle Mike?' my daughter Sophie asked yesterday, scared for the answer. 'I think he’s dead' Janine said, 'go check him Bry.' My mother-in-law was in the corner laughing for some reason. Uncle Mike simply fell asleep and when he awoke to the dog barking, he repeated the same story about how his parents used to take them to the 5 and 10 for Christmas but one year didn’t because they all got Bs in grammar class. God bless them. Both Michael and Ellen live independently most of the year battling an encyclopedia of conditions: dementia, vertigo, osteoarthritis, prostate cancer, skin cancer, and anxiety. One wears compression socks, the other wears pain cream. They are the face of aging in America and highlight so much of the challenge ahead….but when they are here, thank God, they sure do bring a bit of levity.