39: Percent of insurers, up from 14% last year, who will focus on adjusting or trying to ‘rework’ value/shared savings contracts given first wave of contracts are ‘too easy’ to hit targets for. Results published in the upcoming Managed Care Investment Index.
ENT's Balloon: A number of insurers are updating policies for balloon procedures done by ENTs to address chronic rhinosinusitis. Starting this year, several Blues will require a full course of treatment for all of the following before considering balloon dilation: nasal lavage, intranasal corticosteroids, and antibiotic therapy if the physician suspects a bacterial infection. The earlier criteria was more lax, allowing physicians to either skip some of these or not carry out a full course. If symptoms persist after full courses of all of these, then insurers are more likely to approve.
Have You Met Formin? Diabetes is an interesting new priority for Medicaid plans given there are several changes taking place in the treatment of the condition, and in early 2020 new treatment guidelines are expected. Medicaid managed care drug utilization review boards are planning to debate. Both Utah and Mississippi’s board are running analytics and found at recent meetings that a lot of their Medicaid beneficiaries with diabetes have no history of a documented trial of metformin before initiating another diabetes drug, and many who have been prescribed the drug without any diagnosis. These review boards want to explore opportunities for pharmacies to be able to intervene at the point of sale to change metformin from immediate to extended release and likely make other changes as more data gets reviewed.
Dry Needling: If you work at a practice that does dry needling, perhaps a PT group, there are some new billing rules coming out. Blue Louisiana, for example, now requires you to bill this under manual therapy code 97140 and use modifier CG. You can longer use codes 20560-61 for dry needling.
Surgical Appropriateness: If you do spine surgery, radiation therapy or advanced imaging of the abdomen and pelvis, new coverage criteria will be published in February by AIM Specialty. The guidelines will sharpen the rules on what’s clinically appropriate, and what isn’t. AIM is increasingly a key managed care decisionmaker for Anthem and BCBS health plans.
Oh Baby: 11% of United members in Mississippi deliver babies before term if enrolled in the plan’s healthy first steps program that offers individual care plans including getting followed by a care coordinator until 2 months after delivery. This compares favorably to the Mississippi average of 17%, according to United Healthcare community plan pharmacy director Heather Odem. Other insurers have similar care coordination initiatives. Molina’s pharmacy manager Trina Stewart says they have a process for identifying good candidates for their motherhood pregnancy monitoring program, then they give coordinators the patient’s information.
Quality Behavioral Health: Illinois BCBS has created new tip sheets (click here) to help providers satisfy HEDIS measures for behavioral health.
In Network: Houston’s Kelsey-Seybold multi-specialty group is in network with BCBS in a new value-based contract kicking off this month for PPO and HMO members. The group, founded just after WWII, has 400+ physicians.
Extra Point: That knee pain I felt after a few games of basketball over the holiday persisted last night so much so that I’m now self-diagnosing arthritis, though whether I do anything about it is another question. My bride says I should just talk to a doctor and not my buddy Jay in between hoop games. ‘Don’t be a dummy,’ she says. In my defense, I’m not all that different than most guys on the cusp of 50 – just 19% go to the doctor regularly according to one poll I saw. It’s probably why so many health systems are looking to expand woman’s health as a service line, because they see value in the household’s health CEO. My dad will take a look at my knee later today and, knowing him as I do, tell me to ‘just go see Dave.’ Dave is Dr. Burstein, an orthopedist who did my ACL repair when I was 19 and has helped my kids over the years with their litany of injuries. I’m sort of nervous about the visit because I don’t want to have to rely on medication, injections or God forbid miss hoop games. The only chronic condition I’ve ever had is losing. I started writing about it 8 years ago here in this column (click here). I guess the one difference is that losing isn’t bad for your health. I would argue it’s the best medicine. But pain in my knee? That’s a horse of a different color.