AT THIS HOUR

July 15, 2022

20: Percent of adults who have received a surprise bill for themselves or a family member this year, despite the No Surprises Act that went into effect at the beginning of the year. About 1 in 5 received a bill over $1,000, according to a Morning Consult survey. Those who received unexpected bills were most likely to get them for in-network lab work that was sent to an out-of-network lab. Unsurprisingly, 1 in 4 survey respondents indicated they have skipped or delayed healthcare services because they’re worried about these unexpected costs.

Cataract Reversal: Aetna no longer requires prior authorization for cataract surgery for most patients as of July 1st, reversing the policy that was implemented in July 2021. Some exceptions apply, as Medicare Advantage members in Georgia and Florida will still face PA requirements for one of the most common procedures performed in the US. 

Flaw In Diabetes Management? According to a survey conducted by BCBS Arizona, 1 in 10 Arizona adults have diabetes. The insurer is teaming up with the Arizona Department of Health Services and others to create a Diabetes Action Plan to work on lowering HbA1c, reducing outcomes disparities and performing routine surveillance to monitor progress. Plan design can be a challenge for diabetic management. Physicians may recommend eye exams to prevent diabetic neuropathy, for example, but patients in high deductible plans may not be able to afford these, and physicians typically only get value-based incentives if patients actually get these services.

Inflation Adjustment, Sort Of: BCBS Kansas will be providing a 1% cost relief adjustment in reimbursement to most providers beginning September 1, 2022. According to the plan, “this relief is meant to help ease a portion of the effects [providers] have been feeling from the recent pricing hikes across our country.” The adjustment will apply to all professional services except clinical lab and ambulance.

Adolescent Psych Training: Aetna recently expanded its program offerings with Psych Hub, an online mental health educational platform, by launching an Adolescent Treatment Training Series. The series gives in-network behavioral health providers, Aetna clinicians, and CVS Health’s licensed counselors at some MinuteClinic locations access to evidence-based courses and resources to identify and treat adolescents and young adults at risk of suicide. This builds off the adult suicide prevention continuing education series launched in 2021. BCBS Michigan and Henry Ford Health recently launched their own collaboration to improve suicide prevention. Providers share data in what’s called the Michigan Mental Health Innovation Network for Clinical Design.

Construction Spike:  Harrison Ford may be able to go back to his roots as a construction worker given a recent boom in healthcare building projects. 70% of the 89 construction and design firms in Modern Healthcare’s 2022 survey say they are seeing increased demand for a behavioral health component in their medical projects.

Quizlet: As many as 15% of the US population have this condition, it’s more common in women than men but it shares many of the same characteristics as other diseases, so it’s difficult to diagnose. Ben Stiller had this condition in Along Came Polly pretty much at the mere mention of this spicy food. One specialist deals with these patients more than others, but PCPs tend to be the first to attempt diagnosis. There’s a great opportunity to construct a chronic care value-based arrangement for these patients given the high cost of treating and getting patients to goal. Anemia, fecal occult blood and unintended weight loss can be very helpful in diagnosing and creating protocols. What’s the condition? Click here. 

Kidney Expansion: Approximately 1 in 3 adults in the U.S. are at risk for kidney disease. Somatus, a provider of integrated kidney care, has partnered with the Kidney Care Center to create a multi-state partnership to expand coverage for the treatment of chronic kidney disease and end-stage kidney disease in Illinois, Indiana, Georgia, Tennessee, Pennsylvania and Florida. The partnership uses an innovative care model that brings together local teams, AI and machine learning to provide care.

Going Retro: Maybe not as retro as a Polaroid, but there is a new bundled payment program BCBS of TX is launching for knee and hip replacement services in partnership with the clinically integrated network MPOWERHealth. Payment will be retrospective, based on the entire episode from replacement surgery to post-op care.

In Home Urgent Care: UPMC’s program has treated more than 200 UPMC Health Plan members in their homes since its launch in September 2021, saving the health plan money while increasing patient satisfaction, according to UPMC. The program only serves Allegheny County currently but is looking to expand in the state.

Extra Point: As Archie once said, ‘why do they always give me a shot where the pain ain’t…?’  It was classic Bunker—worried, agitated and usually offensive. I wonder what he’d make of all the changes in healthcare – urgent care clinics, for one, are often staffed by allied health providers. Bunker only wanted ‘regular doctors’ as he called them and, even though he didn’t know it, he had a bit of managed care in him. ‘Do I really need this, um, needle?’ he would argue. If there’s one delivery model set to face some turbulence between now and 2025 it may just be urgent care. Even though it has found an important niche in the health system, particularly in areas where doctors and nurses are hard to find, the advent of more front-line tele models and nurse hotlines and apps will likely continue to be a volume diverter that hurts these retail clinic models at least those in competitive, saturated markets. ‘They absolutely have a place but when we start seeing the ambulance show up every hour to take patients to the hospital, that’s a big flag for me,’ says Valerie Andrews, a network manager who just moved into the Connecticut market. ‘My sense is 20-40% of cases would self-resolve too, so there’s a value question here.’ The ones able to use data and use their clinic to do urgent and follow-up care, to identify and change behavior, and ‘have a PCP traffic cop mentality,’ have sustainability.