AT THIS HOUR

June 10, 2022

13: Percent of employees at some of the US’s largest companies don’t believe their employer offers mental health benefits, when in fact they actually do, according to a recent survey commissioned by Human Resources Director America. Topping the list, 24% of Walmart employees claimed their employer doesn’t provide mental health resources, which is contradicted by 33% of Walmart employees who took the same survey saying they used employer-provided mental health services in the past year. Even more stark, the same survey reports that more than half of employees said they haven’t used any mental health benefits offered by their employer.

PCP Incentive: Regence is launching a Commercial Quality Incentive Program (QIP), beginning on June 20th. Primary care physicians will be able to earn incentives for closing care gaps for individual on-exchange patients, similar to their current Medicare QIP program. PCPs will earn a set amount per patient for measures like cancer screening, childhood immunizations and diabetes testing.

Shared Savings: CareMax recently acquired the Medicare business of Steward Health Care System. CareMax will now serve as the MSO for this network which includes Medicare Advantage members, along with Medicare members who are covered through the Shared Savings Program and the Direct Contracting model - 171,000 members overall. Part of the deal terms give Steward ownership of CareMax stock. If CareMax is able to convert 100,000 partial-risk and FFS Medicare patients into risk-sharing value-based arrangements with an MLR below 85% for two consecutive quarters, Steward’s stock share in CareMax will increase.

Overpriced: A new white paper published by the USC Schaeffer Center featuring an analysis of Medicare claims showed that consumers are overpaying for generic drugs by as much as 20%. The authors say this is largely due to the way PBMs operate as middlemen between drug manufacturers and health plans and practices like spread pricing and copay clawbacks add up to billions in overpayment. A different recent study published by the same group found that Part D plans paid $2.6 billion more for 184 common generics compared to the cash prices paid by Costco members.

Homeward Bound: Rite Aid is following in the footsteps of CVS and Walgreens by moving into clinical care delivery through a new partnership with Homeward, a home health company that focuses on rural communities. Rite Aid pharmacists will direct eligible customers to Homeward’s clinical services, including wellness visits, screening, and diagnostics, and Homeward will bring their mobile clinician units to Rite Aid’s rural locations, allowing customers to see a provider and pick up their medication in the same trip. 

Stopping The Pre-Approval: BCBS Kansas recently removed its prior authorization requirement for all partial hospitalization and intensive outpatient services. As the mental health crisis continues across the country, we may see more payers moving in this direction. Removing prior authorizations likely helps patients get into treatment more quickly while removing some of the administrative burdens for both payers and providers.

Addiction North: Northstar Recovery Center, an evidence-based treatment center for addiction, is partnering with Tufts Health Plan, now part of Point32North, to expand access to treatment for substance use disorder. Northstar’s continuum of care including PHP, IOP, and behavioral health services will now be available to 1.1 million members covered by Tufts. 

Buy & Bill Pressure: Beginning July 1, 2022, Cigna is launching a new medical specialty drug management solution, Cigna Pathwell Specialty. Similar to other specialty drug programs we’ve seen from payers over the last couple of years, the program aims to reduce overall specialty drug spend. It will include the Cigna Pathwell Specialty Network, a narrow network for specialty injected and infused drugs - in other words, requiring these drugs to go through a designated specialty pharmacy rather than allowing physicians to buy and bill. Additionally, not all providers will be included in the network, so some members may have to find different providers to administer these drugs. The program is first being launched only for select employer groups and will expand to fully insured plans upon regulatory approval.

Extra Point: 9 years ago, Connor Farquhar ran to first base on an unintentional bunt single–his first hit in little league in his first game, one that featured 47 walks, 111 passed balls in 3 innings spanning 123 minutes of yawns, and parents asking each other, “seriously, are there any outs yet”? This was one of those games where the ump, my dad, used such a liberal strike zone that you basically needed stilts to reach some of those high strikes. Bridget perched herself in center field and complained about the ump until she realized it was her own father-in-law, at which time she probably complained even more. “Oh come on Papa, that was right there.”  It took Connor maybe 14 seconds to make it to first for his moment, not exactly record time but for the 9-year-old and his parents, it was Jessie Owens fast as they willed him to the bag. They don’t measure time like a lot of us. They measure it in how much dirt Connor kicked up running to first and how many times his glasses bobbled off his nose. They measure it in how when he got there, he immediately found me on third base and saw the steal sign and then took off on the next pitch, fearless. Sure, the odds of the catcher throwing him out were 7 billion to 1, but Connor didn’t know that. Here’s the kid who’s been told for 9 years he doesn’t have the ability, that he has “limitations,” “challenges” – but I don’t really agree. Sure, he may need to swing the bat before the pitcher even winds up just to catch up to it and he may not run so fast, but his brain is running laps around a lot of kids, and he used whatever force he could muster to make his way around those bases. I think back to that game when we were down 11 runs after 3 innings and the relatively painful moments when the ball would trickle beneath the catcher’s glove and roll to the backstop with 2 kids on base. The catcher, weighed down by the gear, would fall over trying to get himself up, would adjust his knee pad and itch his behind and with the mask covering his eyes start poking around for the ball. I think of that, and I realize like a lot of us that for all those lost moments and passed balls there’s one kid who probably only thinks of last night’s game as a win. This week, Connor, now 18, gets ready to graduate high school. Once labeled as that kid on the spectrum and with epilepsy--and the kid who “shouldn’t really be on the team” --Connor was a 3-season student-athlete in high school this year, a runner, and is headed to Amherst in the fall. So much for limitations.