Managed Care Friday

1. Lineup, Part I: True story this week from a hospital near Chicago, where an ER doctor and her team struggled to diagnose an elderly man’s heartburn and delirium and ‘shakes’ but, after a series of tests and interviews with family, ruled out heart or neurological issues and determined the man simply got too upset over a Cubs game Tuesday in which the team was down, but ultimately prevailed while he was in the ER. The moral? Perhaps payers are right when they say there’s an overutilization problem with diagnostic tests. Still, maybe there is such a thing as sports fanaticism syndrome.

2. Prior Authorization Shift: Starting in January, United will no longer require prior approval on a number of its plans for DME, orthotics, cochlear implants, enteral supplements, bariatric surgery and home health. Orthotics and prosthetics over $500 will require a PA.

3. Lab Rollout: Beacon Lab Benefit Solutions will start handling outpatient lab utilization requests on behalf of United, as of March, for additional states, like Texas.

4. Dialysis: In a small but meaningful example of the value of being in network, Coventry no longer needs pre certification for dialysis performed at a participating facility, but it will for out of network providers.

5. Hospital Tiering Switch: 11 hospitals in BCBS of Massachusetts’ network have recently changed from the standard benefits tier to the enhanced one (meaning lower patient cost share), while 5 switched from enhanced to standard, including a Beth Israel facility. Two hospitals near Boston jumped to the enhanced tier after a period in the basic tier (highest cost share to patients). And interestingly, all New Hampshire hospitals, where a large number of Massachusetts residents go given proximity, are no longer in the basic tier.

6. Credentialing: Allied health professionals including nurse practitioners, certified nurse midwives and physician assistants must get credentialed just as physicians have under new rules BCBS of North Carolina will enforce starting in January. Other health plans we asked about this say they have or will have similar changes in the year ahead, although their main objective is to improve or make more frequent the ‘recredentialing’ process, which is probably good for quality but represents operational challenges for medical groups.

7. OP Rehab Authorization Change: In 2017, Premara BCBS will use EviCore to handle prior authorization requests for outpatient rehab and chiropractic services in Washington, Alaska and Oregon.

8. Allergy Treatment Removed From Formulary: Inhaled nasal steroids to treat allergies will no longer be a covered therapeutic class of drugs for at least 7 different health plan formularies, as of 2017.

9. Readmissions: 56% of hospitals in our poll earlier this month say they are putting resources into doing more real-time interviews of patients and families about readmission causes, to address a common problem—too many readmission causes labeled as ‘doesn’t fit criteria’ in medical records. Of those putting resources into better identifying causes, 87% say they are in risk-based arrangements with payers, or have a self-insured population they are managing.

10. Drawing Patients From Out of Country or Out of State: Check out this week’s feature about a global medical tourism accreditation program trying to elevate standards and patient experience, while requiring healthcare businesses who draw patients from out of country and out of state—particularly through web marketing—to prove cultural competency and ‘collect and report outcomes’. See if health plans are aware of the program and their thoughts. Click here.

11. Is A Fix for Refugee Healthcare Crisis...A Fix for Healthcare: Hospitals and health plans in 5 states are telling us that one of the fasting growing ‘managed care’ challenges they are confronting is dealing with healthcare utilization and complications—and therefore costs—among aging immigrants and teenage refugees who migrated to the US in the last 5 to 10 years. Medicaid tends to be the primary payer for the refugee population, but ultimately hospitals see and bear a good deal of the burden, as they are ‘defacto’ primary care for refugees. The states (Minnesota, Texas, Delaware, Connecticut, Arizona and Michigan) are struggling to deal with this trend and expect greater pressures given recent immigration trends. To solve these issues, Medicaid plans and states are interested in exploring new models like a volunteer social work model that reduces unnecessary ER use and promotes primary oral and medical care. I’m involved in one such group and it’s easy to see the value. ‘I think if we can find ways to more cost effectively deal with a population like this it can be useful for how we think about other high-risk populations – perhaps we need more social investment,’ says Nicole Verrengia, an Anthem case manager. See details of one model by clicking here.

12. Lineup, Part II: On December 13th, we are hosting our first annual healthcare leadership forum in DC and we wanted to mention that the managed care lineup includes Excellus BCBS Chief Pharmacy Officer Mona Chitre, CareFirst BCBS Medical Affairs Director Jonathan Blum, Optum’s Christian Long, FL-based medical director Michael Yanuck, and sessions on how to get managed care’s attention in the risk era, as well as the truth about behavioral healthcare quality metrics. Don’t miss a great opportunity. Register by clicking here or contact program director Meredith Anastasio (