The American Medical Association says that new CPT codes it developed should make it easier for health plans to determine whether doctors have screened for drug abuse and provided brief intervention when patients visit doctors’ offices, emergency rooms, health fairs, or community clinics. The AMA hopes that this in turn will mean that insurers will pay physicians promptly for providing such services.

The new codes, 99408 and 99409, will streamline reporting and the payment procedure for doctors who perform alcohol or substance (other than tobacco) abuse screening and intervention, the AMA hopes.

The process will increase the likelihood that those with substance abuse disorders will receive an appropriate intervention.

The AMA developed the codes at the urging of the White House Office of National Drug Control Policy. Bertha K. Madras, MD, deputy director of National Drug Control Policy, says, “These new codes will enable physicians to reach those in harm’s way — during a doctor’s visit — and provide them with appropriate medical services. Widespread screening and brief interventions can effectively reduce substance use disorders.”

Sample questions from the screening tool include:

  • Can you get through the week without using drugs?
  • Are you always able to stop using drugs when you want to?
  • Do you ever feel bad or guilty about your drug use?
  • Have you neglected your family because of your use of drugs?
  • Have you been in trouble at work because of your use of drugs?
  • Have you engaged in illegal activities in order to obtain drugs?

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.