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Health Plans Mind the Brains and Kidneys

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Health insurance companies aren’t really sure how commercial health insurance will work in 2018, so they are trying to focus on something they do understand: the need to do a better job of keeping enrollees healthy.

A major health insurer trade group, America’s Health Insurance Plans, did offer sessions on federal health policy earlier this month at its AHIP Institute annual meeting in Austin, Texas.

Given the profound uncertainty about what will happen, or not happen, in Washington, the most detailed, most concrete sessions tended to the ones dealing with keeping healthy enrollees healthy, and keeping enrollees with chronic health problems from getting more serious problems.

(Related: Tavenner Asks Congress to Save 2018 Individual Health Market)

Here’s a look at some highlights from the meeting sessions, based on a review of session slidedecks:


Federal and state agencies are trying to do more to press health plans to offer parity between coverage for mental health services, addiction treatment services and other types of medical services.

Dr. Sherry Dubester, vice president for behavioral health and clinical programs at Indianapolis-based Anthem Inc., told attendees that improving the performance of behavioral health programs is critical for everyone.

About 29% of adults with medical conditions also have behavioral health conditions, and 68% of the adults with mental health conditions also have other types of medical conditions, Dubester said.

About 80% of patients with behavioral health problems show up first in primary care clinics or emergency rooms, but fewer than one-third of the primary care providers say they have an easy time connecting patients with outpatient behavioral health providers, Dubester said.

Blood pressure check (Photo: Thinkstock)

(Photo: Thinkstock)

One solution might be to expand access to digital behavioral health care services, so that patients who show up in a primary care office with behavioral health problems can quickly see a behavioral health care provider through a video conferencing system, Dubester said.

Dubester also called for improvements in other types of care coordination efforts, such as local care coordination collaboratives and provider reimbursement arrangements that reward providers for post-treatment care quality.


Federal health surveys show that about 3 million U.S. residents know they have chronic kidney disease.

Dr. Joseph Vassalotti of the National Kidney Foundation and Jamie Greene, program director for quality and clinical practice at Owings Mills, Maryland-based CareFirst, said they believe 26 million U.S. residents actually have chronic kidney disease.

CareFirst estimates that it spends an extra $30,000 on care per year for each enrollee known to have kidney disease. The average is so high partly because enrollees with severe kidney disease generate an average of about $90,000 in claims per year.

Doctors can check for kidney disease by testing for the level of creatinine, a substance filtered by the kidneys, in the urine. Even enrollees with a minimally abnormal level of creatinine cost a plan twice as much as other enrollees, and patients aren’t always tested for that, the presenters said.

CareFirst recently set up a pilot program, for 128,000 patients in its “patient-centered medical home” care coordination program. Pilot program managers looked for patients with possible indicators of susceptibility to kidney disease, such as diabetes or high blood pressure, and got their primary care doctors to test their creatinine levels.

Program managers encouraged the primary care doctors to make sure that patients with signs of kidney disease received care that met National Kidney Foundation care guidelines.

The average medical costs for the patients in the program were about $600 per year less than the average for all CareFirst enrollees, according to Vassalotti and Greene.

CareFirst is now thinking about making kidney care program available to all patients in its patient-centered medical home program.

Program managers also want to strengthen ties to local kidney care doctors, to ease referrals, and to continue to educate primary care doctors about kidney care, the presenters said.

— Read AHIP Institute 2013: Price Check on ThinkAdvisor.


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