10,000: The number of psychiatrists across the country we’re missing, and 40% of the ones we do have do not take commercial health insurance, according to a panel of Medicaid behavioral health professionals who debated the issues at BRG’s healthcare leadership conference Thursday in Washington DC. Other takeaways: payers are asking providers to ‘please accept Medicaid and please make telehealth work’, and they see a growing need for transitional housing for patients swept up in the opioid crisis.
Worried Well: 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 more often than not 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, 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.’ The ones able to use data and use their clinic to do urgent and follow-up care or ‘have a PCP traffic cop mentality,’ they have sustainability.
East Meets West: 517 parents who have children on the spectrum are not shy – about 75% in our poll say the best place to get their kids services quickly and cost effectively has no doubt been the northeast and mid-Atlantic, including Pennsylvania, but by the time their kids roll through their teens and hit adulthood, the geography changes. 81% say there’s limited access to any sort of programs to help their kids, now adults, transition to vocational schools or jobs, but if there’s a region better suited to help foster a good transition, it’s the west. Think Seattle, San Francisco, Portland. Cities with companies focused on populations needing help transitioning into adulthood. These companies should become more necessary and visible over the next 5 years. Question will invariably be funding. Anthem’s moves recently to reduce payment rates are a signal that they anticipate increasing volume for autism treatment.
63: Percent of commercial plans who say telepsych is now one of their top priorities for 2020 – how to pay for it, contract, and fit it into benefit design. Driving this? ‘Dissatisfaction’ with existing ‘behavioral vendors’ who lack the savings and integration with primary care. The number of ‘vendors’ now pitching the plans is going up, though – from smaller start-ups like iHope to the pioneers like Insight and now the traditional telehealth companies entering the space. Their role in helping get appointments for patients right away will be a key to success for risk-taking primary care practices, hospitals and schools.
Rx Patterns: A physician group in the Midwest used to just grade its own doctors at a therapeutic level by compensating them based on their generic dispensing rates, but now they’re getting creative – convincing its Blue plan to share data about the prescribing patterns of all the doctors in the area where its PCPs refer. The idea, practice administrator Melanie Figlante says, is to get visibility into doctors outside the group and help show the PCPs that their ‘referral decisions’ may be either too costly or simply clinically inappropriate.
The Ambulance Won’t Leave. Ambulances of all things will be incentivized through new forms of contracting to go directly into people’s home to diagnose and treat and avoid the transport to the ER, according to interviews we have been doing with commercial and Medicare plans. It’s like what I thought Peapod ought to do back in 2013 by adding nutritionists or therapists when they drop-off food. Bring more value to that home visit. For ambulance companies, it could be tricky: Doesn’t mean the 70-year-old with chest pain won’t be transported to the hospital, but it does give the ambulance clinical flexibility to make a decision based on data it may have on their device based on a patient’s history. To check blood pressure and ask questions. Yes, it means the ambulance’s clinical team need the ability to diagnose and ‘make a call’ and it may create challenges around all the gray area, but it’s a step in the right direction for healthcare. Suggests that the healthcare company of the future isn’t just a doctor or a service, nor is it a technology company or a logistics company. It’s really just a health delivery company that blends everything.
Pressure: Not A1C control for diabetes or regular dental check-ups or, heck, exercise. No, the number one way that the health system can have its biggest impact is with hypertension. 61% of 310 practitioners say so from a cast of private practice doctors and payer medical directors. If missed and not managed, the so-called silent killer leads to stroke, hospitalizations, dialysis, wheelchairs. Expensive wheelchairs. If you’re in the primary care space in some capacity, or even if you’re a therapy provider dealing with pain and injury, how you are looking for and addressing hypertension will be increasingly important, particularly if your payment increasingly shifts to cost avoidance.
Specialty Pickle. So value based models are encouraging less testing, more primary care oversight and management of patients, and more flexibility to frontline providers to manage patients themselves. But value models are where the payment is headed, particularly in Medicare. How the capitated payment from the insurer is shared, how savings or payments are attributed or divvied up is going to get more complicated particularly in markets where the insurers hang their hat on a PCP led value based strategy. How will savings and payments be attributed for example particularly in situations when the PCP has the risk contract and uses outside specialists who have contracts with the insurer. Several specialists have an opportunity to make a play to be the primary care provider for their chronic patients and essentially avoid these attribution challenges. Think Crohn’s or irritable bowel disease managed by the GI doctor, or OBGYNs, behavioral specialists focused on addiction or cardiologists for heart disease. Some primary care groups are building multi-specialty practices to avoid the disjointed system, to make the handoff more effective – to share data right away so the specialist – or subspecialist – has all the information to do the right thing to solve the problem and stop it from happening again.
Intelligence: Worried machines are going to take over managing patient care? Don’t fret! A panel at our conference said AI needs human curation, particularly in healthcare. Data is so massively complex that a human eye needs to help determine that the output is correct and safe, but we can’t enter data with a bias. The machine will pick that up. So just as we’ve created programs in real life to guard against bias, like affirmative action, we need to think about creating these in AI. Start small in your practice: design an intelligent solution with 3 things: historical data, labels, and a well thought out business problem that can be stated in a couple sentences.
1 v 1: Health insurers are turning to technology platforms to reach teens and young adults for their mental health needs. Blue Shield of California has collaborated with the California Department of Education to make mental health resources available online for middle and high school students. Its program, BlueSky, will have one-on-one therapy for students and a mental health first aid training for public school teachers and staff. BlueSky will include organizations such as Wellness Together, National Alliance on Mental Illness California and DoSomething.org, and will be evaluated by a research team from the University of California following its pilot to determine the impact on student- and school-level outcomes.
Extra Point: So true to form, I ran over the recycling bin again today enroute to say goodbye sadly to an old friend. Happens every year when the 14 feet of snow pile up and turn our 2-lane driveway into a skinny, icy bowling lane mailman lawsuit waiting to happen. And today is one of those where my conscientious kids decided to put the week old rice and beans and pasta leftovers into the bin. So here I am, 5:30 am, bleary-eyed from a late flight home, on my way to drive 2 hours to Massachusetts and on my hands and knees pulling food scraps off the road, my blue suit muddied, my hands cold. Zaggy, our labradoodle, who I’d describe as part stuffed animal part monster, thumped his 67 pounds down our icy driveway. My problem was about to be solved, only thing is the $1,500 electric fence – Zag wouldn’t break the barrier this time. My neighbor Allen simply shook his head. He knows my pain. Allen gets locked out of his house every other week and can only enter through the back window, made much more difficult in 2 feet of snow. This is life for unprepared and easily distracted dads in the northeast. But I’ll say this for New Englanders – the winter bonds us. There is real community here. The shoveling and ice melt. The D&D runs and igloos. First story I ever wrote for the Herald back in my late 20s was about a group of kids and their igloo. Photo made its way into the Swampscott Reporter in December 1999 and a young teacher from Peabody, Cara Murtagh, had me come in to talk to her students about it. About how to engage readers and write a ‘how to story’ in less than 100 words. It's been 20 years since I was in that class. That friend I'm saying goodbye to today is Cara. Just 44, but boy did she make an impact. Her story here