Behavioral Health Insights

99: No, not the number of red balloons one guy is sending his girlfriend on Valentine’s Day, but the amount in dollars that it costs out of pocket for a coronary CT calcium score test that gives PCPs and cardiologists a window into heart attack risk, but insurers basically do not cover the test, which 84% of cardiologists we polled find absurd. “It’s a baseline and an important one – it shows the amount of hardened plaque and guides treatment, particularly for those in their 50s,” one cardiologist said.  Insurers may argue about its utility and value, as it typically kicks off other tests like an echocardiogram and a stress test.

Cardiac Mobility: Premera BCBS now pays for mobile cardiac outpatient telemetry, a method using a small portable device to record a patient’s heartbeat as they exercise. It was previously considered investigational.

MAT Gain: Effective April 1, 2024, BCBS Minnesota will remove the visit limitation for medication therapy management services for their Medicaid members. For CPT code 99606, there will no longer be a hard limit on visits, but after seven, the provider will need to send clinical documentation to justify more.

Cancer Going Downhill: Starting March 15, BCBS Michigan will add 11 oncology drugs to its site of care program, including Keytruda and Opdivo, which will now need to be administered in an outpatient infusion center, provider’s office, or home setting for commercial members.

Switching To Telehealth: Psychiatric nurse practitioners lead a group of clinicians more likely to shift their practices to telehealth only, 19% in all, according to research published in JAMA’s Health Forum. By contrast, 13% of psychiatrists shifted to telehealth only in 2022. Those working in highly populated counties with higher real estate prices (17%) – typically urban areas – were more likely to shift compared to those working in low density areas (9%). Pediatric focused practices (7%) were among the least likely to switch compared to general clinicians (14%) and females made the move more than males, 14% to 11%. A “telehealth-only” practice was defined as a practice where more than 95% of visits were conducted virtually.

Finding Pharmacy: Walgreens is partnering with 17 pharmacy schools to better align training with the changing pharmacy business model and increase supply. Pharmacists are increasingly expected to provide more healthcare services, but the industry is dealing with burnout. Applications to pharmacy schools fell 64% between 2012 to 2022.

Enroll With The Changes: 293 million Americans (88%) had dental coverage in 2022 according to a National Association of Dental Plans report. Enrollment in commercial health plans – 61% of which was tied to employer sponsored plans – was flat between 2021 and 2022 while enrollment in publicly funded plans increased ~22%, just ~2% of which was specific to MA plan enrollment, indicating that the biggest growth driver was continuation of PHE policies that halted Medicaid redeterminations during those two years.

Incentive: Regence BCBS is adding a financial incentive for providers who submit at least 10 months of data for at least 80% of their attributed members.

Weight For It: GLP-1 weight loss drugs are the centerpiece of a range of new programs. Mayo Clinic is launching an Rx program combining meal planning, at home fitness and GLP-1s, when appropriate. Cigna’s EncircleRx from Evernorth uses GLP-1s to treat obesity, diabetes and cardiovascular disease, and Calibrate, a clinician-guided obesity treatment program, says its patients achieved 18% sustained weight loss combining GLP-1s with intensive lifestyle intervention, better than what GLP-1 clinical trials alone have shown.  Supply issues for one drug, Wegovy, may improve now that Novo Nordisk acquired drug manufacturer Catalent.

Extra Point: Schools are trying to find funding to reinvest in physical education the way it was once upon a time in the 70s and 80s when recess was kickball and sweat and scooter races. Most schools want to change but don’t have the staff or, admittedly, the training to get today’s kids moving. Well-intended policies like California’s new law protecting student rights to at least 30 minutes of unrestricted play time may force schools to reallocate budgets, like reluctantly taking from art or music. It’s a good move to resurrect recess after 25 years of gym-less days, but 30 minutes for the “possibility” kids will play handball on the blacktop candidly only scratches the surface. Today after recess most middle schoolers check their phones, back then we checked our pits. Funding for play programs serving schools has been rising with some districts getting north of $1M, tapping into foundation grants from the private sector, sometimes pro-sports teams. But these programs are now competing for that funding with mental health services. My son polled his teenage listeners about this and just 27 percent of the 14,609 still have gym class. Believe it or not, nearly 30% of the other 73% say they have thought about suicide, sometimes for a friend’s struggles, sometimes their own. I wonder when we’ll realize play is mental health and that it’s time we re-learn what things like recess can do.

Editor: Ashley Chilton; Contributors: Samantha Kaishian, Hannah Landi; Extra Point: Bryan Cote

140,000: The number of Tyson Foods employees who will now have their pharmacy benefit managed by PBM Rightway, as the company announced plans to drop Caremark. Rightway says it can guarantee employers savings of 15% on pharmacy benefit costs. Rightway will be one of the first PBMs to work with a Fortune 100 company.

Unlimited Labs: As of January 15, Cigna removed annual limits for presumptive and definitive drug testing.

Pre-Natal Nonsense: In interviews with a handful of Medicaid MCOs, each said they continue to struggle to find ways to get newly pregnant beneficiaries to use an OBGYN for the initial ultrasound and pre-natal care, as most just "go to the hospital" instead. The patients, like Than Soe and his girlfriend, say it's a two-way street, as they couldn't find OBGYNs in their area of the state who had openings. Soe said his sister went just one time to the hospital after her pregnancy, and the next time seeing a doctor was at labor. "My nephew is 4 now and not speaking - I'm not sure if that would be different if we had a doctor earlier."

DACON Artist: Pharmacies have a system to measure when patients fill their scripts too early or too late, known as daily average consumption or DACON, but is it underutilized? At an informal straw poll at the local pharmacy this week, 4 of 9 patients told us they were late refilling the script, as much 1-2 weeks, mostly because they "missed some days." But the pharmacy assistant said the system does not send a flag to the patient's doctor.  "They won't know - unless you tell them," the teller said. Managing care can be more art than science, but when evidence of poor adherence like this is clear, shouldn't the system find ways to share that intel?

Teeth Grind: Several dental insurers have told us they've seen a significant increase in the number of occlusal night guards delivered to adult patients and an increase in crowns in patients 65 years and older - trends indicating an increase in stress-related bruxing or teeth grinding, which may also have led to an increase in cracked or fractured teeth in seniors, sources said. One insurer, Delta, has recently partnered with the American Heart Association to implement a new standard of care for heart health screening at dentists’ offices via blood pressure screening and primary care referrals.

Pain Delay: On January 1, a BCBS of Massachusetts policy that limited coverage of monitored anesthesia for certain colonoscopies and other endoscopy procedures went into effect, as we reported last month. Following backlash from the provider and patient advocate community, they announced last week that they are postponing this policy change indefinitely.

Disparity Data: The newest healthcare acronym is SOGIE, which stands for sexual orientation and gender identity and expression, and some providers are pushing for this to become a standard part of data collection. Marginalized populations like those who identify as LGBTQ+ often experience health disparities, but the extent of those is likely unknown because this data isn’t consistently captured.

Stay Home: Priority Health, the Medicaid plan in Michigan, recently began reimbursing urgent care centers for services provided virtually. Prior to January 1, urgent care centers were excluded from the plan’s telemedicine policy.

Gonorrhea Precursor: Gonorrhea cases rose by 28% between 2017 and 2021 and if left untreated can lead to long-term health problems, including pelvic inflammatory disease and infertility. If only the health system consulted Kramer, who made it look easy to diagnose Gonorrhea back on Seinfeld when he compared his ‘burning pain’ to the haunting memories of lost love. Diagnostics may get easier now that the FDA has approved the first commercial at-home test for sexually transmitted diseases. The kit, called Simple 2, is made by LetsGetChecked and currently costs $99, but following FDA approval, could gain commercial coverage.

Pre-Authorization: New Jersey has signed a comprehensive prior authorization bill into law that lays out mandated turnaround times, public reporting of some metrics including the number of denials and their reason, and which physician is permitted to deny a request. Another key element of the bill is that if a patient receives a prior authorization from a former health plan, the new health plan must cover the treatment for at least 60 days until a new approval is processed. Other states, along with CMS, have also been active in enacting prior authorization related legislation. Look for our report on developments in this space later this month.

Extra Point: Amara Ojo grew up in Nigeria catching dinner by plugging an empty water bottle over a cricket hole at dusk and playing marbles on a bumpy dirt bamboo floor in her one room home until it was time to sleep - she couldn't have known life in the US would be harder. Amara is a home health aide here in the southeastern part of Connecticut, makes about $20-25 an hour helping older folks mostly. She has largely been out of work over the last week after bringing her 9-year-old daughter Jasmin to the hospital last Friday for "the asthma," at least that's how Amara describes it. She had been waiting for approval for a medication at the pharmacy because the state wouldn't cover the prescribed brand. The asthma got worse while she waited and so Amara picked up her 4th grader, headed to her red Hyundai and drove four miles to that hospital. The pediatrician who was still trying to get the treatment approved says her practice spent more than 30 hours on calls with pharmacies and insurance companies last week alone, trying to adjust medications and get authorization. The practice estimates that it costs them about $144,000 a year in time dealing with these requests, and it's part of the reason they hired another office manager to assist. Jasmin was discharged this morning - a bit weak, but stable and ready to be home. Her hospital visit unofficially cost about $24,000. Amara missed 4 days of unpaid work this past week, lowering her $600 weekly income to less than $250. "I was very worried about some of the families who need me - they can barely stand without falling," she said. She took Jasmin for a root beer float on the way home that would have cost $5.00 but the waitress spotted Jasmin's hospital ID bracelet.  "She said, 'it's on us'." All told, Jasmin missed 5 days of math and 3 days of her favorite subject, science, plus a dance recital and her grandma's birthday. Amara told me parts of her misses the predictability of her time in Nigeria. "There was violence, and we were scared most nights - marbles were a distraction," she remembers. It was in some ways a simpler time but "I wouldn't trade my time here in America - I do it for her."

Editor: Ashley Chilton; Contributors: Samantha Kaishian, Hannah Landi; Extra Point: Bryan Cote

55%: The portion of rural hospitals that don’t offer maternity care, according to a new report for the Center for Healthcare Quality. And in 10 states, that portion is more than two thirds. More than 200 rural hospitals have stopped delivering babies over the past decade, leading to increased travel times for expecting mothers, and often poorer outcomes.

Staffing Pivot: A new initiative funded by Bloomberg Philanthropies is pairing high schools with health systems, setting up students with guaranteed jobs in the healthcare sector. The first partnership is between a public school in Boston and Mass General Brigham. MGH will develop the curriculum to prepare students for careers in nursing, lab science, emergency medicine, medical imaging and more. By the end of the 10^th grade, students will choose a specialty and after graduation, instead of college, students can start full-time jobs at the health system, which currently has about 2,000 vacant job positions.

Autism Training: 77% of parents of kids on the autism spectrum say they need more help despite ongoing ABA services. Parent-led autism therapy startup Forta, for example, certifies parents as technicians after a 50-hour training course and assessment, then creates a therapy plan for the child. If parents commit to 20 hours of therapy a week with their child, they can receive hourly compensation through their health plan.

SNF Transfer: BCBS Massachusetts is once again temporarily waiving authorization requirements for patient transfers from hospitals to SNFs and rehab hospitals to help manage an influx of inpatient admission requests. Until April 1, patients can be transferred to post-acute facilities without prior authorization, but providers should notify the plan within 24 hours of admission. The first five days are approved and then the plan will require clinical documentation to support additional days.

Cancer Spend Plan: Roughly a third of all cancer patients also have a behavioral health issue, and a study from the Evernorth Research Institute shows that having a person with a cancer diagnosis engaged in behavioral health treatment significantly impacts avoidable ER visits and boosts outcomes. Some health plans and medical centers are integrating behavioral health and oncology by incorporating distress screenings into oncology case management, bringing together specialists and referring patients to community support groups.

Gene Therapy Risk: Blue Cross Blue Shield’s Synergie Medication Collective has signed risk-sharing agreements with drugmakers BlueBird and Vertex to offer their multimillion-dollar gene therapy treatments to some self-insured employers, making it the first insurer to cover these new gene therapies for sickle cell disease. There is currently no cure for sickle cell disease, and patients typically live with intense pain, frequent ER visits, potential organ failure and early death. New therapies are intended as cures and are expected to dramatically improve life for those living with sickle cell. More insurers are expected to cover the therapies. BlueBird recently signed a similar deal with another major payer and is negotiating a pilot program deal with CMS.

Midwest Move: Commercial payer policies tend to start on the two U.S. coasts then slowly move inward and a new BCBS of Nebraska decision is a good example. Effective April 1, 2024, the plan will do what most other commercial plans have done, reducing payment when multiple diagnostic imaging services are provided to the same patient on the same day by the same provider.

Device Launch: Dexcom plans to launch a new CGM for people with Type 2 diabetes who don’t take insulin. The new device, known as Stelo, will be based on the company’s G7 CGM but will include custom features tailored to people who don’t take insulin. Users will have to pay directly out of pocket for the device, but Dexcom said they plan to seek insurance coverage and reimbursement at some point in the future.

Teacher’s Pet: The American Federation of Teachers will partner with Talkspace to offer therapy and other digital behavioral health resources to 1.7 million union members to help with issues like burnout. For context, read our paper here on the behavioral health ecosystem.

Extra Point: So, I think society may have underappreciated the value of the donut as a health benefit. The donut isn’t just empty calories – it’s camaraderie around a table with wobbly legs, the centerpiece of stories from vets and old friends about people like Sister Mary who used to discipline kids by throwing chalk and pulling them by the ear down to the principal’s office. An academic center here in the northeast actually found donut-holding families in their ERs appeared less stressed and more receptive to discharge instructions. The rate of readmission among those with donuts in the exam room was about 30% less compared to those without one. Donuts have had a love-hate relationship with the healthcare system but given the state of the mental health crisis, there is an argument that donuts could play a role in treatment. “It’s not the donut, it’s the conversation you have with someone when eating one,” psychologist Vern Stanton told me while we shared cinnamon munchkins and coffee last year at the local Dunkin. Some people who swear by a daily donut often seem to have a glass half full attitude. Kelly Saven, a nurse’s aide in Connecticut, told me she likes the jelly ones, “because my doctor said I need to eat more fruit.” Dissolution of the family these days and family meals has been a major driver of mental health deterioration in both kids and adults.  Suicide care is now necessary and for many the common reason is a lack of social interaction, real connection, laughing about stories, people watching. “My daughter is 37 and says it’s hard to find time to make supper and sit down with the family – her kids constantly being raced around,” laments Norm Tartaglia, 70. “She should slow down and have a donut and coffee once in a while.” I caught up with three old men and a lady down at the local donut shop in my hometown last week – 92-year-old Benny, 95-year-old Sam, 87-year-old Kristine and 86-year-old Roger. They’ve met here off Lasalle Road for coffee and a donut and a conversation for most days since the 1970s. “I remember when the place opened,” Roger said. “Used to have penny candy, peanut brittle and hot donuts. We’d come after school.” Fred Marcucci, a Marine Corp vet living in West Brighton New York said today that he is upset about the local D&D closing for 3 hours each afternoon given unruly students and parents causing traffic issues. “This prevents us from going inside to sit and enjoy a cup of coffee and a donut,” he said.  I’m personally not suggesting the healthcare industry needs to lean into donut shop franchises or that we’ll lower healthcare costs with more donut diners. Nor am I advocating Medicare insurers should use supplemental benefit dollars to give free donut vouchers to seniors, but the broader public might want to re-think about the value of the donut. When I was a kid, my folks would take us to Gil’s Bakery for a cinnamon cruller and Very Fine grape drink after Sunday mass. We would just tell stories, listen to the people, savor each bite – maybe coincidence, but afterwards I always felt lighter.

Editor: Ashley Chilton; Contributors: Samantha Kaishian, Hannah Landi; Extra Point: Bryan Cote

2,719: The number of 20–30-year-olds out of 8,600 we polled who said they will likely try to forgo using traditional health insurance if possible and instead use other means to pay for healthcare if needed. Nearly twice that many – 5,330 – say they won’t use a primary care doctor, instead relying on urgent care. A majority said they’d rather use funds for exercise programs, better sneakers, and concert tickets and aren’t worried about not having a PCP. About half said their instincts are drawn from frustration their parents go through with insurers and wait times and physicians who aren’t available. “My mom seems powerless,” said Catie, 27, who works for an art company but has not selected insurance. Our new study delves into the state of consumer frustration with the healthcare system. Click here.

Willing & Able: Uwill, which offers virtual behavioral health services to college students, acquired Christie Campus Health. The deal will help Uwill expand their reach to serve more than 2 million students at 300 institutions around the country.

Low Utility: Employee mental health services may not be as helpful as employers like to tout, according to new research from Oxford. The study looked at the outcomes of 90 different interventions, such as apps, coaching, and mindfulness classes, across ~46,000 workers and found that people who took advantage of such programs reported no significant benefits compared to those who didn’t. The one exception was participation in charity or volunteer work, which did seem to have a positive effect for employees.

Funding Triage: Since the launch of the 988 Suicide and Crisis Lifeline in July 2022, it has faced challenges in staffing call centers and providing callers with adequate resources. A new bipartisan bill, known as The CONNECT Act, would provide $30 million in grant funding to provide at-risk callers with follow-up services.

Independent Physicians Unite: Independent physicians have launched their own their own lobbying group, the American Independent Medical Practice Association. Some independent physicians feel that the AMA isn’t advocating effectively for their unique interests so the new group will focus on advocating for ways that will allow physicians to retain control of their own practices. According to the creator of the new group, this may mean being more open to private equity.

AI Making Care Decisions: No, the great 76ers point guard Allen Iverson is not the new medical director of healthcare but like the hall of famer’s agility navigating to the goal or passing the ball, healthcare’s “AI” is taking on the role of traffic cop under a pilot program from HCSC, the parent company of Blues plans in five states. The AI pre-authorization tool doesn’t deny any requests - it will kick it over to a clinician if it feels it doesn’t have enough info to approve. During the initial pilot in 2022 for specialty pharmacy and behavioral health, approvals were granted 80% of the time for behavioral health and 66% for pharmacy, and the health plan said it streamlined the process substantially. Now requests for a variety of services will utilize the tool, including inpatient, long-term care, home health, hospice and outpatient services.

Phone Drop: Elevance, aka Anthem, is launching a new program to provide smartphones to some Medicaid members. The phones will include unlimited data, talk and texting service at no cost to members in an effort to improve access to healthcare.

Extra Point: Coach Rick Hauk’s Parkinson’s took his nerves at the end, but they didn’t take the impact he made. On a brisk Monday back in 1987, Coach Hauk jogged over to a group of us kicking soccer balls like football field goals over the crossbar moments before soccer practice. Coach smiled and asked us how many points we’d made with all those field goal kicks through the uprights. I said 18, Donny said 24. “Great – you could play football, if we had a team,” Coach quipped. “Now that’s how many laps you have to do – get moving.” Rick Hauk impacted thousands of students at my school growing up as the Coach and gym teacher and, when the school needed it, a health class substitute. In one class, Coach took the health students down to the gym where we played keep away. Physical education is making a resurgence again after losing ground over the past decade. Teachers like Coach Hauk are part of an era that made students accountable and helped them see the value and joy in sports before the travel sports movement started to take that away.  He died this past week after a long struggle with Parkinson’s disease – a disease that slowed him down and took his nerves – but not his story. At his funeral yesterday, the coach’s former players came to show support for a man who never really asked for much – just that you show up and put in effort. He helped a generation of us kids see the potential we had and the value of work ethic. At a halftime down a goal in a semi-final, he came over, not thrilled, and said “I think you all know you can work harder out there – I believe in you – I’ll give you the halftime to think about what you need to do.” There is thankfully progress on Parkinson’s research. The disease may have won for now but if stem cell researchers continue to find ways to stop deterioration in Parkinson’s patients, maybe, just maybe, folks like Coach Hauk can have another chance run on a field, and maybe for old time’s sake, even kick a few soccer balls through the uprights.

Editor: Ashley Chilton; Contributors: Samantha Kaishian, Hannah Landi; Extra Point: Bryan Cote

2,005: The number of drugs excluded from the Big 3 PBM’s 2024 formularies. Caremark and Express Scripts both added more drugs while OptumRx’s list decreased slightly. CVS reported that 1.4% of its members will be affected by 2024 exclusions, which sounds like a small number, but in 2023 that number was only 0.28%. The other PBMs haven’t reported any numbers around patient impact.

History of the Pre Auth: Pre-authorization seems to be disappearing faster than phone chargers in my house, but are the range of laws and policies to push insurers to curtail the practice really a big change at all? Many probably don’t remember the long-history of gold carding. In 2007, in the heyday of MRI utilization in physician offices, doctors could get a so-called gold-card for having a 97% or higher authorization approval rate, allowing them to skip the authorization process but, like today, there is still a “retro” authorization that audits the providers work every 6 months. Even commercial insurers who have been halting pre-authorization regularly for years have shifted attention to the back end, adding “re-authorizations” and “pre-pay review” systems to manage spend.

Direct To Consumer: Mailman Newman once told his girlfriend that zip codes are meaningless on an episode of Seinfeld, but they matter a great deal for drug manufacturers like Eli Lilly who will be shipping medicines directly to people’s homes under a new business called LillyDirect. The telehealth platform will allow the company to cut out middlemen like PBMs, only using a third-party service to ship drugs at no cost to consumers.  The patient will also have access to independent telehealth providers if they don’t already have a prescription from their own. Lilly recently had a new weight loss drug approved which will be sold via the platform, along with treatments for other conditions like migraines and diabetes.

OutFusion: The shift to alternative infusion sites continues and the decision by Anthem (now Elevance) to acquire infusion provider Paragon is the latest out-of-the box move. The acquisition will help deepen the plan’s specialty pharmacy operations after its 2023 acquisition of BioPlus. For independent companies, the threat of vertically integrated operations is not a new one. In 2024, a bigger question for these infusion operators is more likely the impact of policies to promote self-administered drugs and biosimilars, as well as the realignment of plans, PBMs, hospitals and mail-order pharmacies. Patients also may have something to say - 72% of people aged 50+ in a recent poll we did would like their infusions at a hospital compared to 39% of those under 50.

Habit Change: Constanza once famously started doing the exact opposite of his usual behavior in a last-ditch effort to lift himself from being a self-prescribed loser. George was ahead of his time as healthcare companies like Newtopia are working on habit changes to help employers prevent disease. They tout savings of 70% or more under an Aetna study. The program includes genetic testing and 1-on-1 coaching with a focus on keeping people healthy and changing behaviors in those who have signs of potential disease. These employer programs aren’t new, per se, but they are evolving, with more focus on mindfulness and yoga and use of test results to guide habits and avoid disease onset. But they have the same challenge - they get a PMPM for a period with a goal of bending the cost curve and ultimately need to show ROI quickly up.

Therapist Reimbursement Expands: Beginning February 1, Horizon BCBS will expand the behavioral health practitioners eligible to receive reimbursement to include associate marriage & family therapists practicing under a licensed marriage & family therapist (LMFTs), along with psychology permit holders practicing under a licensed psychologist. The supervising providers must be licensed in NJ, contracted with Horizon, and have an approved Plan of Supervising Clinical/Counseling Experience in place.

New Reimbursement Tier: In case you missed it, Aetna expanded their Mid-Level Practitioners policy to include a new reimbursement tier for certain practitioners. The Mid-Level Practitioners policy now includes audiologists, genetic counselors, massage therapists, nutritionists, respiratory therapists, and registered dietitians, allowing reimbursement at 75% of the negotiated fee or recognized charge for covered services. This only applies for Commercial business.  Other companies are corralling these practitioners – such as midwives – and packaging services that can be available to employers, commercial plans and Medicaid plans, largely as part of an effort to improve women’s healthcare.

Covid (Don’t) Comeback: The Covid variant known as JN.1 is spreading quickly and represents approximately 62% of current Covid variants. Covid hospitalizations increased 20% during the last week of 2023 and despite evidence showing JN.1 does not cause more severe disease, Covid related deaths rose 12.5% in that same period.

Extra Point (From The Archives): All this talk about the cost to pre-authorize and whether more health insurers and doctor groups can figure out a way to stop getting in the way of care and remove authorization has me questioning my own authorization behavior. In my house, I’ll admit there are times I just go ahead without so much as a heads up. Take Thursday – I went to play hoops to burn off some energy. Didn’t get pre-approval, didn’t pre-notify, and while it was generally no big deal I missed a college prep meeting I agreed to 3 weeks ago. Then last night I ate the Key Lime Pie Bridget’s friend had made for her. I mean, it looked lonely in the fridge at 10 o’clock, even if it wasn’t mine to devour. So, here I sit on a Friday morning, my so-called Gold Card revoked, and a corrective action plan likely coming. And much like an oncology practice that needs to give the insurer’s case manager Sandy a heads up since she has a wider lens into the patient’s recent medical history, I suppose at 51 I too still have a few things to learn about the merits of authorization. I need to be managed sometimes.

67: The percentage of hospitals where family practice doctors delivered babies, in a survey of 216 rural hospitals in 10 states. At 27% of the hospitals, they were the only physicians who delivered babies. Family doctors are heavily relied on for obstetric services in rural hospitals, and without them many patients would have to drive over an hour for care. With maternal mortality rates on the continual rise, rural areas are employing new strategies. For example, the University of Colorado’s College of Nursing received a $2 million federal grant this fall to train midwives to work in rural areas of Colorado.

You're Doing Too Good: One of the leading national insurers is going out to primary care groups succeeding in Medicare Advantage risk arrangements and telling some they will be lowering their percent of premium.

Sleep Uneasy: BCBS Kansas has seen an increase in the billing of at home sleep apnea tests that do not meet coverage criteria due to lack of clinical, peer-reviewed literature. The health plan is reminding providers to review their medical policy before ordering home sleep tests to make sure the technology the patient and provider are planning to use is covered.

Drug Price Swing: More than 500 drugs are expected to see price increases early this month, according to a new analysis from 3 Axis Advisors. Yearly price increases typically average around 5-6%. Pfizer plans to raise prices for more than 120 drugs, which will account for 25%+ of the planned increases. On the other hand, three companies said they will cut prices on at least 15 drugs, including GSK’s drugs for asthma, herpes and anti-epileptics.

Hurdle Lifted: Behavioral health providers will no longer need to apply to join BCBS Michigan’s High-Performance Network. The plan says that by removing the application process, they can better ensure members have access to behavioral health providers.

Alzheimer's-Schizophrenia Boost: Bristol Myers Squibb announced it will acquire Karuna Therapeutics, which makes drugs to treat schizophrenia and Alzheimer’s. Karuna’s drug KarXT is expected to be on the market in September 2024, pending regulatory approval. With an increasing prevalence of schizophrenia in the US, the demand for treatment is rising. AbbVie recently bought Cerevel Therapeutics, which develops drugs to treat neurological disorders including schizophrenia.

Reality Bites: Virtual reality headsets are being used to help treat Amblyopia, or lazy eye, in children. The standard treatment for amblyopia, which is the most common cause of vision loss in children, relies on an eye patch over the stronger eye to force the brain to rely on the weaker eye, but new treatments work on ways to encourage both eyes to work together. Luminopia is one of a few companies focused on designing virtual reality treatments which involves children watching videos through a VR headset which blocks out certain parts of the display for each eye.

Monitored Anesthesia Cut: BCBS Massachusetts updated its anesthesia policy for January 1 and is facing pushback from provider groups. The policy now restricts coverage of monitored anesthesia care for patients undergoing procedures like colonoscopies, bronchoscopies and certain pain procedures if they are classified as class I or class II. These patients typically do not have any comorbidities and will only be approved for conscious sedation.

Extra Point: If you get instructions from the Peaky Blinders, you follow them like your life depends on it. But get instructions from a doctor or nurse or insurance company to change your diet, run a few laps at the new gym, maybe take the meds without chianti for once then, well, yeah, you don't take these literally. You chart a different path. Instructions tend to confuse me anyway. The ones we need least seem to be right in front of us, like that sage advice on some beer cans to "tap twice and pull the tab."  Then the ones we need most seem to be as clear as my wife's closet. I once asked the grocery clerk to point me to the gluten free vanilla pudding mix - it took Joe a good 20 minutes just to find the right aisle. "I could have sworn it would be next to the apple sauce," he kept mumbling as we circled the store. My Uncle Mike sent me instructions in ALL CAPS the other day - a detailed rundown of how to get from San Francisco to the Los Gatos Jesuit Center next week. He even had an "AVOID THE POTHOLE NEXT TO DIO DEKA DINER." Michael married me and my bride 24 years ago on his break from Gonzaga University classes, so I will avoid that pothole, heck I may even stop into the Deka for a milkshake. People in healthcare give us all kinds of instructions and sometimes they too are in ALL CAPS, but I often wonder if they are just testing us. My dad and I spend hours trying to decipher instructions for his medications. One bottle read "EVERY NIGHT BEFORE FOOD ONCE DAILY TO BE TAKEN FOUR TIMES A DAY THREE TIMES A DAY EVERY THREE TIMES DAILY TAKE ONE TAKE TWO TAKE THREE ONE OR TWO." I'm not a fan of commas, but dear lord these would have helped. This is a particularly cruel run-on sentence that makes literally no sense. Sounds more like my dance instructor's orders. We had a good laugh but not as much as this one for Ventolin to treat an acute bout of bronchospasms -- INHALE 2 PUFFS BY MOUTH EVERY 4 HOURS RECTALLY....My bride got some admittedly great instructions recently from our health insurer - the flyer said to use one of the two listed GI doctors for her colonoscopy. It said SCREENING SAVES LIVES and had 5 gold stars next to the doctor's name. It even included a gift card offer if choosing the doctor.  We got a $1,700 bill instead -- complements of the anesthesiologist and the GI practice. Her primary care doctor sent a referral, but the insurer said they didn't get it, so a collection agency would be sending correspondence and alerting credit agencies, which is nice. Imagine those without the wherewithal to pay that bill. I can tell you it's not exactly a gift for us with four kids 17-22. Maybe I should call the Peaky Blinders...just to send a letter of course. Perhaps something like my Aunt Nancy used to tell us when it was time to go -- "TAKE A GOOD LOOK AROUND KIDS...WE WON'T BE BACK."

490,000: The number of surprise billing disputes submitted by providers and insurers from April 2022 through June 2023. 61% of those are still unresolved, according to a new report from the Government Accountability Office. A single disputed claim can take up to six months to settle.

Broken Record: By the end of the year, the FDA is expected to have approved 51 specialty drugs in 2023, which would break the previous record of 40 approvals back in 2021.

No Room At The Inn: 80% of mental health provider listings in Medicare Advantage directories are inaccurate or, as a recent Senate Committee on Finance found, lead the patient to a psych professional who isn’t taking patients. These so-called shadow networks are even more prevalent in the commercial population where, in places like Washington state, psychiatrist panels are full when patients call. Digital/tele companies are trying to fill the gaps.

Wait For It: WeightWatchers launched a telehealth service last week focused on GLP-1 medications. WW acquired telehealth weight loss provider Sequence in March - clinicians will prescribe eligible patients GLP-1s and other weight loss drugs along with a behavioral program focused on nutrition and physical activity. The program can be used by anyone on GLP-1 drugs regardless of who prescribed them. Several other telehealth companies have also jumped on the GLP-1 trend. Some self-insured employers and health insurers are closely monitoring the uptick in utilization and likely adjust coverage requirements next year as spend rises.

Nursing Home Star: A handful of nursing homes with low STAR ratings are actually in close partnerships with hospitals to take their highest risk patients – those on vents, trachs, and with complex substance use addiction. Interestingly, the hospitals find these low STAR ratings irrelevant because these nursing homes have changed capabilities to take the higher risk off their hands. “We round in the hospital, go see the patient, help with the discharge – the hospitals really just want to avoid the bounceback readmission penalty,” Alice King, a care coordinator told us. Many SNFs are closing or struggling - St. Louis’s largest nursing home, which housed 170 residents, closed suddenly last Friday, forcing transfers for the residents of Northview Village Nursing Home to other centers. The shutdown followed an employee walkout after 130 employees went unpaid. From 2020 to August 2023, 579 nursing facilities have closed, according to CMS Quality and Certification Oversight Reports data. Nursing facilities will likely continue to face staffing challenges in 2024, particularly in the wake of CMS’ proposed minimum staffing rule. 94% of nursing homes across the country do not currently meet at least one of the requirements.

Closing Time: VillageMD, the primary care provider backed by Walgreens, is closing its 12 locations across Indiana following Walgreens’ cost-cutting plan announced in October. VillageMD closed 10 clinics in the Jacksonville, Florida area earlier this month and plans to close 60 locations in five different markets. Amid primary care closures, the demand for services is rising and so is consumer frustration - with an average wait time of 21 days to see a family medicine doctor, according to an AMN Physician study. Patients, especially younger ones, are turning to urgent care and retail primary care to dodge the wait. Our consumer report, coming out in January, will talk about these trends that are far more pronounced in specialty care – including a 320-day gap for a patient to see a cardiologist for an initial visit after getting a referral from his internist.

Brush Rush: A review of 15 clinical trials found that "rigorous, regular" daily toothbrushing was associated with a 33% lower risk of hospital-acquired pneumonia among patients on ventilators, according to a study in JAMA Internal Medicine. Brushing patients’ teeth also was associated with a 20% lower mortality rate and shorter ICU stays. Maybe toothbrushes should be the must-have stocking stuffer this year. Santa, did you hear that?

Extra Point (From The Archives): Great Aunt Mary used to hate this time of year. “I don’t get what all the gifts are about – I have everything I need right here,” she’d tell me, pointing to her Virginia slim cigarettes and mini powdered donuts. “Mary!” my Uncle Auggie would say, “it’s not about what you have, it’s about giving to others.” She would shrug with a distasteful Ebenezer look and puff on the cigarette.  But every once in a while, Mary would surprise me. “Comere kid – you play Gin right? Let’s play Carmella. She has the dementia so it’s an easy win.”  My aunt Adeline once described Mary as a real-life dry heave. To her face. You can’t make this up.  We would see Mary at Sunday suppers throughout the year but never on Christmas Eve or Christmas Day.  Mary was a nurse, an LPN, over at the Mercy Medical Center in Springfield, Massachusetts. She worked double shifts on those days. “Someone has to,” she’d say. When I was old enough, I interned there in the early 90s and I remember visiting the hospital on Christmas Day for a small holiday party for staff. Mary wasn’t there at the party. I was told she was sitting bedside with a patient up on the 8th floor of the 300 bed hospital.  Best I could see, she was holding a full house in her left hand, and holding the patient’s hand with her right.  I’m not sure I miss Mary in the way you miss the fun aunt who gets down on the floor and plays football with you and races matchbox cars, but I bet her patients miss her. She wasn’t exactly the model of compassion we talk about, but she was there. On Christmas. And I suppose as I think about it, maybe Mary was the gift.

$2.2 Billion: The estimated price tag for the first CRISPR gene-editing treatment for sickle cell disease approved by the FDA last week. But health systems, health plans, employers and patients all face potential challenges in paying for the potential cure. ICER says the price tag may be justified compared to the cost of lifelong treatment, but paying for a lump sum of that size all at once is something our healthcare system has been struggling with how to handle as more and more high-cost gene therapies continue to be approved.

4th & Goal: Tom Brady may be able to find new work. We talked to 6 medical directors for behavioral health this week in a series of in-depth interviews – each of them interested in pressing psychiatrists and psychologists to “get to a goal, because many aren’t,” and likely rolling out new policies, including reimbursement adjustments tied to performance.

At Home Pediatrics: Nemours Children’s Health plans to be the first children’s hospital to launch a pediatric hospital-at-home program. The program, intended to launch in 2024, will enable Nemours to provide care for more patients when its hospitals are at capacity, and will provide acute care to patients within a 40-mile radius of the health system’s hospitals in Wilmington, Delaware and Orlando, Florida.

Domino Effect: Carelon, formerly known as the benefit manager AIM Specialty, is launching CarelonRx Pharmacy. The digital pharmacy will offer text and phone support between pharmacists and patients, easier comparison of drug prices and a Dominos’ delivery style tracking update for delivery prescriptions.

Take A Left After The Cereal Aisle: Kroger, a supermarket chain that operates 225 in-store healthcare clinics, announced a shift into primary care for seniors. Kroger Health will transition eight of its “The Little Clinic” sites to focus on senior care. The senior care sites will try to take a more value-based approach and offer longer appointments with nutrition counseling and medication review. Fellow retailer Best Buy also continues its push into healthcare, this time partnering with remote patient monitoring firm Biobeat. The company will integrate Biobeat to boost its home care offering.

Buy & Bill Lives On: Effective February 2024, Highmark BCBS will eliminate its “mandatory” category for medical injectable drugs, which had required providers to go through an assigned specialty pharmacy for 36 drugs for its Medicare Advantage patients. Once the change goes through, providers can buy and bill these drugs or choose to use a specialty pharmacy, though the particular pharmacy will still be assigned and not up to the provider.

Steering Wheel: Empire BCBS, an Anthem plan, is launching a new High Performing Provider (HPP) designation for providers who meet certain cost and quality metrics. Effective February 1, 2024, HPP designated providers will be promoted in a number of ways, including member searches and when members call for referrals.

Menopause Support: The virtual mental health company Talkspace announced a partnership with digital menopause care organization Evernow to help women who experience anxiety, depression and hormonal shifts throughout the menopausal period, which can last 7-14 years. There are efforts at a federal level to support virtual psych. The Home-Based Telemental Health Care Act, a new bipartisan bill, aims to boost access to virtual mental health services for rural communities by authorizing grants of up to $10 million until 2027.

Extra Point: So apparently I’m turning to the health insurance community for help raising my children. A collection of unions, health insurers, and Medicaid and Medicare plans are starting to use predictive analytics tools to target patients at high risk of a painful event like a fall, a myocardial infarction, COPD exacerbation or suicide. What’s interesting is several are doing this by looking at patterns of behavior, not by diagnosis – like trips to three specialists inside three months, the daily average consumption rate revealing an early or late prescription refill, a series of missed appointments.  The insurers will then deploy peer navigators to help fix the behavior. This is a good trend I may try at home – our youngest, 17-year-old Tommy, seems to have these patterns of forgetfulness. My wife says it’s his way of making a mark as the last child – leaving half-filled red Gatorades in the bathroom sink – like literally in the sink – discarding gummy wrappers in the tub, putting his stinky tennis socks in the stove, baking at 350 because “doesn’t everything cook at 350,” then leaving the kitchen. R41.3 is the technical diagnosis code for forgetfulness, but I’m inclined to follow the health insurer lead and use predictive analytics, aka cameras. The problem is there is apparently no good treatment. My wife says the solution is really to just “wait it out.”

348: The number of post-residency fellowships available in geriatric internal medicine available this year, but less than half of those spots were filled. The fill rate for geriatric family medicine was even lower, at 26.8%. Doctors specializing in geriatric medicine are increasingly in demand as the population ages, but younger physicians and those in medical school don’t seem to be interested in the specialty. Some of this could be due to low reimbursement compared to other specialties - in one of our polls of physicians in training in 2018, 73% said compensation would be a factor in their residency decision.

Wig In Or Out? Starting in January, Aetna's Medicare plans will begin offering a $400 annual wig benefit for those dealing with hair loss after chemotherapy.

Co-Surgeons: Aetna will institute a new policy starting in March 2024 reimbursing co-surgeon services at 62.5% of the eligible rate when a surgical procedure is submitted with modifier 62 and a second provider submits the same procedure code on the same date of service without modifier 62. The combined allowed amount is 125% of the eligible rate.

George Jefferson Policy: Like the theme song to the 1970s sitcom, the health insurance world is trying to help people move on up. BCBS Minnesota will add a benefit for moving expenses for their Minnesota Health Care Program members effective April 1, 2024. Members who are transitioning out of Medicaid funded institutions to private residences will be eligible for up to $3000 annually, which can be used for expenses like applications, security deposits, furniture, utility deposits or home accessibility accommodations.

Hospitals At Home: Rural America has lost nearly 140 hospitals in the past 10 years, leaving patients traveling up to 100 miles to receive care. Hospital-at-home models could help fill a void in care in rural areas, and several health systems are working to launch or improve models. Sanford Health, one of the largest health systems in rural America, plans to launch its first acute hospital-at-home program in North Dakota next spring. Researchers at Ariande Labs will soon begin releasing results of a three-year trial of rural hospital-at-home programs in Kentucky and West Virginia, and said early data is encouraging despite staffing challenges.

At The Counter: In an effort to cut costs, Walgreens is focusing on incorporating new digital tools to help decrease the workload for pharmacists. A new tool called Rx Savings Finder will consolidate searches from third party discount cards that patients can then show to the dispensing pharmacist.

Flat Dispensing Fee: CVS announced plans to move to a simpler drug pricing model in their retail pharmacies, following a similar initiative announced by Express Scripts last month. The new model would more closely align with Mark Cuban’s Cost Plus Drug model where drugs have a limited markup and a flat fee for dispensing. CVS Health more broadly is rebranding its health services segment as CVS Healthspire. Included under the new brand will be Oak Street Health, Signify Health, MinuteClinics, Caremark and Cordavis.

Surgery Site: Effective March 1, 2024, Regence BCBS is adding more than 1000 CPT codes to its Surgical Site of Service policy, the latest effort by health plans to push more procedures out of the hospital to a lower site of care.

Extra Point: So, a lot like Lloyd Dobbler, America's youth don't seem all that interested in selling anything bought or processed, or processing anything sold or bought, at least as a career, but they are increasingly looking at healthcare. In a Behavioral Health Hour poll of 37,610 16–24-year-olds, a whopping 57% named a healthcare job as their most likely pursuit. Most pointed to family experience as the reason - a brother or sister on the autism spectrum has nearly 3% interested in working as a therapist or counselor, mom's breast cancer fight has 5% wanting to be a researcher in a lab or an oncology nurse, and grampa's time in hospice and nursing homes at the end of his life has 6% interested in palliative care. Nearly 10% said they love sports and activity and "when the dream runs out on being the next Steph Curry" as one 16-year-old said, they hope to work in social work or exercise science and play programs, particularly in inner cities. About 15% from urban areas said they are interested in robotics and AI-related work in the medical field, largely due to experiences they have had in school, and nearly 50% of those who consider themselves "math geeks" say they are interested in predictive analytics. Several mentioned doing work to figure out patterns of disease and how to slow progression or get help to people sooner, about 4% saying their aunt or uncle's MS is a reason. About 7% named fictional characters as those they "hope to be in real life," like TV's Dr. House. In total, about 10% of the ~37,000 still have high hopes of a big job like George Costanza hoped to have as general manager of the New York Yankees, but as Jerry said, "I think you need to have been a professional ballplayer to get that job." The poll is obviously just a snapshot in time, but it almost seems as though the effects of coming of age in the 2020s amidst a storm of health crisis has drawn the youth in. My own daughter is pursuing performance and singing but focusing on doing that in hospitals and nursing homes - she wonders, "maybe it'll cure someone?" As the definition of what healthcare looks like in America expands, it seems the more attractive the field is for those coming up the ranks. But despite what is a promising study, there are still questions - 78% say they are not sure exactly how to pay for the training and pursue the career, that economic or social factors facing their family may be a barrier. My 2 cents for the 18-year-olds is take a cue from Lloyd Dobbler - spend as much time as possible just being with someone else, maybe a Diane Court, maybe not, but to at least see the world and experience life before settling on anything, particularly a career.

10%: The amount of all physicians in the US who are now employed or affiliated with UnitedHealth, according to the healthcare group’s investor day this week. That equals roughly 90,000 doctors who are part of the behemoth that includes a health plan, a PBM, a specialty pharmacy, and more.

Drug Authorizations: Highmark BCBS will begin requiring prior authorization for 60 high-cost drugs in January 2024 for their Federal Employee Program (FEP) members. The change will move the medical necessity review from post-service to a pre-service review. And starting in January, BCBS Tennessee will no longer use MagellanRx for specialty drug prior authorizations and instead will manage the process internally.

Cleveland Rocks: Cleveland Clinic and Canon are partnering to build a research imaging center based in the Cleveland Innovation District. The center will focus on cardiology, neurology and musculoskeletal medicine and aims to improve patient outcomes, diagnosis and care.

Dad Days: New research from the University of Southern California shows that paternity leave can pay a “lifelong dividend” for fathers. Researchers compared first time fathers in Spain to those in California and found that fathers who spent more one-on-one time with newborns experienced changes in the brain associated with sustained attention. The US is an outlier when it comes to paternity leave with paid family leave laws having been enacted in only 14 states as of September.

Where Is VBC Working? Value-based arrangements made the biggest difference in outcomes for osteoporosis, breast and colorectal cancer screening, and eye exams in diabetes care, according to Humana’s 10^th annual value-based care report that compares outcomes among their members who are in some type of VBA versus those who only receive care through fee-for-service arrangements. 70% of Humana’s MA members are aligned to VBA providers, the highest Humana has seen since tracking this metric. And in good news for providers, VBA physicians earned, on average, 3.4x the Medicare fee schedule.

Cost Based Pricing: Express Scripts is launching a new pharmacy network option, ClearNetwork, which will offer cost-based pricing. ESI will rely on the lowest of three published benchmarks—National Average Drug Acquisition Cost, Wholesale Acquisition Cost, or Predictive Acquisition Cost. Pharmacies will receive a flat dispensing fee along with an unspecified portion of a fee that will be "up to 15%" of one of the above three benchmarks. ESI says this option will be “straight forward” but it’s still not clear how much savings this could result in for employer clients.

Saliva Screen: George’s fiancée, Susan, has made us all think twice about licking the envelope this time of year, victimized by her own saliva and a toxic adhesive in the classic Seinfeld scene. Saliva tests for drug addiction are much safer than Costanza’s envelopes, but are they accurate? Several insurers say there are a high number of false positive results with these tests, particularly in smokers. These tests are likely to be scrutinized more in the coming years by insurers as they attempt to help in drug detection but do so affordably. Saliva tests can help with detecting very recent abuse, but they only detect abuse for a few days. These tests can also be used to help diagnose Autism in children.

Referral In The Way?  Two years ago we reported that 59% of 25-35 year olds in our consumer poll said when the times comes they will “likely” or “definitely” choose Cologuard’s at home screening test for colon cancer over colonoscopy, several citing advantages like “not having to do the prep my dad did” or not “having to be sedated” and even financial benefits for those who say they may just pay cash “and I think the at home is a lot cheaper.” If a Cologuard test is positive, the patient will need a colonoscopy, but only 39% knew this. However, the cost of the colonoscopy in this situation would be applied to the patient’s deductible if they are using insurance. 20% said they would “definitely” choose the test, 39% “likely.”  In our recent poll of the same audience two years later, the results are directionally similar but there’s a new wrinkle – several said their parents have had to pay full cost for the colonoscopy – or fight the cost - because they didn’t get a referral from their primary care doctor. In several cases, the insurer sent a mailer to 45–55-year-olds encouraging them to get a colonoscopy with one of 2 doctors in the insurer’s network – they provided the phone numbers and websites – and said the screen would save lives. But these adult parents still got a bill for $800 or more.

Teen Talk: Virtual behavioral health company Talkspace will provide free services to more than 400,000 New York City teens through a partnership with the NYC Department of Health and Mental Hygiene. The partnership will launch a new program called TeenSpace through which 13- to 17-year-olds can connect with licensed therapists for free over the phone or through text.

Extra Point: My cardiologist and my dog’s vet were equally frustrated this week over our lack of sustained exercise and recent dietary decisions – mine leading to elevated calcium scores, Zaggy’s to what seems to be a combo of sleep apnea and GERD.  Who knew dogs could get those? So we both turned on Rocky’s Gonna Fly Now this week in search of renewing movement – Zaggy chased squirrels, I found my way to Orange Theory after a 4-year hiatus from the hit gym class that measures performance in so-called “splat points,” the theory being that putting each person’s points up on a public TV monitor is a way to push people to be their best.  I have a theory that it makes me nauseous. In my first week, for some reason, I had zero splat points in both my visits—the lowest in the class, 40 worse than my bride and 50 worse than my daughter leading me to believe that managing my own care is exhausting, humiliating and undoubtedly hurting my status in the family.  The hit gym classes aren’t just winning with families, millennials and 30 and 40 somethings, they are getting the attention of self-insured employers and a few large payers too. I asked a half dozen benefits administrators for leading employers with more than 15,000 employees – and all but one are looking at developing a contract and perhaps a pilot program to measure productivity and wellness for employees and several mentioned the popular Orange Theory as a possible partner. The theory is that the class meets you where you’re at, improves strength and conditioning and, according to one analysis, reduces prescription spending, absenteeism and A1c scores. Some said these pseudo gym classes likely have better long-term results compared to the GLP-1 weight loss drugs. We will have to see. I’m just hopeful splat points won’t be a measure companies or insurers use to set premiums and benefits, at least not until I figure out how to do more than 3 burpees without needing to “take five” in the corner.