Behavioral Health Insights

13: Percent of employees at some of the US’s largest companies don’t believe their employer offers mental health benefits, when in fact they actually do, according to a recent survey commissioned by Human Resources Director America. Topping the list, 24% of Walmart employees claimed their employer doesn’t provide mental health resources, which is contradicted by 33% of Walmart employees who took the same survey saying they used employer-provided mental health services in the past year. Even more stark, the same survey reports that more than half of employees said they haven’t used any mental health benefits offered by their employer.

PCP Incentive: Regence is launching a Commercial Quality Incentive Program (QIP), beginning on June 20th. Primary care physicians will be able to earn incentives for closing care gaps for individual on-exchange patients, similar to their current Medicare QIP program. PCPs will earn a set amount per patient for measures like cancer screening, childhood immunizations and diabetes testing.

Shared Savings: CareMax recently acquired the Medicare business of Steward Health Care System. CareMax will now serve as the MSO for this network which includes Medicare Advantage members, along with Medicare members who are covered through the Shared Savings Program and the Direct Contracting model - 171,000 members overall. Part of the deal terms give Steward ownership of CareMax stock. If CareMax is able to convert 100,000 partial-risk and FFS Medicare patients into risk-sharing value-based arrangements with an MLR below 85% for two consecutive quarters, Steward’s stock share in CareMax will increase.

Over Priced: A new white paper published by the USC Schaeffer Center featuring an analysis of Medicare claims showed that consumers are overpaying for generic drugs by as much as 20%. The authors say this is largely due to the way PBMs operate as middlemen between drug manufacturers and health plans and practices like spread pricing and copay clawbacks add up to billions in overpayment. A different recent study published by the same group found that Part D plans paid $2.6 billion more for 184 common generics compared to the cash prices paid by Costco members.

Homeward Bound: Rite Aid is following in the footsteps of CVS and Walgreens by moving into clinical care delivery through a new partnership with Homeward, a home health company that focuses on rural communities. Rite Aid pharmacists will direct eligible customers to Homeward’s clinical services, including wellness visits, screening, and diagnostics, and Homeward will bring their mobile clinician units to Rite Aid’s rural locations, allowing customers to see a provider and pick up their medication in the same trip.

Stopping The Pre-Approval: BCBS Kansas recently removed its prior authorization requirement for all partial hospitalization and intensive outpatient services. As the mental health crisis continues across the country, we may see more payers moving in this direction. Removing prior authorizations likely helps patients get into treatment more quickly while removing some of the administrative burdens for both payers and providers.

Addiction North: Northstar Recovery Center, an evidence-based treatment center for addiction, is partnering with Tufts Health Plan, now part of Point32North, to expand access to treatment for substance use disorder. Northstar’s continuum of care, including partial hospitalization, intensive outpatient, and behavioral health services will now be available to 1.1 million members covered by Tufts.

Buy & Bill Pressure: Beginning July 1, 2022, Cigna is launching a new medical specialty drug management solution, Cigna Pathwell Specialty. Similar to other specialty drug programs we’ve seen from payers over the last couple of years, the program aims to reduce overall specialty drug spend. It will include the Cigna Pathwell Specialty Network, a narrow network for specialty injected and infused drugs - in other words, requiring these drugs to go through a designated specialty pharmacy rather than allowing physicians to buy and bill. Additionally, not all providers will be included in the network, so some members may have to find different providers to administer these drugs. The program is first being launched only for select employer groups and will expand to fully insured plans upon regulatory approval.

Extra Point: 9 years ago, Connor Farquhar ran to first base on an unintentional bunt single–his first hit in little league in his first game, one that featured 47 walks, 111 passed balls in 3 innings spanning 123 minutes of yawns, and parents asking each other, “seriously, are there any outs yet”? This was one of those games where the ump, my dad, used such a liberal strike zone that you basically needed stilts to reach some of those high strikes. Bridget perched herself in center field and complained about the ump until she realized it was her own father-in-law, at which time she probably complained even more. “Oh come on Papa, that was right there.”  It took Connor maybe 14 seconds to make it to first for his moment, not exactly record time but for the 9-year-old and his parents, it was Jessie Owens fast as they willed him to the bag. They don’t measure time like a lot of us. They measure it in how much dirt Connor kicked up running to first and how many times his glasses bobbled off his nose. They measure it in how when he got there, he immediately found me on third base and saw the steal sign and then took off on the next pitch, fearless. Sure, the odds of the catcher throwing him out were 7 billion to 1, but Connor didn’t know that. Here’s the kid who’s been told for 9 years he doesn’t have the ability, that he has “limitations,” “challenges” – but I don’t really agree. Sure, he may need to swing the bat before the pitcher even winds up just to catch up to it and he may not run so fast, but his brain is running laps around a lot of kids, and he used whatever force he could muster to make his way around those bases. I think back to that game when we were down 11 runs after 3 innings and the relatively painful moments when the ball would trickle beneath the catcher’s glove and roll to the backstop with 2 kids on base. The catcher, weighed down by the gear, would fall over trying to get himself up, would adjust his knee pad and itch his behind and with the mask covering his eyes start poking around for the ball. I think of that, and I realize like a lot of us that for all those lost moments and passed balls there’s one kid who probably only thinks of last night’s game as a win. This week, Connor, now 18, gets ready to graduate high school. Once labeled as that kid on the spectrum and with epilepsy--and the kid who “shouldn’t really be on the team” --Connor was a 3-season student-athlete in high school this year, a runner, and is headed to Amherst in the fall. So much for limitations.

15: Even though Andy Warhol thought all people would be famous for this many minutes and Swifties know all too well about teenage angst in Taylor’s song about this age, it’s healthcare that has a claim to this number. In 2022, more providers report as much as 15% reimbursement increases to reflect inflation and pay for performance and several health systems are opening 15+ outpatient centers, like Michigan’s Henry Ford Health System, which hopes to open 15 urgent care centers this year with GoHealth to “patch holes in care across the region” and limit ED visits, which averaged more than 129 per day in 2021 across all Henry Ford hospitals.

Palliative Partner: SCAN Health Plan has acquired a palliative care, chronic disease management, care transition management and personal health assessment business for older adults. SCAN’s Medicare Advantage members will now have access to these services from Residentialist Group.

Social Risk: CareFirst BCBS is partnering with healthcare analytics company Socially Determined to offer insights into tracking social determinants of health and help the insurer support individuals with elevated health and socioeconomic risks. Our research study on social risk factors of health, first published spring 2021, featured an interview with Socially Determined co-founder and CEO, Dr. Trenor Williams. Read the report here.

Reversal Of Fortune: Virta Health of Arizona is offering a first-of-its-kind diabetes management program designed to help reverse type 2 diabetes without surgery. The Virta coach program offers tips to optimize food choices and uses daily support health coaches. After two years of the pilot program, 74% of patients are still participating, meaning that it is more sustainable than other diet and lifestyle programs. Clinical trial results also show an average daily insulin dosage reduced by 81%, and 67% of all prescriptions were eliminated.

Retail 2023: CVS Health announced the launch of their new virtual care solution, CVS Health Virtual Primary Care, which will allow consumers to choose their care when and where they want - in a retail setting, at-home health services, or virtually. This offering is being sold to Aetna, fully-insured, self-insured plan sponsors and CVS Caremark clients and will be eligible for Aetna members starting January 1, 2023.

Maternal Instincts: Health plans are increasing focus on maternal health outcomes through various initiatives, most recent of which is Anthem who is providing $14.5m in grants to community organizations. Four California based organizations will receive $1.9m each over the next three years for programs aimed at reducing preterm birth rate, maternal morbidity and mortality and primary cesarean rates.

Nudge This: Playwright Tom Stoddard said words are sacred, that if you get the right ones in the right order you can nudge the world a little bit and the BCBS plan in Massachusetts hopes to do this with a new “Nudge Unit,” an interesting name for a new resource using behavioral science to influence patients. Since its launch, the unit has identified a number of ways to improve member behavior, like when it took Stoddard’s cue and revised a letter to members that is sent with at-home colorectal cancer screening kits. The change produced a 3% increase in test uptake and 500 additional screenings collected. The unit also notifies clinicians if they are outliers in their rates of prescribing certain medications or ordering certain tests. BCBS MA is one of the first health plans to start this unit, but we expect other health plans to launch their own Nudge Unit in the future.

Which 5 Specialists Expect To Be Pushed Into Value? Earlier this week we released a brief highlighting the results of our survey of 278 physicians from 10 specialties. The results tell an interesting story about challenges facing physicians, their expectations, the interesting juxtaposition between compensation trends and reimbursement trends, and the future of physician pay. Find out which 5 of the highest paid specialties expect to be impacted by value-based contracting here.

C3PO For The Older Folks: The New York State Office For Aging (NYSOFA) is aligning with tech startup Intuition Robotics to provide a companion robot, ElliQ, to isolated seniors to provide medication reminders, wellness suggestions and friendly conversations. The program uses AI technology for this care companion for more than 800 older adults with a goal to increase independence, combat loneliness and increase social activity. Unlike other consumer personal assistants, ElliQ is designed to initiate conversations with its users and suggest activities such as physical exercises, trivia games, or sleep relaxation.

Extra Point: This taller man with a mustache wearing a yellow short-sleeve button down and a sea blue baseball cap left the line at the general store yesterday for why I did not know at the moment. The line stretched like a rotary phone cord around the store’s narrow aisles and for the four of us closest to the counter we were near the finish after 20 some minutes. The man - second in line - set down his fresh bread, dish soap, razor and what looked like calamine lotion. I remember because these seemed like an odd but perhaps perfectly normal set of things to get at a store like this. He rushed quickly to the creaky wooden door looking part Burt Reynolds, part Nathan Lane in the way he moved. He softly pulled the brown bag away from an older lady who was losing hold of the bag and beginning to fall, then held the door with his left hand and her hand with his right and made his way outside. Nothing really changed inside the store and when the man returned about 3 minutes later he calmly scooped up his bread and dish soap, his razor and lotion, stopped and stared for what seemed like a minute then made his way to the very back of that long line. “Sir, sir – is that all?” the lady Billie behind the counter said to me. I hadn’t realized I had moved up to the front, so I nodded in the way you do when your mind is somewhere else and then placed my items down and after a long pause said, “actually, um, Billie, can you add to the bill the 4 items for that man over there?” In a sort of abrupt way Billie called for the man to come up, waving him over the way Bob Barker used to on that ‘80s game show. He reluctantly did so and took out his wallet but Billie, God Bless her, said “This short guy with the Italian hat is taking care of your stuff.” On the way outside I introduced myself and asked him his name. “Fran, well Francis, but I go by Fran.”  “Nice to meet you – that lady you helped back there, was that your…mom, a friend?” “Oh no,” he chuckled, “definitely not my mom. She’d never have let me take the bag….I don’t know who that was.” Funny how sometimes humanity just shows up from time to time, just need to look up I suppose. Best $13 I’ve spent this week.

26: Unofficial length of a marathon because, hey, those last 2 tenths are like a blur (or so I’m told), the number of hours in a day in 2050, because moms rise up and say they don’t have enough time to be “everything to everyone” and—today—the percent of drug cost savings Prime Therapeutics achieved in one year on a PMPM basis through its MedDrive program. That program uses analytics to flag ways health plans can reduce drug spend, with a particular emphasis on using biosimilars over brand-name biologics. The program focused on only three drug categories in its first year, one of which was oncology, which led to the most savings.

Precision Med:  If not the next TV medical drama phenomenon, it ought to be. Mount Sinai and Rensselaer are creating a Center for Engineering and Precision Medicine to find treatments for uncured diseases. The new center opens next year at Hudson Research Center in Manhattan and will focus on cancer, Alzheimer’s disease, tissue degeneration and other conditions.

Cultural Care Pay:  We’ve heard from a few health plan “payment transformation” teams of late who say a sure way to differentiate for more pay is to have a real way to educate and engage an underserved culture. One Medicaid plan is considering constructing a ~$30 PMPM to a group focused on serving about 400 refugees and families who are frequently using the ER in a few markets, at a total annual cost nearly 4-5x what the pilot program will be. The group uses interpreters and people the patients can trust “to explain treatment plans”. The American Medical Association and two partners are also leading a pilot program to help health systems integrate equity into care delivery. The year-long program, called Advancing Equity Through Quality and Safety Peer Network, aims to improve health outcomes for marginalized patient populations by removing social and structural barriers to patient-centered care. Some early adopter organizations include CHOP, Dana Farber, and Ochsner. Other models are forming throughout the US with payment incentives to reward providers for the time and expertise required for offering culturally specific care. For example, CareOregon and the Alliance for Culturally Specific Behavioral Health Providers reward “culturally specific” providers up to a 20% rate.

Dr. Baker Medicine: The wave of on-the-go physician models ala Dr. Baker from Little House on the Prairie continue to make their mark. The latest, DocGo, has just entered a multi-year agreement with Empire BlueCross BlueShield in metro New York. Beginning June 1st, Empire’s Medicare and Medicaid members in New York and their Medicaid members in New Jersey will now have access to DocGo at-home services, including preventive care, urgent episodic care and chronic care management.

Generic Jump: Insurer HCSC is partnering with CivicaScript to provide their 17.5 million members in IL, MT, NM, OK and TX with access to lower-cost generic medications. CivicaScript partners with generic manufacturers and works with payers, PBMs and pharmacies that agree to pass along the cost savings to their customers. Other Blues plans have already partnered with CivicaScript and along with HCSC member plans account for 120 million customer lives.

Richer Benefits:  BCBS Massachusetts recently debuted new benefit designs to provide richer mental health benefits to customers and members. Employers can opt to select these 3 options for their employees (1) waiving an employee’s first set of visits (1, 3 or 6) for a mental health “diagnosis” or “SUD," (2) medication cost-sharing waivers for MH or SUD medication, and (3) wellness incentives for employees to participate in programs, classes and apps for relaxation and stress reduction. The new benefit designs are intended to strengthen and more strongly align incentives for all parties, including patients, employers, and clinicians. It will be interesting to follow the uptake of these models amidst the rising prevalence of direct-to-self-insured-employer telepsych models.

Coming Up: In a special report to be released May 31, learn which 5 specialties are among the highest-paid and most expected to be impacted by value-based contracting.

Extra Point:  If Denzel hasn’t given just about every youth sports coach the perfect pre-game huddle fodder with his “If we don’t come together…” speech in Remember The Titans, then I’m not sure who could. Sports fans remember that line and its power to influence, just like young girls and boys of the 80s were inspired by Fame’s Irene Cara who sang about how we hadn’t seen the best of her yet—that she just wanted us to "remember my name." I remember, heck I still sing that song to my kids. I also remember when ma used to remember my name and used to razz me for being a Yankee and Celtics fan because, well, that is a pretty ridiculous combination. I remember when I was 7 and how dad read the box score just before school and showed me how to figure out why the Yankees were 3 ½ down to the Sox and how I sorta paid attention because all I really wanted to do was read the puzzles on the back of the Honey Nut Cheerios box. After school, I remember when grape soda pop was good for you because it was delicious and came in a 6-ounce plastic cup for a quarter. I also remember when we used to use most of our senses to learn stuff – our eyes, ears and nose, heck even our intuition sometimes. I suppose we had no choice unlike most kids today who just use touch and, voila, they have the answer, the song and the directions. I remember when the journey mattered more than the destination and when we got our news from 3 sources –neighbors named Roger who could tell us precisely when the eye of the Hurricane was coming, the morning paper and the nightly news, and that was never more important than during the Vietnam War when Cronkite showed up on the bunny ear RCA every night to tell us “that’s the way it is,” shaping our opinion about what was happening in the war. By 1972, we were fortunate to have a new distraction from the crisis with the war comedy M.A.S.H. I remember how it gave my folks a few laughs amid a sad time and how Hawkeye used to say funny things like “give me life, liberty and the pursuit of happy hour,” and how I’d laugh but didn’t have a clue what happy hour was. I remember watching that show not really understanding the sacrifice Hawkeye and the 4077 unit were really making. I think Memorial Day is probably if nothing else about that – remembering the sacrifice of so many who have served in different ways and given us the freedom to have grape soda and box scores, fictional heroes and some real ones too. Hawkeye, a self-proclaimed “meatball” surgeon, had to make choices like when he had to forgo trying to reconstruct a patient’s damaged artery saying if “I save this leg, I lose that life.” Healthcare has had its own contingent of crises and pioneers and leaders who we ought to remember for the sacrifices they’ve made for some of the things we take for granted now. Once upon a time, there was no touch a button and your therapist could talk you through a crisis. Nurses would talk to you on the rotary phone at 11 pm to help you figure out how to get through the nausea from that round of chemo, but they wouldn’t be reimbursed for that call, nor the reminder calls to elderly patients the next day to take just the pink medication. There was a whole generation who served with a purpose but without the payment.  A cancer practice in Michigan had to “pilot” a program in ’05 where the state’s biggest insurer would pay them for follow-up phone calls. That debate has changed a lot. Now healthcare companies aren’t arguing so much to get paid for follow-up, in fact, many are incented to start doing it. They are able to do things with a combo of clinicians and one-touch technology and get paid for it. They are given time and tools to solve problems. Hawkeye had neither.  It’s a good trend and one that continues to evolve, but I think as it does we ought to remember the people who started it. They had to make decisions and sacrifice using every sense they could, without a reward or promise of fame, but in my book, they are Titans, and that’s the way it is.

63: Portion of 316 retired physicians polled who say too many doctors, PAs and nurse practitioners overtest. If you’re looking for a measure of quality, I say take Hamlet’s cue and look at your practice’s testing behavior—to test or not to test is increasingly an important question in healthcare. Most of the retired doctors say we ought to use our personal experience with patients more often—our clinical judgment—as a guide when making decisions about whether to order a clinical lab or imaging to figure out what’s wrong. Too many do not lean on that personal experience enough, and it matters a lot, particularly when you are in a payment model that is based on total cost, a majority in our straw poll acknowledged. Martin Frost, a retired internist, said “for patients who are high risk with something like diabetes that extra test may not always add new info – that’s what I always thought about – how is this patient similar to others I’ve treated, what can I draw on from that and will this test result really help.”

Surgery Reimbursement Hike: BCBS Texas recently increased reimbursement for nearly 1,500 surgery services if performed at an in-network ASC. The increase took effect April 1, 2022, and applies to procedures across a range of specialties, including orthopedic, gynecologic, and cardiovascular, for commercial members. The health plan notes that the initiative could mean up to 15-20% reimbursement increases for providers who perform these surgeries in an ASC instead of a hospital.

Recruiting Nurses: In an effort to combat the nursing shortage, some hospitals are creating their own in-house staffing agencies. Nurses are paid a premium rate to rotate within their systems, allowing hospitals to compete with external staffing groups that often pay more and allow nurses more flexibility. In December 2021, UPMC launched UPMC Travel Staffing with plans to recruit 800 nurses at a set rate of $85 per hour, with extra incentives for working nights and weekends. Of the workers recruited into the program so far, 35% have been staff nurses who moved to the travel side.

House Meet Health: Health insurers, recognizing the importance of social determinants of health, are increasingly focusing on access to stable and affordable housing as a key component of healthcare, particularly for youth. In one example, BCBS North Carolina partnered with SaySo, a youth advocacy organization, to help young people moving out of the foster care system obtain affordable housing. Foster children typically make up a small portion of any payer’s membership, but programs like these pay off. A study by the Center for Outcomes Research and Education in 2016 found that better access to affordable housing led to a 12% reduction in healthcare spending among Medicaid recipients, as well as 18% fewer ED visits.

Where Art Thou Sub Specialist: BCBS of Massachusetts is expanding its mental health provider network by adding providers who specialize in obsessive-compulsive disorder (OCD), serious mental illness, trauma and substance use disorders (SUD). They are also contracting with primary mental health groups, including Thriveworks, Headway, Refresh Mental Health and Valera Health, that have sorting and matching capabilities that help match patients to the right type of therapist or psychiatrist.

Pediatric Reward: BCBS Michigan recently launched a Pediatric Weight Management Initiative with the goal of decreasing pediatric obesity in the state. During the pandemic, the national rate of obesity among children ages 2-19 increased from 19.3% in 2019 to 22.4% in 2020. The initiative will reward pediatric practices who reached a specified performance threshold, or an improvement threshold based on the BMI of their overall attributed pediatric population. The incentive for practices meeting their goals in 2022 will be paid out in September 2023.

Payment Conversion: Empire BCBS, an Anthem plan, is converting to a new reimbursement system called the Commercial Outpatient Pricing Payment System (COPPS), which is heavily based on the CMS Outpatient Prospective Payment System. Empire will convert all outpatient facilities to the system throughout 2022 and 2023, followed by all other contracted providers.

Poll Of The Week: May is Mental Health Awareness Month, so in our poll of the week, we asked providers and payers about the top mental health needs in their communities. Respondents identified early detection and prevention programs as most needed, especially for adolescents and new moms. One respondent said, “Kids in school are stressed – they need early access to care, and new moms often suffer in silence from postpartum depression – it needs to be identified and detected early on.” Increased access to care was also identified as a top need. As one respondent noted, “None of us are immune to mental health challenges - that has never been more evident than now.”

Copay Assistance: Priority Health is launching a specialty drug savings program in July of this year. The program, through SaveOnSP, will be available for fully funded commercial group members. SaveOnSP will contact eligible members and enroll them in a manufacturer copay assistance program, which will then require members to fill their prescription at a preferred specialty pharmacy, Accredo or Meijer. All members participating in the program will pay $0 out of pocket for their entire plan year.

Extra Point: So only in my town would parents get in an uproar over high schoolers running through 4-way intersections like Frogger, hiding in bushes, and chasing each other through cul de sacs with water pistols in a seemingly innocent game they call Assassins. Seems harmless, but our town’s helicopter families have gotten so upset over the unfortunately named game that the Police Log had more than 100 calls in one week and a town forum was held this week to ‘get to the bottom of this terrible game.’ They have a point, right? I mean kids running after school in the neighborhood, often sprinting to chase down their target, working together in teams, getting wet. Outside. Not inside. This IS terrible…..One kid, Ben, was hiding in the backyard of my house for so many hours that his phone was ‘losing juice’ so he asked for a charge. ‘Um, Mr. Cote, I know I’m here to get your son, but could I come in and charge my phone?’ The Helicopter parents complained about ‘kids wasting time’ and ‘trying to hurt each other’. I see the opposite – kids who never would interact are playing together, competing. Kids of all shapes, colors, backgrounds, and economic and school status classes, are on an even playing field, brought together in a good ole fashion water fight. Many of them sit on the bench on their high school team, or spend 7 hours learning algebraic formulas they’ll never use….some are labeled by their schools or the medical community with letters like IEP or ASD, but out here in the neighborhood, there are no labels. They are just kids playing.  A little community camaraderie shouldn’t scare us. In fact, Assassins may be the healthiest thing I’ve seen in this town in years.

4,000: The amount Amazon will pay annually for its employees to travel for non-life-threatening medical treatments. The new benefit, effective to January 1 retroactively, applies if a procedure or treatment is not available within 100 miles of an employee’s home and virtual care is not an option. The benefit is open to all US employees, at any level, with coverage through Aetna or Premera.

Behaving Differently: More and more insurers are now designating so-called centers of excellence for behavioral health, the latest from BCBS Michigan, which now has 14 substance use treatment and recovery distinction programs, up from 3 over the past year. Facilities with residential, inpatient, intensive outpatient or partial hospitalization services are considered for this designation. In total, the program has 367 designated providers across 42 states.

Famous Walts: There are many of them – there’s Frazier for the Knicks, the affable if not half-drunk Coach Buttermaker played by Walter Matthau, that famous Disney guy, and for those who knew him closely, Cronkite, who famously changed the nation’s views on the Vietnam War. There’s also the famous Walts we dance to, and I suppose you could argue they all have one thing in common – they make us feel better. Now a new company has formed with the same name to combat prescription drug cost increases. Waltz Health, founded by the former OptumRx CEO, will primarily be a search engine of drug-discount data sources that pharmacies can make available to customers. The company won’t disclose who its clients are but says it plans to announce “major pharmacy chain” clients later this year. 

Cancer Partnerships: MD Anderson is partnering with Community Health Network to launch a clinical and research cancer program in central Indiana. The new program, called Community Health Network MD Anderson Cancer Center, will give Community physicians access to MD Anderson experts for peer-to-peer consultations. The community’s seven cancer centers will follow the same standard of care as MD Anderson and will provide medical oncology, radiation oncology, surgery, pathology, and imaging. Similarly, Cigna launched a new digital consult service through Evernorth that connects patients and their local oncologists with specialists at National Cancer Institute centers. Those oncologists can review treatment plans and diagnoses and recommend testing, therapies, or clinical trial options.

PT-OT-ST Hurdle: BCBS Michigan will begin using SecureCare to manage PT/OT/ST and chiropractic services for commercial and some MA members, effective July 5. All relevant therapists, chiropractors, and athletic trainers must register with SecureCare, which will manage services through a retrospective clinical review program. 

Less Risk, More At Home Medicare: Humana will launch its value-based home health model in North Carolina and Virginia in June of this year with plans to expand to additional markets in 2023. Humana’s home-based care capabilities were accelerated last year with the acquisitions of onehome and Kindred at Home. Humana expects to have 15% of its Medicare Advantage members in these value-based models by the end of 2022, and 50% within five years.  In related developments, United Physicians, an independent physician organization with more than 1900 providers, is partnering with Agilon Health to provide a full risk value-based primary care model for MA members in southeast Michigan. Agilon already works with 17 other physician groups across the country in similar arrangements and plans to add five additional partners in 2023. BCBS Rhode Island also recently entered into a global capitation agreement for its Medicare Advantage members. The payer inked the agreement with Prospect Health Services, an ACO, and under the contract, positive patient outcomes will be linked to total compensation.

Treadmill Diagnostics: The Mayo Clinic developed an AI algorithm that can identify a left ventricular dysfunction, or a weak heart pump, based on patients’ Apple Watch data. The study, which was presented at the Heart Rhythm Society Conference last Sunday, showed that the AI analysis of the Apple Watch’s ECG data presented results as good as or slightly better than a medical treadmill test. Researchers at the Mayo Clinic are also developing an algorithm capable of detecting a weak heart pump from ECG data recorded on Apple Watches.

Virtually OBGYN: Blue Shield of California recently made Maven’s virtual women’s and family care platform available to more than half its members. Blue Shield reported once members were notified, more than 500 members enrolled in one day. Through Maven, members can make virtual appointments with doulas, lactation consultants, childbirth educators, physical therapists, OBGYNs, and mental health providers. The partnership is part of the plan’s Health Reimagined strategy that focuses on maternal health.

Extra Point: In case you missed it on the weather channel, my college kid landed home this week sweeping through the house like a category 4 hurricane.  I found an empty milk carton in the pantry this morning, a pair of dirty socks in the fridge and the trash bag I asked Jack to take out sadly sitting outside, near the barrel, half-eaten by Fred the Squirrel.  “What’s with the trash Jack – couldn’t put it in the barrel, really!?!” “Wait, what?” he said groggily. “You wanted me to put it in the barrel?” …  Back in the day we used to follow through, didn’t we? We didn’t rely on others, because perhaps we didn’t have a choice. We balanced our books and PB&J on the handlebars of our Huffy all 2 miles to school.  We didn’t have backpacks or carpools or ubers and if our bike tire hit a pothole and flattened, we’d get off and hoof it to make the second bell. Healthcare was like that too once upon a time. Doctor Bloom used to do it all. I remember how he’d flag pop’s rising cholesterol and expanding waistline - how he’d remove that nasty foot thingy and treat that belly pain with a good ole’ coca-cola. He’d make the spaghetti in the church hall after Saturday afternoon mass and hit flies to little leaguers on Sunday. Doc Bloom was part of the community, diagnosing us in the general store and following up on that itchy scalp outside the bank. He’d bring you the Sunday paper and check on that constipation. He knew too much and there was very little he couldn’t do for his patients and, well, in the rare chance he couldn’t figure it out, he’d send you to the emergency room. There was no middleman. There was no outpatient specialist or intensive therapy center, and no community cardiologist. As a teenager, Bloom was a starting pitcher on his city team near Springfield Mass – he’d begin the game, throw 150 pitches, and after 9 innings, win or lose, he’d hit the showers, and in the rare chance his 90 MPH fastball became a 70 MPH meatball in the 9^th inning the coach would call to the dugout for an emergency reliever to stitch together the last couple outs. Like in healthcare, things are different now in baseball. You don’t pitch 9, there are set-up pitchers, lefty specialists and guys whose sole job is to throw 3 pitches to close it out. Starters have to know a lot about batters, their tendencies, their injuries and whether they’ll swing at a high fastball, but they are less and less responsible for actually finishing the game. Community doctors aren’t much different nowadays. Sure, they have to know a lot about us—our eating and exercise habits, our mental health and family history, our aches and pains, worries, warts and all—but they only have so much time with us and more and more often call in a relief specialist or refer us to a program. The art of the follow-through, the community doc, continues to fade away, right? Maybe not….maybe the latest wave of primary care at home models are bringing us back to a time when our healthcare was more personal. When our doctors knew us, and we knew them…

118-634%: The range of median price markups for oncology drugs purchased and administered by certain hospitals, according to a new study published in JAMA Internal Medicine. The study analyzed the prices of 25 top-selling cancer therapies at 61 National Cancer Institute-designated cancer centers and looked at how those negotiated prices for commercial payers compared to acquisition costs. Prices varied between cancer centers and between payers within the same center but for every drug included in the study, the median hospital negotiated price was at least twice the acquisition cost.

Robots of Dawn: Robots are coming to nursing homes and no, this isn’t the beginning of a science fiction novel. Several programs, including one at the University of Minnesota Duluth, are part of a newly energized effort to use technology, including robots, to help nursing homes address staffing issues and isolation for their residents. The program in Minnesota plans to place 16 robots in eight nursing homes around the state later this year. The robots can socialize with residents, lead fitness classes, tell jokes, play games, and lead something called reminiscence therapy, which helps residents relive specific memories. They are not designed to replace staff, but rather to help fill some of the gaps nursing homes are currently experiencing.

Pregnant Pause: Brave Health, a virtual behavioral health company, launched a maternal mental healthcare program to help the rising number of mothers experiencing postpartum depressive symptoms. A recent study by the University of Michigan found that one in three new mothers screened positive for postpartum depression during the early pandemic—nearly triple pre-pandemic levels. The program is in partnership with the Doula Network, a service that pairs pregnant Medicaid patients with doulas.  Depression during pregnancy can lead to a higher risk of pre-term labor and some Medicaid MCOs have agreed to pay for and encourage this screening, or find ways to “bake it into the global 1-year rate.”

Bidding For Authorizations: Highmark has expanded a value-based specialty pharmacy program they launched in August 2021 with Free Market Health, a healthcare technology company. Effective April 18th, drugs for chronic inflammatory disease, hepatitis C, and MS have been included, along with some oral oncology drugs. Free Market’s program works by utilizing a marketplace where contracted specialty pharmacies can bid on authorizations instead of payers utilizing an exclusive pharmacy for all members. This can allow for dynamic pricing and the opportunity for specialty pharmacies to earn additional value-based reimbursement on eligible drugs.

Out Of Character: In a change for Kaiser, the integrated delivery network has signed a five-year agreement to give its commercial members access to in-network Cigna providers outside the eight states Kaiser covers. This will be Kaiser’s first partnership that allows members to use non-Kaiser providers without paying out of network rates. As part of the agreement, Cigna’s Accredo will become Kaiser’s preferred external pharmacy for some drugs.

Joint Approach: BCBS Michigan is piloting a joint and spine program with TurningPoint for their commercially insured members. BCBS will identify members who are candidates for the program and TurningPoint will then reach out to them to head off surgery by helping members understand the next best step in their musculoskeletal care and where to go for that treatment. The program will run through December 2022, at which point BCBS will evaluate whether to continue with the service.

Help Wanted At The Next Site Of Care: Judge Reinhold’s character Brad Hamilton may be able to get his job back at the iconic All American Burger joint depicted in the 1980s flick Fast Times At Ridgemont High now that 32 malls across the country house healthcare services, and need staff. He may not be flipping burgers but may be able to take orders for lab tests and throat cultures.  A Georgia Tech professor has maintained a list of the mall-to-healthcare conversions including those revamped by Inova in Virginia and Vanderbilt in Tennessee.

Speaking Of Malls: A Florida auto mall owner, tired of his commercial insurance options, created his own health plan for his employees. Concerned about rising premiums and lack of benefits, the Florida man worked with an employee benefits advisor to create a new plan that offers his employees an on-site physician every two weeks and a nurse navigator service that helps direct to appropriate specialists. The new plan has led to savings of 20-60%, depending on the service.

Spending Spree: UnitedHealthcare and Optum picked up two more independent primary care groups recently, the latest a pair of Oregon practices with about 120 providers at 11 facilities.

Extra Point: A family guidance center in Southern California worked out a deal with one of the Medicaid managed care organizations here a couple of years ago where it got $1.20 every month for every kid it helped to avoid an adverse event and another 75 cents every month for every kid it screened for diabetes. You see, there was a problem in this community with troubled youth, broken homes run by parents struggling to break poverty’s cycle, some dealing with addiction, some working two jobs leaving kids to raise themselves, eating unhealthy, sugary foods. The center took this money, around $2,300 over the year, and it put in one of those river rock climbing walls. They hired one of the kid’s dads, Pa Dah, to build it, paying him $750 out of the $2,300. Pa Dah made minimum wage at a factory in town but “I used to build homes out of bamboo in Thailand” he said before he moved his family to California to flee from violence in Myanmar. That rock wall is now a source of hope for the kids and the community, and points to just how far even a dollar can go sometimes, if used for good.

86: No, not the painful year for Red Sox fans when that ball scooted through Billy Buckner’s legs, but the portion of Aetna Medicare Advantage members in Florida who reported less loneliness, thanks to Aetna’s partnership with Papa, a platform connecting members with people for companionship, transportation and assistance with everyday tasks. The partnership began in 2020 after observing that 80% of eligible members felt lonely or depressed. By 2021, 62% of Aetna PPO members and 52% of Aetna DSNIP members reported feeling less lonely and happier overall after using the companionship services. In light of the positive results, Aetna has since expanded its Papa partnership to seven more states—Nevada, California, Illinois, Michigan, North Carolina, Pennsylvania, and Indiana.

21^st Century Oncology Management: Transcarent, one of the many digital health platforms in the market, is looking to differentiate itself by launching an oncology care management service. The service will focus on the five most common cancers and will include provider search and treatment planning, access to lower-cost medications, social and emotional guidance, and virtual visits from doctors. Self-insured employers, who pay Transcarent through a PMPM subscription fee, a fee-for-service model or a full-risk approach, will soon have this option for their employees.

Rocky Mountain Medicaid: DarioHealth, a digital therapeutics company, announced an agreement with Colorado Access, the largest public sector health plan in the state, in an effort to provide digital chronic condition management solutions for its Medicaid population beginning Q2 this year. Colorado Access selected DarioHealth to help members with diabetes, hypertension, weight management issues and behavioral health needs. This happens through Dario’s chronic condition platform that uses tools, medical devices and digital and human coaches to create a personalized treatment journey.

Pregnancy Connection: Banner Health launched a new pilot program to help connect pregnant people and their family physicians in rural areas with obstetric specialists at other health centers. The program began at Sterling Regional MedCenter, which will now have access to specialists at North Colorado Medical Center. The program hopes to allow patients to deliver at their local hospitals while reducing the need for medical interventions at birth.

Script Precision: BCBS Michigan is piloting a new precision medicine program that aims to personalize and tailor medications more effectively for some members with diagnoses including heart problems, cancer and mental health. The program will use pharmacogenetics to optimize treatment for members based on their genetics, lifestyles, and environmental factors. The pilot will run through the end of 2022, with a comprehensive program launch scheduled for January 2023 for eligible Blue Care Network members with pharmacy benefits. The program will be provided at no additional cost to members or employer group customers.

Autism Partnership Targets Outcomes: Cigna's health services division, Evernorth, and Behavioral Health Center of Excellence (BHCOE) are collaborating to develop ABA treatment standards that will focus on quality and efficacy metrics. The partnership will allow organizations to participate in a value-based care arrangement that will reward behavioral health outcomes and care quality. Behavioral health clients at Evernorth and Cigna health plan customers will be some of the first to experience the joint standard performance metrics.

Retail West: Blue Shield of California and Walgreens Health are opening 12 new Walgreens Health Corner locations in the San Francisco Bay Area and Los Angeles County. Patients will have access to health advisors that can answer general health and prescription drug questions and will be able to receive some health screenings, such as blood pressure checks and A1c tests, and schedule appointments for other screenings. These locations can also assist patients with digital health apps and medical devices.

Reimbursement Boost? The House Energy and Commerce Subcommittee on Health held a hearing on federal mental health legislation, including the Strengthen Kids’ Mental Health Now Act (H.R. 7236). The legislation would increase reimbursement for certain Medicaid pediatric behavioral health services and create grant programs to support pediatric behavioral healthcare. “We faced a pediatric mental health crisis before COVID, which has only been exacerbated by this pandemic,” noted witness Steven Adelsheim, MD, a psychiatrist and clinical professor who directs the Stanford Center for Youth Mental Health and Wellbeing.

Extra Point: Annie Shipp fell off the beam in a gymnastics competition when she was 11, twisted her ankle and didn’t get back on until last year. Shipp, now a mom of two in her 40s, helps run a medical practice in the Midwest and put one of those low-to-the-ground wide-footing balance beams inside the office. It meanders through the hall a bit like a centipede, navigating down the center of a long, wide hallway separating several exam rooms. “It was supposed to be a bit more symbolic, but now most patients and the staff take turns on it. Not the seniors,” she laughs, “but most of the adults and always the kiddos.” Annie always asks her patients “what don’t you have that you need” and more often than not, in no uncertain terms, they say “balance.” I suppose we all need that as we meander through life. “Maybe what balance looks like changes but it’s still essential to health,” she says. As we finished our interview I was struck as Adeline, an older lady from this small Indiana town, stepped on the roughly 12-inch-high beam and with the help of her son put one foot in front of the other, wobbling a few times, but finding her way. “If you raise kids you know about balance – it’s really all you hope for your kids,” Annie says. I know that is true for my own daughter whose balance comes from singing as she does here though admittedly I think hearing her sing is probably my balance too.

518: The number of “available” pediatric psychiatric residential beds in South Carolina, though state agency leaders say that about half of those are actually occupied by children from outside the state. This means South Carolina children with immediate psychiatric needs are waiting days and even weeks for care, and many end up traveling to other facilities across the state line. This strange phenomenon largely occurs due to different Medicaid rates between states. Kaiser Health News recently reported that about 90 children covered by Medicaid in Montana are at psychiatric facilities across 10 different states. Unfortunately, many psychologists suggest children who receive care closer to home have better outcomes, largely because they can stay in better contact with family and caregivers.

Worried Sick: A recent Kaiser Family Foundation poll found that surprise medical bills are the second-highest financial worry for American families, right behind gas prices, with 58% of respondents worrying about their ability to afford surprise bills. Despite recent legislation passed to curb surprise billing, 56% of respondents with private insurance said they were unaware of a federal law that went into effect in January that bans patients from being charged when they receive out-of-network care.

Novel Staffing Solutions: Denver South High School and Denver Health have teamed up and launched a pilot program to train students as paramedics. The program aims to pique interest in careers in emergency medicine, which has become more critical as Colorado’s hospitals struggle to keep up with the worsening staffing shortage. The class curriculum comes from Denver Health, which also trains the high school teachers instructing students. To combat the staffing shortage in Michigan, newly formed health system BHSH is partnering with Grand Valley State University to create a nursing program that will provide financial assistance to nearly 500 nursing students over the next 6 years.

Couch P(o)T(ato): In an effort to reduce costs and unnecessary invasive treatments, United is launching a virtual physical therapy program to improve support for members with musculoskeletal issues. Eligible members will have access to 24/7 on-demand physical therapy exercises, individualized feedback and access to one-on-one health coaching through the AI-powered app, Kaia Health. Exercises will be analyzed over time through algorithms and self-reported outcomes, such as perceived pain levels and mobility, to help identify patients in need of more coaching.

The Kids Aren’t Alright: Our team covered the National Council for Behavioral Health in DC this week, where thousands of healthcare professionals and companies gathered to discuss the future of behavioral health. Adolescent mental health was a significant focus throughout the event, sessions highlighted innovations in school-based mental health, building a foundation of infant and early childhood mental health services, interventions for LGBTQ+ youth and more. More stories on this, emerging treatment trends, and innovative companies to come.

Extra Point: The young man with the button-down shirt and brown shoes missed his bus today for that job in Rome. The young man was to be a builder but on the way through the village square in Cicerele he saw an older man with a white shirt and a gray cap fall to the ground near a water fountain. The young man helped the older man over to a bench and brought him water and then carried the older man up a hill outside the village to the doctor’s home. That older man was my great Uncle Cosimo and the young man who saved him that day and gave up his bus for a chance at a new job and a better life, was George. On a weekend when most of us are supposed to think a lot about sacrifice – about caregivers and teachers and parents, nurses and neighbors - I think about George’s selfless act. George went on to help care for Cosimo for many years and he remained in the Cicerele village building tables and benches and fixing broken windows for the town’s 300 some people.  Monte Cicerele was a simple town about two hours south of Napoli where my grandfather Giovanni and his brother Cosimo grew up. Neither knew George until that day in 1938.  I remember listening to Uncle Cosimo and my grandfather tell stories under our gazebo when I was just 5.  They had both come to America in the late 50s with families and dreams of opening the bakery with anisette cookies and cannoli, and they would tell tales about life in Cicerele—Cosimo in his fiery, gristled Italian and my grandfather trying to translate for me.  I don’t remember most of their stories, but I can picture them under that gazebo, and I can remember the story about George. The young man who gave up his dream to eventually help two brothers have theirs.