Behavioral Health Insights

57: Percent of 17-23-year-olds in our poll last month who are going to use urgent care as their primary care provider after college, down from 70 percent a year ago. The reason? Covid – for a meaningful portion of the 523 polled, senior relatives, parents and friends got sick, passed away, or did not get diagnosed quick enough with a serious or terminal condition like cancer. “I used to think urgent care could handle all of it but I think it’s probably more for the convenience,” Abby Knowles, 20 says. “I think having a regular doctor will be a good idea, particularly after what I’ve seen my family go through.”

Approval: In something few would have guessed a decade ago, Regence BCBS is now starting to use artificial intelligence (AI) to determine if preauthorization requests should be approved, without the need for an actual medical director or nurse case manager review. The plan has started with just a few procedures, including transcranial magnetic stimulation and some genetic tests, and expects to expand to additional procedures eventually. This feels sort of like telling your 20-year old that when they want $50 to “get them through the weekend” you send them through a computer program and tell them, well, it’s frankly out of our hands. This insurance system apparently allows preauthorizations to be approved at a much quicker rate for providers and patients, but it also creates some questions on whether the AI system can handle the nuance of some requests, particularly for “therapy”. For those worried about denials, AI will never actually deny a request, for now, Regence says. If medical criteria aren’t clearly met, it will be passed on for clinician review.

Wellness Outcomes: As reported in our 2022 Payer Index, health plans are increasingly prioritizing wellness, and Highmark has seen tangible positive results from members having access to wellness coaches. They found that members participating in the weight management program with a wellness coach saw an average weight loss of 4.5% and 42% of members who participated in the Tobacco Cessation Program were able to quit and stay tobacco-free for 30 or more days.

School Rules: Sen. Anthony Portantino has authored a bill that would require all California middle and high schools to train at least 75% of employees in behavioral health. “I don’t want to read about another teenager where there were warning signs and we looked the other way,” Portantino said. “Teachers and school staff are on the front lines of a crisis and need to be trained to spot students who are suffering.” The training program is operated by the National Council for Mental Wellbeing and is available in every state. Other states like New York require mental health education. Our team will be covering the National Council On Behavioral Health annual meeting April 11-12 in DC where this issue will be discussed – stories from the event in future weeks.

Check-Up: In Tennessee, children that are part of BCBS’s TennCare program for Medicaid beneficiaries are allowed additional check-ups beyond state guidelines.  For example, when a child visits the doctor’s office with a sore throat but is due for a checkup in one month, the practice can perform and bill for an early and periodic screening, diagnostic and treatment exam during the check-up, even though it’s only been 11 months since the last checkup. Doing so increases the likelihood that the child will stay up to date on well-child care because they don’t have to visit the office for another appointment.

Classified: Healthcare companies added an estimated 8,300 jobs in March, down from 66,400 in February, according to preliminary data the Bureau of Labor Statistics released last Friday. Providers continue to experience staffing challenges, but lawmakers, health systems and educators are trying to create real-time solutions. Read our report on nurse staffing here.

Extra Point: I have to admit I barely paid attention during my 14-year-old’s doctor’s appointment this week. That’s sort of what happens when you have teenagers and yet you still find yourself awkwardly in the exam room sitting on that sheet of Winnie the Pooh paper reading a frayed copy of Curious George Goes To The Hospital that candidly makes the hospital seem like the best place on earth. “Any questions Bry – are you clear on the plan?” Dr. Leo asked me. “100 percent,” I said.  But alas I was not clear. On the way home, Tommy turned to me at a traffic light at about 9:15 am en route back to school. “Dad, don’t we need to stop at the pharmacy?”  “Um, I suppose – but what would you say Tommy that we need to actually get there?”  At my dad’s appointment a day later I was far more focused, particularly when dad said he had 3 square meals a day. “Really pops – don’t you think that’s more like 3 a week?” I found it fascinating that the doctor paused, gave one of those “uh huh uh huhs” and then wrote on her iPad. I felt like I was transformed into that Seinfeld episode when Elaine’s doctor fake erased her medical record. Going to doctor appointments with your older parents is inherently awkward. First, “dad you don’t need to show the office manager your new mole.” Second, there are the uncomfortable old mannerisms like when dad takes 20 minutes to leave the lab sample because the toilet overflows. “Are you alright in there pops?” Then in the exam room, my parents tend to lie or act as though everything is perfect, then you challenge in a kind of patronizing way, the doctor plays arbiter and 30 minutes after the appointment your mom doesn’t remember any of it – when to take her medication, what she needs to record in her journal, heck why she was even there. I had my own appointment yesterday. My wife set it up. “Just scheduled a consult for you with Dr. B – for your shoulder pain you keep ignoring.” Thanks, honey, “but I won’t be going, shoulder is fine. I’m good.”  24 hours later I was at the appointment because, well, when you’re married, with kids, and you procrastinate, you go to the appointment. “So Dad,” said Tommy, “what did the doctor say about your shoulder, or were you not paying attention?"

43: Portion of 325 18-23-year-olds we polled who are interested in pursuing a career in sports psychology. “If I can’t compete after college I might as well help others with it – it’s 90% psychological,” said Nikki Phillips, a former swimming medalist. Much like most healthcare businesses, schools and families who are putting more stock into “psychology”, the sports world is seeing the benefit too. Full story here.

Remote Control: Cigna’s telehealth operation MDLive is launching its own remote patient monitoring program for patients with chronic conditions. The program, available to all health plan clients of MDLive, will allow patients to track biometrics like blood pressure and glucose levels, which they can then review in telehealth appointments. The program doesn’t yet include monitoring devices that connect directly with MDLive’s patient portal, but the company said they expect to roll out that feature later in the year.

Fools Gold? Prior authorizations are no longer required for all healthcare services….sorry, April Fools….but wouldn’t that be nice? There is some hope of this, particularly for providers in value-based arrangements, given that a new bill may help provide more transparency into prior authorization decisions and favor providers who often complain that decisions seem arbitrary. Details and implications in a future edition.

Born Free: As insurers continue to refine what was arguably the first true “episode of care,” health systems are making other improvements, like Mount Sinai, which will launch a multidisciplinary clinic this month focused on reducing stillbirths and supporting women and families who have experienced pregnancy loss. At the Rainbow Clinic, based on a UK model, physicians will tailor care to each patient and try to determine the cause of patients' previous stillbirth, along with a strategy for conception and pregnancy moving forward. Clinical staff will undergo specialized training to understand their patients' emotional needs surrounding the pregnancy.

Controlling Full Spectrum: UnitedHealthcare, through Optum Health, has bought the national outpatient behavioral health company Refresh Mental Health, according to new reports, in a move that signals two things - continued efforts by payers to try and buy mental health operations to “meet network adequacy” regulations but also to control more of where people get treatment. Optum also acquired LHC Group, a provider of in-home and hospice care.

House Calls: Florida Blue is collaborating with Emcara Health to offer Medicare Advantage members access to home-based primary care in 17 counties including Jacksonville, Orlando, Miami, Southeast Florida, Tampa Bay and Pensacola. The program focuses on house calls and will offer exams, tests, vaccinations and even imaging in the home.

Ohio Health: Columbus City Schools announced a partnership with Nationwide Children’s Hospital and PrimaryOne Health to build two new school-based health centers. The centers will be located in high schools and funded both through grants and by the two healthcare systems. Services will include dental, behavioral, vision, hearing and substance use disorder treatment. The services will be for students and staff plus families and community members.

Extra Point: Next to a spin class center in Michigan oddly sits a historic donut shop where locals like Manny Ruiz and Peter Collangello go for coffee and a cruller after church or high school football games. It’s community and it matters, but the juxtaposition of the two businesses is a fascinating study in human behavior. “Used to be the donut shop had a line out the door on a Sunday at noon – now that bicycle exercise place has the line,” Ruiz, 61, says.  “More donuts for me,” quips Collangello, 58. The trend is probably good, but the story isn’t over. Obesity runs rampant, particularly in inner cities and rural areas where access to spin centers is limited but greasy donuts clutter the corners. The insurance companies and employers here in the state are trying to promote services and change behavior, but it takes time. BCBS of Michigan recently updated its policy to allow overweight and obesity diagnoses to be payable diagnosis codes, which should allow physicians and allied health providers to better diagnose and treat obesity in their patient population. Ruiz, who admits he is just a couple bites shy of 300 lbs, says he doesn’t have a diagnosis but knows he should probably ride one of these bikes. “Start slow,” his friend Peter says, “Eat that cruller on the bike.”

135M: The amount the Dr. Lorna Breen Health Care Protection Act, which was signed into law last week, will provide to support the mental health of healthcare workers. The bill was named in honor of Dr. Lorna Breen, the ER Director at NY-Presbyterian Hospital who died by suicide in April 2020. She was one of many frontline healthcare workers who struggled with their mental health during the COVID pandemic. “Physicians are at a significantly increased risk of suicide compared to the general population, with suicide rates 40% higher in males and 130% higher in females,” Dr. Madara, CEO of the American Medical Association, said.

Philly’s Social Health Experiment: Independence Blue Cross, AmeriHealth Caritas, Penn Medicine and other payers and health systems are partnering to launch a multiyear initiative aimed at combating health disparities throughout Philadelphia County, which consistently ranks last out of the state’s 67 counties in quality of life, health factors, clinical care, and social and economic factors. The initiative, dubbed Accelerate Health Equity, will form pilot programs and measure progress through a publicly available digital data dashboard.

The Color Purple Twist: Turquoise Health, an online tool that now allows patients to compare prices for many hospital services, launched in beta development stage this month. The platform uses cost data from machine-readable files that hospitals were supposed to have made public due to the federal price transparency rule that went into effect in January 2021. Many hospitals have not yet so Turquoise Health also issues a scorecard for hospitals based on their compliance with the rule.

Sharing Savings: “We set up a shared savings arrangement with a PT practice that handles all our total hip, knee replacements and many of the ankle and shoulder procedures too – they get 20% of the savings on total joint replacements and 15% on arthroscopies and other procedures. We realized that the quality of PTs was wide ranging so we picked one that got patients to goal faster and did extra things like screening and response to potential addiction. Our payment was north of $350K for a 6-month period vs. the initial cost target, so the PT practice got a share of that” – Allen Kent, a practice manager in Northeast

Three’s No Crowd For Kidney Care: Three companies - Fresenius Health Partners, Cricket Health (the tech company offering a kidney care patient engagement and data), plus kidney care physician organization InterWell Health - are forming an independent entity that will use digital tools and value-based care to serve patients with chronic kidney disease. The organization will take on the InterWell Health name and aims to reach 270,000 kidney disease patients by 2025.

Benefits Brokerage Tool: Nava, a benefits brokerage, launched a free, publicly available benefits search engine last week. The company's benefits search engine allows employers to search for digital-friendly benefits across 28 categories including telehealth, mental health and addiction. The platform verifies all vendors, more than 600, and lists their information and reviews. Through the platform, Nava hopes new, digital-first vendors will have a way of getting out to market, and employers will be able to better select or at least narrow down their options.

Extra Point: My 14-year-old picked up dozens of tennis balls during tryouts this week by stacking them in a pyramid on his racket the way we taught him when he was a toddler. The balls used to just roll off from the weight of the racket and balls in his little ~4 year old hands, but they didn’t this week as our freshman showed some value to the coach beyond just being able to hit a ball over the net. Like Tommy, I was struck this week by the growing emphasis on paying some of the youngest healthcare providers for their value, including the litany of new in-home, behavioral health, or virtual models. Insurers like Regence BCBS in the northwest says about ~45-50% of their member’s claims flow through some 130 value-based arrangements, a source said, and increasingly these arrangements aren’t just the domain of the veteran practices. Rob Selden, who works on value based contracts for a local plan in Indiana, told me last week that “these arrangements often pay $5, $10 or $20 per patient per month just to handhold the riskier patients or do preventive work, but they aren’t just for primary care doctors. You can get my attention in a lot of other ways, like checking if patients understand their treatment plan for asthma, managing where they go for therapy or picking up where the hospital or doctor leaves off.” That’s sort of a good guide for healthcare providers looking to explore these arrangements – it will serve you well, and it’s serving kids like Tommy well in getting the right kind of attention from the coach.

38%: Reduction in pediatric hospitalizations due to Cincinnati Children’s Hospital and the Legal Aid Society of Greater Cincinnati partnering to connect children to social services, including three primary clinics in schools. The partners manage about 900 referrals a year, connecting families with resources for housing insecurity, poverty-related issues, and educational concerns. Fundraising and grants are the primary sources to fund the program but reimbursement through insurance could help long term.

Self-Insured Coupe? BCBS Minnesota began offering a new product, Coupe Health, to self-insured employers at the beginning of the year. Coupe Health, which is administered by Alabama’s BCBS plan, leverages the Aware network, and then tiers providers based upon four attributes: quality, relationships, experience, and cost. Members search for providers through a phone or web-based app that reviews each provider’s quality rating, location, and co-pay option. The member receives one simplified bill at the end of the month from Coupe Health and providers will not be responsible for collecting member out-of-pocket costs. Providers will be reimbursed 100% of the allowed amount by the plan.

Be Generic: Civica Rx, a nonprofit generic drug company created by a group of hospitals, plans to lower the cost of insulin by producing its own version. Civica plans to manufacture and distribute three different kinds of insulin that will be capped at $30 a vial and $55 for a box of five prefilled pens. The products will be biosimilars of the versions currently available and Civica hopes to have them ready for sale by early 2024.

Prenatal Diagnostics: Aetna now has preferred labs for noninvasive prenatal testing, a method of determining the risk that a fetus will be born with certain genetic abnormalities. No big surprise, those preferred labs are LabCorp and Quest.  Some insurers pay for testing as part of a global bundle that is increasingly 1-year to factor in post-partum depression. Other insurers, typically Medicaid MCOs, are very interested in trying to limit pre-term complications and one way to do that is to do depression screens during the pregnancy period. Elevated depression increases the risk of pre-term complications.

Jersey Blues: Horizon BCBS members can now get their medications delivered to their home by Amazon Pharmacy. Horizon members (excluding those enrolled in MA or Part D plans) also get a drug discount card called MedsYourWay built into the Amazon Pharmacy experience. All covered and eligible purchases count toward the member's deductible or out-of-pocket costs whether they use their insurance or MedsYourWay. Four other Blues plans are also adding this benefit.

Home Sweet Home: PIH Health, a Los Angeles-based health system, is launching a new in-home care business line with 24/7 home care in collaboration with home care provider company 24 Hour Home Care. The offering will include housekeeping, personal care, meal prep, transportation, and medication reminders.

Site Of Service: Insurers like Empire BCBS continue to add procedures to a list that can only be done in hospitals with a medical necessity review. A 33-page list of procedures, including gastroenterology, orthopedics, ophthalmology, auditory and nervous system procedures are included, and ASCs are the beneficiaries. These shifts come at a time hospital-insurer disputes continue. Blue Cross Blue Shield of Texas failed to reach a contract agreement with Memorial Hermann Health System after many months of negotiations, leaving Memorial Hermann hospitals, surgery centers and some health professionals out of network with certain BCBS plans effective this month. 

What’s In A Name? 18-25 year olds think urgent care is too slow and centers that call themselves “fast” or “go” sound more like Dr. Seuss healthcare than actual science. Their views, drawn from our poll of 2,100 nationally, are largely consistent with two themes with this age bracket – they have grown up expecting immediacy in all things and have their own views on what health means, and it doesn’t mean waiting at a so-called Fast Care for a test they may not need. Or as my 18-year-old who helps conduct these polls says, “This is stupid Dad.” 61% do, however, see some value in businesses trying to innovate with names like “health” and solutions to back it up like exercise tracks and dieticians and nurses. One 26-year-old from Missouri says she found an Ozarks wellness center that has a gym and nutritionists, plus childcare. “I’d rather go there to make the most of my time than some urgent care that doesn’t know me.” 91% say they see healthcare as more of an experience, a destination even, and the name ought to reflect that. Perhaps that’s why the old guard of health insurers is rebranding. Cigna is now Evernorth and Anthem, as of this week, is now Elevance Health. Oh, to have been in the room for these renaming brainstorms! For Cigna, the name conjures images of snowshoeing and hot cocoa, both very healthy activities if you ask me, though I wonder if the name geniuses considered the geographic implications? Expanding into the deep south may be a harder sell, no? For Anthem, the move may be as much about reframing what these insurers want to be than trying to shift the narrative. Less so a claims payer and coverage denier, more so a healthcare support system. There’s proof, as most of the big insurers continue to acquire providers and open their own centers. If I had to guess, Anthem’s renaming brainstorm went something like this: “How about Escalate?” “Good, let’s keep spitballing.” “Elegance…Reverance…Excellence…Excitedtobehealthyance….Reverberance…Evolent.” Oh, wait, that one’s taken. “Wait - I got it - Evanescence!” Too bad, that’s taken by my daughter’s favorite rock band.

Extra Point (From The Archives): Who knew that everything we needed to know about healthcare we’d learn from Lloyd Dobbler: click here for the point.

$1.76M: The amount CareFirst has awarded to local health organizations to help address the diabetes epidemic and the social determinants of health that drive the chronic condition’s development. The grant recipients included 27 local health groups and represent Phase 1 of CareFirst’s commitment to addressing diabetes through a $10.5 million contribution.

Lab Utility: The utility of lab testing and the overall cost, namely physician referral to out of network labs, is creating demand from health plans to manage and change physician behavior in more proactive ways. Later this year, several health plans, including BCBS of Michigan and the HCSC plans in Illinois and Texas, will begin working with Avalon to manage lab spending and utilization. North Carolina’s Blue plan recently reported saving $112 million since beginning its partnership with Avalon in 2017. Lab testing for some patients is considered unnecessary, as noted in a poll we did several years ago (click here). One medical director said he sees a lot of “borderline” hormonal tests like to check for metanephrines or cortisol levels. “They are more confusing than helpful.”

This Disorder Doubled In 2020: The number of people hospitalized for eating disorders doubled in 2020, according to research published in JAMA. To help meet the growing demand for providers, Aetna is partnering with Equip, which provides virtual, evidence-based eating disorder treatment for young adults ages 6 to 24. The Equip partnership is currently available in six states, including New York and Texas, and will possibly include more in 2023. Equip employs the Family-Based Treatment model with a five-person dedicated care team consisting of a therapist, dietitian, physician, a peer, and a family mentor to support the person in their recovery. Eating disorders in younger athletes are among the reasons for the spike I suspect. Click here for one story.

Is There A Doctor In The House? First Taylor Swift, now Doctor House. Amazon’s Alexa users will now be able to play more than music, now they can say, “Hey Alexa, I want to talk to a doctor,” and Alexa will connect them with Teladoc’s call center. A provider will then return the patient’s call through the Alexa device. The service only has audio capabilities, but Teladoc plans to add video visits. For managing care, this has pros and cons – it no doubt ought to limit hospital visits and overreliance on misinformation people tend to glean from the Internet – no offense, Internet - but it also may mean people start calling in every symptom and scratch. 

Disruption Of Direct-To-Employer Models: In recent years, a wave of virtual disease companies has created some disruption for insurers who find themselves in a catch-22. These models have potential, but they tend to go direct to employer and can upset local physician networks who are kept out of the loop on their patients. “It bifurcates care delivery, messes up all the work we’re doing to address diabetes, incent physicians to manage those patients, do value pay correctly.”  But there is a renewed effort it seems from some virtual platforms to now partner directly with insurers. Integrated delivery network Highmark Health is partnering with Onduo to launch a virtual diabetes care program for adults with type 2 diabetes. Through a tech platform, Onduo will reach out to eligible members and deliver lifestyle and clinical interventions to those that sign up. In the joint pilot of this program, Highmark and Onduo saw 92% of participating members with a baseline A1C of 9% or higher improve their A1C by an average of 2.7 points upon follow-up. On average, members also reported losing 13.3 pounds or 5.7% of their starting weight.

SpartanVille: A Geropsychiatric Evaluation and Management Service unit to care for more patients afflicted with memory disorders and to train more physicians focused on addressing the mental health crisis is part of a new $600 million healthcare facility jointly opened by McLaren Health and Michigan State University. The site has a cancer center and 240 hospital beds.

Rx Speed: Optum has launched a new program, Specialty Fusion, meant to manage specialty medication costs, along with easing administrative burdens, like prior authorization processes. The program has one portal that providers can use to request a PA for specialty drugs, while having access to their patients’ diagnoses and medical and pharmacy coverage, allowing providers to choose the best option. An internal analysis by Optum predicts that Specialty Fusion will result in 17% total cost savings on specialty drugs as providers will be able to “conduct a best benefit evaluation at the drug level, lowering both the medical and pharmacy spend”. Florida Blue is also trying to streamline the PA process by using an AI platform called Olive. In the pilot program authorization turnarounds shrunk by 10 days.

Oral Health For Underserved: This summer, the large dental service organization Aspen Group plans to open an oral health center for underserved patients in Chicago. This 25,000 square foot oral care center will provide free dental care and procedures to low-income residents in Illinois.

Refer? Nah, You Got This.  Dr. Van Nostrand from the clinic in Seinfeld once had to evaluate Costanza’s boss for moles but Van Nostrand got upset when Constanza wouldn’t let him use his meat slicer to remove a mole.  Can’t imagine why. “George! Why would I, a Julliard trained dermatologist, need to refer your boss to a different doctor?” Kramer’s fictional Dr. Van Nostrand character was perhaps ahead of his time, even if a tad mistaken about what Julliard is for. In a poll of primary care doctors 40 and younger, 64% say they want to expand their medical knowledge and skills to be able to “do more at the point of care” rather than just refer. PCPs over 40 are more conservative, just 30% fall into this camp. The results are a lesson as you build out your companies and services – can you refer less and improve health?

Extra Point: The kids in my gym class don’t have much access to physicians and nurses who look like them and know their culture, much less a grocery store in their neighborhood with a half-decent selection of fresh fruit and veggies.  Aryanna, 11, says “we usually just go to the hospital if one of us is sick” but “none of the doctors are black.”  Hter, whose family migrated from refugee camps in war-torn Myanmar, says her aunt takes her to a place but no one speaks her language or understands her culture and the breathing issues they suffer from, exacerbated by not understanding how to use the inhaler properly. These are difficult situations, but the healthcare community is starting to figure out ways to tailor services. Spora Health is a small telemedicine platform in Texas and Tennessee specifically for people of color. It just started collaborating with a health insurer for self-employed people and their families. The insurer, Decent, will help its members select a Spora provider for primary care – one that looks like them and understands their situation, inequities. I hear about these models and it’s encouraging, but telemedicine is only one component. These families and kids need more of an overarching social service support “home” than a medical home. Bifurcating the two is a mistake. On Wednesday the kids named their volleyball teams before playing. “What’s your team’s name Jaylah? “P.O.C.” she said proudly.

56: For Giants football fans, it’s the number of the best linebacker in history, but for those in healthcare it’s a new indicator that virtual psych apps can work, as a reported 56% of patients stopped using Silvercloud for their anxiety or depression after 8 to 10 weeks, according to John Jesser, general manager for Amwell’s population health.

Homeless Healthcare: CVS Health has invested ~$30 million to build affordable housing in several cities, the latest a 36-unit complex in the Denver area for individuals currently experiencing homelessness or physical, intellectual, and/or developmental disabilities. CVS Health, similar to other payers, has been paying increased attention to social determinants of health.

IVF Boost: Gaia is a new fertility startup that wants to help “de-risk” the IVF process by offering personalized insurance. Several fertility companies in the U.S. offer risk-sharing models but it's rare to see IVF insurance offered as a stand-alone product. In addition to insurance and payment plans, Gaia says it has technology that predicts the number of rounds a couple will likely need in addition to the clinics that can offer the right treatment, based on clinical data sets. The CEO says that Gaia’s model means those who do not have live births will pay lower costs for the treatment and those who do have a child can spread the cost of their total treatment cycles.

Reversing Diabetes: Insurers are deploying two new strategies. (1) Season, a new company that focuses on “food as medicine” is betting on health plans eventually covering food as a standard benefit. Season already works with Geisinger and other health systems and launched a clinical trial of its program with CommonSpirit that aims to study how clinically-driven food as medicine programs can help diabetic quality of life. (2) Aetna and Banner Health’s JV is now offering specialized nutrition plans and virtual care to fully insured and ASO groups from Virta, whose pilot lowered blood sugar levels, weight, and use of anti-diabetic meds.

The Undoing Of OON: Mayo Clinic will stop scheduling appointments for out-of-network Medicare Advantage patients, though they will continue to treat OON patients who show up in the emergency room. The decision was made due to an increase in OON patients, particularly from United members. At least half of the 32,000 OON patients coming to Mayo for treatment are covered by United plans. The health system cited capacity concerns, amid worry they would not be able to appropriately serve in-network patients. The decision is not subject to surprise billing regulations, but the health system could use the refusal of service to OON benefits as leverage for more favorable terms and in-network status with payers.

First Batman’s Robin, Now This: Anthem has partnered with Sidekick, a digital therapeutics startup, to offer an app to help those with cancer, Crohn’s disease, and now a COVID Concierge Care app. Patients can track symptoms and outcomes, send messages to clinical care managers and gain virtual rewards for sticking to their treatment plans. The app will first be rolled out in a pilot program to Medicare Advantage members in Connecticut and New York and will target those with acute symptoms, as well as members with long COVID. An estimated 22.6 million Americans have long COVID symptoms.

Cancer Test In The Kitchen: Home testing company Everly Health is partnering with a home cancer testing company to offer its early-detection home cancer test to members of employer health plans.

Primary Care Future: The erosion of the PCP office visit circa 1980 continues, but consumers in a poll we have started seem to like the old way, saying virtual and retail clinics are “convenient” but there are questions about quality.  Walgreens and Village MD are on track to have more than 200 in-store primary care clinics this year, recently opening a new clinic in Jacksonville, FL which brings their current total to more than 80 clinics across 12 states. Long term, the initiative aims to have more than 600 primary care practices in more than 30 US markets by 2025, and 1,000 in 2027. More than half of the clinics will be in underserved areas. Amazon Care hopes to serve 10 million self-insured people by the end of the year with brick-and-mortar health clinics in 20 cities and virtual primary care in 11 new states.

One Million To Treat Asthma: Physician groups can get $1 million or more bonus pay for using analytics from Vital Data Technology, then proving the data is lowering ER rates in asthmatics. Vital Data used to provide data to the ER profiling patients, but there wasn’t much benefit. “I don’t need that,” says Barry Lachman, MD, who’s served as a medical director for 3 decades and said the problem is kids would end up back in the hospital 1 or 2 days later “because there wasn’t any education” and “no one knew the patient was there, except the ER.” The data was getting to the PCP 8 weeks later—which is not too helpful, obviously. The PCP, or pediatrician, needs to be the next resource and quickly. “The key is to make sure we get the information,” says Than Soe, a PA who works with refugee populations in Connecticut who says families take their kids to the ER due to untreated asthma and because “it’s what they know – the hospital is their doctor.” Soe, like so many other clinicians, says the ideal time to intervene is when the kid is in the ER or the practice to “give mom who’s missing work tools like a free incentive spirometer that translate into changing behavior” to head off the next asthma attack.

Extra Point: A year after Eric Zeiberg lost his sister Julie to heart complications after a 30-year struggle with severe autism, the 22-year-old is now hearing of new challenges from relatives in Russia, some who have reached out since yesterday saying they are scared and feel trapped and want to leave but are unable to go outside or go to schools or the doctor. Zeiberg is hopeful communication can remain open and that the innocent people in Ukraine, Russia, and other countries can have a voice. He should know. When Eric was just 13 he created a handwriting-to-speech app to help his sister communicate given her speech disabilities. “She was my inspiration, she couldn’t get words out,” he says. His app, HandySpeech, made it onto Apple’s app store to help people with autism, Lou Gehrig’s Disease, stroke, muscular dystrophy, and post-operation voice difficulties. Eric is a bit of a celebrity in our neighborhood for all of this. I watched him grow up, do good for his sister and others without a voice, and make his folks proud. I suppose the world needs more people like Eric.

45: Percent of people who say technical issues interfered with their ability to effectively utilize telehealth services, according to a recent study conducted by the Bipartisan Policy Center and Social Science Research Solutions. For many of us, it’s because we can’t remember our passwords, but for rural and older populations, there are more barriers, including lack of broadband internet access. Roughly 4 in 10 report these obstacles compared to 2 in 10 among younger people and those who live in cities. Some Medicaid and MA plans have started covering broadband as a benefit, like Humana’s benefit that pays for data plans up to $1,000 a year, but similar benefits are not yet widespread for most people with health insurance.

Riders Of The Storm:  Our interview with new Lyft Healthcare CEO Buck Poropatich reveals how rideshare companies are trying to improve access, lower cost, and play a new role as a traffic cop, but the discussion also raises new questions about driver training. “Are we walking into a perfect storm” wonders Melissa Sampson, an ER nurse, about drivers being put into difficult positions if symptoms occur during the ride. “Like will they be able to tell the difference between a heart attack and a panic attack?” Uber has of course also entered healthcare, partnering with CVS recently to help address transportation gaps in five  “Health Zones” in Atlanta, Fresno, Phoenix, Columbus, and Hartford. Read the interview here.

When The Baseline Moves: John McEnroe never believed the baseline official had it right and his iconic if not incredulous stance serves as a metaphor for those of us in healthcare prepping for the world of bundled payment and total cost of care arrangements that force us to manage to a number. 321 of your peers weigh in here in this look back on what happens if that baseline changes. Click here.

Golfers For Cataract: Not all of us have Danny Noonan to carry our bag down the fairway and track our wayward slices. One of the top questions that specialists like ophthalmologists get from many male patients who are about to get cataract surgery is, not surprisingly, ‘how soon after can I play golf….’ What is often not discussed, is just how important the surgery is for these golf-obsessed seniors who don’t hit it quite as straight and can’t see the ball off the tee as they used to. A Medicare Advantage plan’s utilization analyst, Mary Kellogg, says the plan is looking to study cataract utilization trends and related social factors, like surgery by gender, climate, and even something as obscure as to whether the patient is an avid golfer. ‘Do they need it to see the ball better or do they need it to drive to the course…two different things’. While it seems unlikely that denials for cataracts will increase drastically, with the increase in MA and medical management of vision, it wouldn’t be surprising to see greater analytics around the medical necessity. A more likely debate and trend to at least acknowledge is the likely market move to more pay for lowering infections and more in-office cataract surgery. Questions about infection and anesthesia safety factors exist but there are outcomes – a Kaiser spokesperson told us they have performed about 50,000 in-office cataract procedures without any eye inflammation complications.

Ziplining The Script: Magellan Health’s PBM division will begin delivering medications using drones later this year, pending federal approval. Magellan Rx Management, through a partnership with Zipline, will begin with members in North Carolina who take specialty drugs for chronic or complex conditions. Patients will be able to schedule their deliveries within 15-minute windows without any additional costs.

Serenity Now: Pretty sure Frank Costanza could have used this instead of his Festivus for the rest of us airing-of-grievances pole in the iconic Seinfeld episode. Calm, a meditation and mindfulness app, is acquiring Ripple Health Group, a health tech company that connects users with healthcare options. These tech plus service combinations are accelerating, namely in behavioral health.

Oncology Circa 2008: 14 years ago, Highmark and UPMC partnered in what was one of the earliest shared savings models to address the cost of cancer.  More than a decade later, payers continue to find ways to improve outcomes. Anthem has created the Cancer Care Navigator program to support oncologists and patients who are at high risk of complications during treatment. Practices get access to predictive analytics while patients get access to dietitians, medication adherence assistance, individualized care plans, goal setting, and remote after-hours support.  These kinds of programs were ranked #15 in this year’s Healthcare Payer Index.

Palliative Oversight: CareCentrix will begin managing post-acute and palliative care for Horizon BCBS of New Jersey’s Medicare Advantage and fully-insured commercial members beginning this May. CareCentrix will take over authorization requests for members who are admitted to or require extensions of stay at SNFs and IRFs, along with care coordination and nurse coaching for up to 90 days for patients post-discharge. They will also manage a community-based palliative care program.

Lassoism: Ted Lasso said we “gotta remember, your body is like day-old rice. If it ain’t warmed up properly, something real bad could happen.”  Payers like New Mexico Blue are seeing value in warming up kids, giving a grant to the Play Sharity Foundation, which helps low-income families create active play learning environments using free bikes and scooters. If you’re going to invest in social determinants, a tip – these payers have historically used grant funding to allocate millions a year through their foundations to support 10-20 non-profits focused on social risk.

Police Partner: Nashville is expanding a pilot project that pairs mental health professionals on the scene with police after the program’s first seven months producing positive results. Roughly one-third of the 247 calls flagged as potential mental health crises led to someone being transported to treatment compared to just 5% leading to arrest or use of force.

Extra Point: I think we ought to be careful about eating disorders and generalizing who they affect. I should know. I pretty much missed all the signs. Read the story here.

40%: Proportion of MVP Health Care’s Medicaid members who have not seen a primary care provider in the last 18 months. To change this, MVP, a health plan with members in New York and Vermont, recently launched a bilingual app for its Medicaid members that will connect them with primary and specialty care. The health plan partnered with Galileo, a tech-driven medical group, to create the virtual offering as a way to help members access services despite impediments many of them face, including transportation and language barriers.

Dog On It Ortho: Orthopedic specialists and some health insurers report an uncanny number of ankle breaks from dog owners who hang on to the leash while Fido sprints away, causing an unnatural twist of the ankle.  Surgeries for ankle repair are rising and so is appetite to create a bundled payment for the surgery, like $7,500 for the surgery and a month of PT. Challenge for the patient is rehab is often a year-long struggle including strength and conditioning and pain management and, in many cases, need for surgery again. Pricing these is challenging. “The biggest challenge is the rehab – a lot of non-compliant patients,” says Mark Cote, director of outcomes research and quality for the UConn  Musculoskeletal Institute.

Credentialing Gains: For behavioral health providers like Mella Health, a start-up telehealth provider, credentialing providers has been challenging and this has affected ability to schedule appointments, but it is getting better. “Initially it was 60-90 days, but now we have some group contracts (need at least 5 providers) so it’s taking less time,” says founder Ivy Patt, PhD, a clinical psychologist in Connecticut.  On average, it is taking providers 30-45 days, but can take 3 months.

Welcome To The C-Suite: Not so long ago, circa 2002, health systems decided to create value analytics committees to assess the cost-benefit of devices and implants and now, two decades later, they are creating dedicated roles to expand value-based care. One hospital in New England appointed a Chief of Social Services to lead efforts to build joint community housing and wellness centers, Nemours Children’s Health System hired a Chief Value Officer, joining the ranks of NYC Health + Hospitals, Mayo Clinic, and Novant Health. Expect a majority of hospitals to create these positions by the mid 2020s, similar to how they have evolved chief strategy and chief patient experience positions.

Tele Advocacy Push: A new telehealth advocacy organization recently launched to help ensure patients across the country have permanent access to telehealth. ATA Action, led by the American Telemedicine Association, along with groups like HCA, Intermountain, Walmart, Teladoc and others, will advocate at the state and federal level for continued coverage beyond the pandemic as well as appropriate reimbursement policies.  There are gaps that remain in telehealth, like restrictions limiting ability for psychologists to treat someone in a state where they aren’t licensed. But there is some progress. UCLA has created a problem gambling intervention service that several have used and it may be accepting patients outside of California given some relaxing of teletherapy regulations.

Mass Move: Earlier this month, Harvard Pilgrim Health Care and Tufts officially completed a merger that had been in the works since August 2019. The merger increases the overall market share of the new health plan, Point32Health, which now serves 2.4 million members across Massachusetts. BCBS MA is still the dominant payer in this market, but since Fallon Health announced in 2021 that they would be leaving the commercial insurance market, Point32Health will now be the second largest payer and more important for providers.

Imaging Network Change: UnitedHealthcare is launching a program to steer patients toward low-cost imaging centers. Hospitals and freestanding imaging centers contracted with UHC can submit an online questionnaire demonstrating their services meet certain thresholds required to become a Designated Diagnostic Provider. Beginning January 1, 2022, for fully insured small group plans and July 1, 2022, for large group commercial members, high-cost imaging services, including MRI, CT, PET scan, MRA, and nuclear medicine must be performed by a Designated Diagnostic Provider in order for a patient to get the lowest out-of-pocket cost. UHC implemented a similar program for diagnostic lab services last year, though there was significant pushback from providers.

Walmart Steering Care: Walmart employees now have more tools to help find top providers, thanks to the employer’s new collaboration with tech company Health at Scale. Health at Scale’s software shows provider recommendations based on outcomes, ratings and other metrics for over 25 different specialties, along with 34 procedures and imaging services. The company also utilizes AI to match patients to the right providers and treatments.

Retinal Screen: MedArrive, a tech and healthcare services business focused on home-based care, has partnered with data-science company Spect to bring retinal screenings to people’s homes. MedArrive providers can now use Spect’s AI-enabled telemedicine platform to perform screenings for diseases like diabetic retinopathy, glaucoma and age-related macular degeneration.

ASO vs. Fully Insured: In an example of differences in managing utilization, Regence BCBS is removing prior authorizations for most chiropractic, acupuncture, and massage services for its health plan members. Providers will no longer need to go through eviCore for authorizations, unless the member is part of an ASO group that requires them.

Olympic Dreams: Healthcare ought to form its own Olympic games, if for no other reason than to give us a more interesting alternative to curling. I mean, curling seems to be the only primetime option every time I turn on the TV and  I’m pretty sure it’s the least entertaining event, like ever. One of the players  was wearing a v-neck sweater and khakis of all things, looked like my 7^th grade biology teacher Mr. Boehm. The sport looks at times like an aggressive dish washing contest and would be more palatable perhaps if players could blitz like in football, but what do I know. If healthcare formed its own games, there could be races pitting teams of caregivers and seniors filling pill boxes or optometrists competing to get as many teens as possible to put in contacts within an hour. PTs could square off to see who is faster at improving range of motion for patients coming off ACL repair and the new wave of home delivered meal companies could race, literally, to deliver the most meals. Of course getting patients to eat those meals is another story.

Extra Point: Please pray for my 14-year-old Tommy who has to write two actual paragraphs by next Thursday about what it means to be healthy, and for my 78-year-old dad who walked into the shower again this week wearing his hearing aids. My bride also could use a prayer – she started as an adjunct teaching religion to college freshman nursing and music students and is getting peppered with questions about how to talk to sick and terminal patients about faith, and perhaps if there may even be a way to cure disease just by holding a hand or singing a song.