Behavioral Health Insights

62: The percentage of consumers who are not familiar with value-based care, according to a recent study conducted by EmblemHealth. The health plan surveyed 970 consumers online in 2021 and found that more than half were not familiar with the concept at all, and only 25% of those familiar with VBC could correctly define the model. My own bride, who occasionally has to listen to me carry on about all things value, thought it had something to do with vouchers for supplies for people who stop smoking or lower cholesterol. If the healthcare system wants to truly move toward value-based payment models, maybe we should make sure that the patients themselves are in the loop.

A New Pack: In an interesting move, Quest Diagnostics is acquiring Pack Health, a patient engagement company that tracks behaviors like medication adherence, diet, exercise and other issues with the goal of improving the health of patients with chronic conditions.

Toothpicks: Seinfeld dentist Tim Whatley has competition. Two recent partnerships will expand access to remote dental care. First, BCBS AZ members will now have access to 24/7 virtual emergency dental care through a partnership with teledentistry.com while Oral-B has partnered with Grin to expand access to their app that can measure changes to patients’ teeth.

Faster Time To Behavioral Screen: FL Blue’s behavioral health benefit manager, New Directions, acquired digital behavioral health company Tridiuum, which has automated behavioral health screening, triaging, and matching capabilities. This acquisition was built from a partnership the two companies had, which within 5 weeks resulted in the screening of over 450 individuals and reduced the average speed to a first appointment from 25 days to 4 days.

Go Doc Go: Aetna is now working with home health provider, DocGo, providing 2.5 million Aetna MA and commercial members in New York and New Jersey access to mobile at-home care, including episodic and emergency care.

At Home Kidney Care: Medica is one of many health plans focusing more on members’ kidney health. Starting this year, at-risk patients will receive Health.io’s Kidney Check kit in the mail, which allows members to perform an at-home urine test, looking for elevated levels of albuminuria. Patients who receive abnormal results will be able to then schedule an in-person appointment with a provider.

Trying To Curtail Duplicative Care: A new study by Cigna and MDLive found, unsurprisingly, that utilizing virtual healthcare visits saved members both money and time. By looking at actuarial data, Cigna found that patients who saw virtual providers had 19% fewer visits to the ER or urgent care. In addition, virtual urgent care visits reduced duplication of care by 16% compared to other virtual primary care providers or specialists. Their study also shows that the average cost of a non-urgent virtual care visit is $93 less than an in-person visit, with virtual specialist visits averaging $120 less and virtual urgent care visits averaging $141 less.

Baby Shark’s Script: Shark Tank judge Mark Cuban launched an online pharmacy last week that focuses on offering generic drugs at a lower cost. The Mark Cuban Cost Plus Drugs Company is a pharmaceutical wholesaler, which means they purchase drugs directly from manufacturers, bypassing middlemen to lower the price of more than 100 medications. The online pharmacy’s prices for generics factor in a 15% margin on top of actual manufacturer prices and a $3 pharmacist fee and the company does not accept insurance. Customers will pay out of pocket, but the pharmacy said those costs will be less than most health plans’ deductibles or copays.

Carrot & Stick: In our recent poll on the adoption of value-based arrangements, nearly 50% of respondents said value-based payments will be the dominant form of how healthcare providers are paid in 10 years. Most expect the models to look similar to models that exist today, including pay for performance, shared savings, and full risk, but expect more providers to enter these arrangements, perhaps whether they want to or not. As one health plan executive noted, “Dangling carrots no longer works” – maybe we’ll see health plans focusing more on sticks?

Top 20: Unlike the often stale Top 20 of college football and basketball, healthcare’s rankings are beginning to get a fresh new look. Cardiology and social services crack the Top 10 of healthcare payer priorities this year, representing nine services making their way up the rankings, while five services debuted in the Top 20, including interventional pain management and wellness centers—both likely getting more managed care attention in the year ahead. GI, perhaps the least managed specialty, moved up nine spots to no. 3, as more payers expect to focus on medical necessity of procedures like esophagoscopy. Stay tuned for the 2022 Payer Index coming out in February.

Extra Point: I’m lucky that I have access to more behavioral health therapists, psychologists, psychiatrists and social workers than I can manage – so many I should probably just start my own network – but when it came time this week to help an old friend find a specialist for his kid to help him deal with his addiction, I struck out like poor Casey at the Bat. Everyone tried to help, offering connections, advice, even sub-specialists, and yet despite this kind of VIP access, the rules have left me waffling without a next step, much less an appointment. Regulations limit the ability for a licensed therapist to treat someone in a state where they don’t have a license, making it awfully difficult to get appointments at all, much less halt a crisis. So if I struggle to get access, I wonder about those far less connected, and I wonder if there might be a better way, not just to allow for treatment without barriers but to measure and rank therapists like we do athletes or songs, or at least organize them by skill, efficacy, empathy – let the market drive choice. I mean, with my Connecticut license to drive I’m pretty sure I’m allowed to make my way west in my blue-rusted 1998 Volkswagen all the way to say, Missouri, pay the state tolls there, pay the rest stop gas station for a fill-up and a cup of coffee, pay the Super8 for a bed and breakfast and even get reimbursed for the whole trip…but a license to treat mental health across state lines - to help a kid who’s struggling 2,000 miles away to prevent a spiral that’s already started - that doesn’t seem to mean squat.

One: The number of people out of 4 who have a chronic musculoskeletal condition, such as arthritis, back and neck pain and osteoporosis, according to data from insurer Highmark. These conditions collectively account for 50% of medical spending and so Highmark’s Well360 program is providing self-funded employer group members access to wearable FDA-listed motion sensors that give real-time feedback through their exercise sessions.

Born Free: The Boss, Bruce Springsteen, could not have predicted this - BCBS of Massachusetts members now have access to childbirth services through a free-standing birth center network. This includes Seven Sisters Midwifery and Community Birth Center in Florence, but may expand as other birth centers become licensed in the state.

See, I Told You So: If you have a teenager, you have told them that they will be blind by the time they are 25 if they keep looking at their phone, and so it’s not all that surprising to see innovation around vision benefits. UnitedHealthcare now offers its members discounts on blue-light-blocking laptops as part of their vision benefits. UHC partnered with Dell to offer members a 20% discount on Dell XPS laptops with blue-light-blocking screens.

Incentive Pay For MAT, Psych: BCBS Michigan is launching a new Collaborative Care Designation Program for 2022.The program will help support practices that focus on collaborative care and will use the patient-centered medical home model. The first year of the program will only require practices to build out a full care team, including a behavioral healthcare manager and consulting psychiatrist, while more requirements will be added in the second year. The insurer is also expanding its MAT initiative for patient-centered medical home practices, OBGYNs and maternal-fetal medicine clinics in 2022. The program now includes incentive funding for delivering MAT to all patients (expecting mothers or not) that they treat in these specialist practices.

Finish Line: Mental health provider Meru Health is collaborating with health insurer Evry Health to reward members for following through with their mental health treatment. They offer an incentive program for participants with the chance to receive up to $100 upon completion of Meru Health’s 12-week therapy program.

New Reimbursement Tier: Effective April 1, 2022, Aetna is expanding their Mid-Level Practitioners policy to include a new reimbursement tier for certain practitioners. The Mid-Level Practitioners policy will now include audiologists, genetic counselors, massage therapists, nutritionists, respiratory therapists, and registered dietitians, allowing reimbursement at 75% of the negotiated fee or recognized charge for covered services. This will only be applicable for Commercial business.

Wellness School: San Diego State University is opening a new Wellness Club, in partnership with Wellcare. The club will provide both physical and behavioral healthcare, along with social connections and education specifically targeted to senior issues, such as mobility issues and medication management.

Wait For It: Wait times for therapists continue to be a problem, up to 2-3 weeks on the low end, months on the high end depending on how much specialization is needed. Headspace Health is trying to provide a solution by recently acquiring Sayana, a self-care app that leverages chat sessions with an artificially created persona named Sayana who encourages users to track their moods and recommends exercises rooted in cognitive behavioral therapy.

Extra Point: I bet Tiger’s chip on 16 at the Masters will go down as the second best moment in sports behind only this. I bet I know what the next epidemic will be and I bet that if we only invest in this one thing we might actually lower healthcare costs. I bet I will forget my Apple ID by the time I finish this column. And I bet if you read the rest of this here you’ll have something to talk about at supper tonight.

73: The percent of 20- to 35-year-olds in our poll of 652 consumers this month who say they don’t see themselves ever getting a colonoscopy and, for about 40 percent, the idea of the at-home test Cologuard “seems” like a better option, while a not-so-surprising 30 percent expect there to be an easier solution by the time they need to be screened for colon cancer. “There isn’t a pill yet? If not, there will be” says 27-year-old Caylee Parker of Springfield MA.

Remove The Blues: Minnesota Blue is removing preapproval requirements for its commercial and Medicare members needing partial hospitalization for psychiatric reasons, under a new policy based on recent approval data that shows most of these visits have been necessary and approved.

Gastro Park It: These food parks are the new family picnic and social scenes in urban America, but they are also increasing cases of heartburn for those who aren’t used to a spicy gyro or fried cheese on a stick. Gastroenterology as a healthcare specialty is facing its own heartburn ahead with new preauthorization requirements for esophagoscopy and capsule endoscopies and other pressures for what was once an unmanaged category. GI is up to the 3^rd ranked priority for payers this year, according to the 17^th edition of the Healthcare Payer Index set to be released in February.

Treading Young: Endocrinology practice Valley Health in northern Virginia has been using mini treadmills for its doctors so they can walk or run at the office, and we expect exercise stations to become more common for patients too, as part of a new wave to connect check-ups with wellness. “Trying to think about attracting the younger generation,” says Liz Colbert, PA, who says the 30-somethings in the Chicago market see healthcare differently.

Remote Control: LG, best known for its appliances, is getting into healthcare with a new virtual workout and telehealth appointment platform available on its latest TVs. LG is partnering with Independa to provide medical and dental consultations, a discount pharmacy platform, and WebMD videos. Users can schedule telehealth visits with providers directly through an app and Independa says it plans on charging a flat fee of $75 for dentist calls and $55 for a doctor for uninsured patients or in cases when the health plan won’t cover the consult.

Shifting Procedures: Washington State insurer Premera BCBS recently added additional surgical procedures to their site of service program, continuing its goal of shifting care out of the hospital. Effective January 7, 25 codes have been added, including single-level cervical discectomy and lumbar spinal fusions, along with some hysterectomy procedures.

Pulmonary Detection: Highmark Health and Bosch are expected to team up for clinical studies of SoundSee audio technology to detect pediatric pulmonary conditions. The clinical trial is expected to take place at the Allegheny Health network this year.

Is It Hypertension, Dehydration Or Unresolved Grief? Home blood pressure monitor creator Omron announced plans to build a myriad of remote patient monitoring and hypertension-focused services, as well as a new app that will be designed to predict cardiac events. These sound important but there is a deeper question around monitoring – what’s the root cause of something like an acute orthostatic drop in BP in people with hypertension? These drops can lead to transient cerebral ischemia from diminished blood flow to the brain, which may exacerbate a chronic decrease in cerebral blood flow and subsequently lead to falls. Seniors are at high risk, but in an analysis we did back in 2014, the underlying cause of the fall in a majority of seniors was tied to dehydration, malnutrition, but further linked back to unresolved grief from losing a family member, namely a spouse.

On Second Thought: BCBS in Massachusetts is collaborating with 2nd.MD to offer some employers the option to provide employees a virtual second opinion. Members enrolled in this benefit will have remote access to 900 doctors.

Tooth Fairy’s Wish: Pacific Dental is partnering with Envista to bring imaging software to all 850 affiliated practices. This partnership is a first step towards further developing AI capabilities that can assist dentists in diagnosing, planning, and treating dental issues.

When Value Meets Autism: Action Behavior Centers, one of the country’s largest autism services providers, will open 10 new applied behavioral analysis (ABA) centers and employ 750 new jobs to meet therapy services for children with autism in Illinois. It already has centers throughout Texas, Arizona, and Colorado. Autism is back on the radar of insurers – “I’m convinced we need a better way to pay for the ABA – 30 hours a week at $50 to $100 an hour for  3 to 6 years, without meaningful progress or a cure…” according to a health insurer planning to design some value-based models this year, or increase audits of ABA.

Extra Point: Chris Brown’s “Next To You” featuring Bieber and Tom Petty’s “American Girl” take Dana Evans from Women’s Care Enterprises home in the final stretch of a 20-minute run as part of his “Top 5 Songs” to move to. Evans, who heads up payer contracting, likes to open with the classic Rolling Stones tune “Start Me Up” then Motley Crue jam “Kickstart My Heart” and is one of 1,353 who took part in the Exercise Poll last month. Results are still being compiled – you can enter your list here to win one of 5 exercise gifts – but early results seem to suggest that the “Beeb’s” songs are among the most popular, especially among those under 40, while “Pink” is a leader in 30-something males. Go figure. Personally, I finish with CCR’s Fortunate Son and Pearl Jam’s Rearviewmirror, but to each his own…

131: Number of hours PA Lauren Valley worked at a busy urgent care clinic this past week in my town, often spending off time sleeping at the clinic, filling in for staff who were quarantined. Lauren is a terrific PA – smart, thoughtful, doesn’t just prescribe antibiotics and tests needlessly, calls the sinus issues the little kids have “boogies” but can adapt to help the older lady find her busstop after her appointment. There are thousands of Lauren Valley’s out there – but right about now, we need thousands more…

DropOut: Cigna dropped Livongo from preferred status in its digital formulary on December 15th. Livongo, the digital health product focused on diabetes merging with Teladoc, will now be listed as an alternative, along with LifeScan, and Omada Health will be preferred. Omada Health offers five personalized programs for treating diabetes, hypertension, and other chronic conditions.

Food For Thought: HealthPartners, a health plan in Minnesota, is offering its Medicare HMO members a new benefit in 2022 called FarmboxRx. Eligible members can receive up to two boxes of fresh fruits and vegetables per month, which are put together by nutritionists and they can be customized for specific health conditions, like diabetes. HealthPartners is also addressing food insecurity through initiatives aimed at children, like fruit and vegetable vouchers, and partnerships with community organizations like SuperShelf and Hunger Solutions. Many health plans expanded their offerings to include meals and healthy groceries in 2021 and we expect to see this continue beyond this year.

Travelling Nurse: UPMC is forming its own in-house travel staffing agency for registered nurses and surgical technologists to take rotating, six-week assignments at its hospitals across three states, depending on where the need is greatest, according to a press release. The health system wants to rely less on outside agency staff to help retain current workers and potentially bring back those who previously left, it said in the release.

TeleConsult, Aisle 11: Supermarket chain Hy-vee is launching a new telehealth service, RedBox Rx, which offers virtual health consultations through a partnership with Reliant Immune Diagnostics’ telehealth platform MDbox. Patients can meet with a provider and receive treatment plans for primary care, dermatology conditions, migraines and mental health conditions. And Atrium Health, a North Carolina based health system, has established a new virtual care clinic at a church's Community Life Center in Shelby, NC. People can make an appointment or just walk into the clinic which has telemedicine equipment set up and hopes to provide more access to patients who may not be equipped to do telehealth visits in their home.

The Thing No One Wants To Talk About: The Flagler Access Center, a new mental health center, will open later this month in Bunnell, Florida, providing much needed behavioral health services. Flagler County has one of the highest suicide rates in the state. In 2020, the number of deaths by suicide was 20.9 deaths per 100,000 residents, up from the 2019 rate of 19.3. The center, a partnership between SMA Healthcare and Flagler Health, will host a program to engage youth with mental health services earlier in their lives called the “Be Resilient and Voice Emotions” (BRAVE) program. The center will also utilize and refer to other social services so residents can continue to receive the care they need in their community.

A Win For Emergency: UHC’s ER coverage policy where insurer would review claims for emergency services and retroactively deny or only partially cover claims deemed non-emergent was set to go into effect on January 1, 2022 but UHC is no longer moving forward with this policy.

Surgery Slide: When George Costanza found out he could get his insurance company to pay for physical therapy he had no idea that that meant a man would be giving him a massage.  But PT will need all genders to meet growing demand over the next 5 years, buoyed in part by studies like a recent one in the British Medical Journal which found that 6 of 10 of the most common orthopedic surgeries are not meaningfully more effective when compared to less invasive procedures like exercise and PT. Randomized trials showed only minor advantages over interventions like PT. For carpal tunnel surgeries and TKR, their research showed surgery was often most effective. In a quick poll of medical directors who read our journal, 80% said that the results are directionally accurate with their own internal analysis. “Why do you think we are pushing PT?” one physician said.

Extra Point: There’s about to be a major staffing shortage in my household when both Jackie, 18, and Mukue, 20, go back to college Sunday. Neither of our high schoolers leave their rooms as far as I can tell, so I have had to rely on the older kids quite a bit to lay on the couch and leave dirty dishes on the floor and put empty cereal boxes back into the pantry. They’ve really done a great job with that. “But dad, the dog just cleans my plate so it’s fine.” To be fair, Jackie has gotten better. This week he’s been jamming the Special K boxes on top of the already full garbage. Mukue, too – she used to warm her socks and mittens in the oven but then they caught fire last weekend, so she’s stopped doing that, which is nice. Healthcare is going through its own staffing shortages, depleted by the pandemic and the aging of the population. It’s interesting that in the 15 some years I’ve been involved in helping those with healthcare investment, not once has staffing been a major diligence priority, much less the #1 focus that it will be this year, according to nearly 80% in our annual Healthcare Investment Index. I don’t personally have a solution to recruiting and retaining nurses and doctors, though it probably lies somewhere around fair pay, incentives for doing a good job, and enough time off week to week to beat the kids in pickleball.

50%: Increase in families requesting grief support services in 2021 according to Boston Medical Center. Primary care doctors in Boston identify families who could benefit from the Good Grief Program and refer children to the medical center. The program estimates that about 10% of the new families are grieving a loss from COVID-19. Maureen Patterson-Fede, the clinical social worker who oversees the program, expresses worry about the future for these children, “I think we're all holding our breath. We're feeling like we're just seeing the tip of the iceberg about what's going to play out for kids."

Smart Implants: Orthopedic surgeons in New York recently completed the first total knee replacement with Zimmer’s “smart” knee implant. The device, the first “smart” implant cleared by the FDA this summer, has an embedded sensor that monitors a patient’s steps, speed, and range of motion so that the provider can monitor progress real time and objectively, rather than relying on patient reported outcomes. It will be interesting to monitor how these sorts of advances change surgeon behavior, and patient behavior.

Kidney Ties: Starting in 2022, BCBS of Massachusetts Medicare members with chronic kidney disease (CKD) will have access to services from Square Knot Health as a supplemental benefit. This program will pair members with a trained navigator to meet with via video and phone to help educate, assess, and mentor members on treatment options, including transplantation. Along with support and education services, Square Knot Health partners with nephrologists, primary care physicians, and transplant centers to remotely monitor members.

Virtual Design: New virtual benefits continue to proliferate as MCOs look to use virtual platforms for triage, primary care, and “steering” to high quality specialists.  Starting in 2022, Hydrogen Health, a joint venture between Anthem, investment firm Blackstone, and K Health, a digital primary care company, will be offering nationwide virtual primary care coverage. The joint venture provides text and video-based digital primary care leveraging K Health’s artificial intelligence capabilities to customize care for enrollees. The service is currently offered to Anthem’s fully insured business and aims to expand their user base to more than 10 million enrollees by the end of 2022. How much these virtual plans are adopted by consumers is still to be determined but likely gives us a window into how young adults are changing their stance on preventive healthcare.

Cancer Link: 12 years after City of Hope moved into the land of 340B saving ~20% on their OP drug spend the national cancer center non-profit in Los Angeles is buying Cancer Treatment Centers of America. The combined company expands City of Hope’s geographic reach to Illinois, Arizona, and Georgia and will allow more people to get access to City of Hope’s diagnostic and treatment setting capabilities. It may also lead to some adjustment in how insurer’s approach network design for oncology. There are also likely gains in drug acquisition and potentially more alignment between oncologists on treatment regimens for patients in later stages of cancer, many who complain when local oncologists won’t implement national center protocols.  Dale Adams, City of Hope’s pharmacy director in 2010, told us at the time that the center hoped to shave $8 million off the center’s projected $40 million in outpatient drug spend (they spent ~$70 million in total) by qualifying as a 340B covered entity. At least 30% of the center’s inpatient net revenue at that time came from state and local governments for indigent care.  Cancer care has evolved in the last decade – more payer-provider partnerships, more drug treatment pathways to promote certain drugs, and more oncology spend through the 340B program. Unlike other services–like orthopedics, GI or cardiology—where payers can benefit most from trying to shift site of service out of hospitals, oncology is typically different, with so much spend tied to the cost of the drug.

Psych Partner: Quartet has acquired telepsych provider Innovatel in the latest example of tech meets service delivery. The mental health analytics company has brought in the psych provider known for serving community mental health clinics. Quartet has had a string of payer partnerships, most recently with BCBS in Philadelphia, and can now leverage its new crop of providers to link demand with one of its own providers.

Extra Point: However you like to move (racquetball, rollerblade, treadmill, ping pong, parachute, or swimming laps) and at whatever pace (slow, fast, steady, sad or strangely superhero-like), you can probably agree that it’s way more motivating to move to music. And while I suppose we all may move differently and at different speeds, I suspect there’s a certain musical measure of camaraderie that binds us. What 5 songs must be on your list? What one song is essential at the 9-minute mark when your kid asks “are you alright dad?” and you can’t answer because talking would derail the entire activity, or roughly 18 minutes in your dog somehow knows to dial 911 because you are holding on to the bars like superman, your back arched and your feet barely gripping the treadmill.  I’m of course speaking hypothetically.  For me, my 5 songs have probably stayed fairly constant over time, even if my commitment to moving has not—(5) Theme From Superman, John Williams, (4) Gonna Fly Now, Rocky, (3) Theme from Pirates of the Caribbean, (2) Fortunate Son, CCR, (1) Rear View Mirror, Pearl Jam.  What’s your top 5, and what does it say about you and your health? Click here to share your views and enter our drawing for 5 exercise gifts. Official rankings to be released in the new year.

2.3: Percent of 8-year-olds in 11 states diagnosed with autism in 2018, up from 1.9% in 2016, according to new data released by the CDC, which shows that childhood autism rates are at their highest level yet. Utilizing a new ASD surveillance method that relies on ASD diagnosis, special education classification and medical billing codes, researchers were able to capture more fully all those diagnosed. A separate report shows that 4-year-old children born in 2014 were 50% more likely to be diagnosed with autism or given an ASD special education classification compared to 2010. Luckily, most research indicates that earlier diagnoses of ASD are beneficial because children can get into treatment earlier.

Weight For It: New Mexico’s Blue plan is incentivizing providers with a $50 per visit bonus if they simply document that they have done a weight assessment and counseling for nutrition and physical activity for children and adolescents. The program will start up mid-2022.

Needle In A Haystack: Aetna will start covering acupuncture as a standard benefit in 2022.

Home Alignment: Highmark Health, Penn State Health, and Contessa are partnering to launch Penn State Health Home Recovery Care which will include hospital-at-home and skilled nursing care at home. Patients will be sent home with remote monitoring devices and will be seen through a combination of in-person and virtual care.

Virtually Autism: BCBS Michigan began making some behavioral health telemedicine policies permanent on November 1, 2021. ABA services, including assessment and skills training, can now be delivered through real time telemedicine on an ongoing basis, as can IOP and PHP services for behavioral health.

Drug Switch: Inflectra will be the preferred infliximab product and any members currently on another type, including Remicade, will need to switch over under a new Regence BCBS policy starting in 2022, while Washington state’s other Blue plan, Premera, will remove Lantus from its formulary to start promoting Semglee, the first interchangeable biosimilar insulin.

Money Back For—Guess What—Being Healthy: Aetna and Allina Health, the Minneapolis-based health system, launched four new health plans targeting employers and self-insured customers. Covered services and cost-sharing vary across the new plans, but two plans offer members up-front coverage before meeting their deductible and another, aimed at self-insured employers, will provide money back in years when a member’s medical costs are lower than anticipated.

He’s Making a List And Checking It Twice: Santa Claus is coming to town and this year he wants to make some healthcare dreams come true. Last week’s Poll of the Week asked for healthcare wishes for the new year and topping the list at #1 was caregiver support for the aging. More time with primary care providers and better coverage for residential mental health treatment also hit wish lists.

Mental Health Freedom: Independence BCBS of Pennsylvania will begin offering mental health services to all members through Quartet Health, a company that uses data analytics to connect members with solutions that are tailored to them. This should provide better access and patient care, while allowing Independence to measure and reward quality providers more effectively.

Aisle 6: Walgreens CEO, Roz Brewer, laid out the pharmacy chain’s vision for keeping people healthy enough to avoid readmissions into the healthcare system during the Forbes healthcare summit last week. Walgreens’ future plans include a primary care presence at most stores while also partnering with more health systems and payers to ensure their members have access to these primary care services.

Remind Me: CVS and Microsoft will work together to develop new digital health and personalized care products, like mobile alerts when it's time to receive a flu vaccine, counseling from a pharmacist on potential side effects for a new medication, or to tell people with heightened risks for melanoma to buy sunscreen. The 5-year partnership will help CVS with its push into more primary care services.

Along Comes A Sports Benefit: I played 2 on 2 hoops last weekend with an Orange Theory (OT) business development leader who on the one hand played a bit like Phillip Seymour Hoffman’s character in Along Came Polly but on the other opened up about the OT’s move into modern day healthcare. The new-age exercise center has been in talks to partner with a regional primary care and cardiology group and an insurer to form a kind of preventive care meets exercise benefit targeting the 26-35 age group. The OT center uses a point system and cross-training approach to get people into their optimal calorie-burning zone. Before COVID hit, I gave the OT a try and my personal theory was that it made me nauseous, but that’s just me.

Extra Point: Couple years back in my days as a struggling journalist I followed a home care agency around for 26 visits for about a year in the northeast, all of whom were die-hard Patriots fans, and 19 were flagged as higher risk due to two or more hospitalizations in the prior year but limited primary care visits. ‘That’s a balance that’s not right,’ Sharon Masters, RN, said. Of the 19 flagged, a surprising 8 showed Masters that they took their medications by dropping them in a jar of peanut butter—the only problem was all 8 took lots of medicine, most had blood pressure prescriptions and the peanut butter was crunchy, so on some days they weren’t chewing pills, they were chewing Jiffy. “It was a see saw—hypotensive one day, hypertensive another…overdose or no dose. Masters said most had some form of cognitive challenges or were on the dementia spectrum, which probably explains their behaviors. I’ll never forget Nancy. She was about 77 and kept offering me cookies. She cried when talking about her pills and her late husband Bill but then smiled when talking about her kids. “I miss them,” I think she said. “They have their lives..."

75: The percent in our Poll of the Week who believe a virtual visit for someone with substance use disorder is less effective than in-person treatment even though there are examples of companies like Eleanor Health able to use telehealth without worrying about whether it’s a billable visit given they are paid differently to manage a patient from addiction through recovery. They use the telehealth encounter as a way to check-in, to do anxiety and craving scales, and stay in front of patients as part of a goal toward recovery. A recent study published in AMA’s journal Psychiatric Times highlighted that addiction treatment via telehealth can increase patient engagement and reduce harmful stigma, but there is still clearly some resistance. One poll respondent agrees, saying “It is convenient, and patients would be more comfortable at home. It would reduce stigma as it is more private.”

Fry It Up: The great late night talk show host Craig Ferguson doesn’t get enough credit from the healthcare world. He was among the first to acknowledge the double victory of the healthcare-for-all-movement. “Now that healthcare is guaranteed, I’m frying everything I eat.” Cardiologists are among those who can thank Ferguson.

At Home In NYC: Anthem is acquiring Integra Managed Care, a long-term care plan in New York that serves 40,000 Medicaid beneficiaries with disabilities by providing services in their homes. The purchase expands Anthem’s Medicaid footprint in the state.

Payment Reduction, Eventually: Aetna is delaying their payment adjustment for multiple endoscopy procedures again. Previously supposed to go into effect September 1 and then December 1, the new policy will now be effective March 1, 2022. Aetna will reduce payment for multiple endoscopy procedures in the same family when billed by the same provider on the same date of service for the same member. Multiple surgery reductions can also apply.

Therapy Going Out To Pasture: An inpatient recovery center in Georgia is giving patients access to, wait for it—therapy cows as part of a broader treatment program to help people with anxiety and panic attacks. Does it work and will insurers cover it? Read our correspondent Samantha Kaishian’s perspective here.

Tech Miss: Insurance startups heavily relying on technology innovations are struggling. Clover Health and Bright Health reported missing their medical loss ratios (MLRs) during the third quarter of 2021, both clocking in at over 100%.

Veteran Support: Humana is adding veterans to its Bold Goal communities, giving them the same kind of population health management other Humana members receive. The insurer plans to work with community-based organizations and medical partners to deliver integrated care to the veteran population, who often have more complex physical and mental healthcare needs like PTSD.

Predictive Health: Northwell Health is forming a JV with an investment group to help fund AI startups targeting challenges in healthcare. Engineers and data scientists working at the JV will collaborate with Northwell Health clinicians to create tools to predict, diagnose, and manage health conditions, starting with chronic diseases and preeclampsia. Similarly, LifePoint Health, the Tennessee-based hospital organization, is working with venture firms to launch a startup incubator for health tech in Nashville. The new venture won’t necessarily focus on AI but will look for any type of innovative startups working to improve healthcare quality, access, and outcomes.

Palliative Launch: Kara Health, a hospice and palliative care provider based in California, is launching a joint venture with Palomar Health System in San Diego in an effort to focus on patients with cancer, heart failure, and other serious or terminal illnesses. The partnership is expected to begin in January 2022 and will include a shared savings arrangement for the palliative care business where each party will benefit if they are able to prevent hospital admissions and readmissions.

Academic Home Care: Bayada is entering into another hospital partnership to provide home health services to the system’s patients. Jefferson Health and Bayada’s new company, preliminarily named Jefferson Health at Home, will focus on seamless transitions and virtual care and will also include an academic affiliation, which should create new training opportunities for Jefferson students, particularly at the Jefferson College of Nursing. Back in June, we reported on Bayada’s similar venture with VCU Health System in Virginia. Wonder where the home health company will look for their next partnership?

Extra Point: I suppose I’ve had my fair share of blessings in my life. When I was my 5, Santa brought me a putt-putt speedway and when I was about 17 Mr. Hughes still let me take his daughter Shelly to prom, even though I ran over his basketball hoop with dad’s Dodge. At 22, I got to introduce Rosa Parks at my college commencement and interview Jack Nicklaus about why he shanked his chip on hole #11. And in the fall of 1996, about a month after the Yankees won the series and around the time the so-called Soup Nazi from Seinfeld fame gave me an extra piece of bread with my potato bisque, I got to sit in the 5^th row to see Rent on Broadway. It was life changing - the show came at a time when some of my colleagues and friends were living with HIV and facing a world that didn’t understand them, nor their disease. I was probably one of them. Some of them sadly passed on but now, 25 years later, I remember them for the grace and courage they showed. People can live longer with HIV thanks to treatment and early diagnosis and the impact of shows like Jonathan Larson’s Rent. We took the family to Rent last month and it struck me how the show just doesn’t have the same meaning or impact for our kids. They can’t appreciate those times or the disease. Much like they can’t understand why their Black classmates would ever have to sit anywhere on the bus but right next to them. They do have their own cultural crises to deal with now, their own epidemics, and their own music for their own time. But there is one song from Rent that probably does transcend. 525,600 minutes – it opened the second act with the cast of 15 moving in unison to the front of the stage. How do you measure a year, they sang out. How do you measure this year, or how will you measure the next one? For those of us in healthcare it may still be things like COVID shots and vaccines, but also those moments when real humanity shines through, like the nurse who sits bedside, holding a hand and singing a song. Maybe for our kids, it’s measured in lost masks or hours of homework or Instagram friends…or maybe it’s laughter, love, and those Friday night “let’s have pancakes for dinner” with mom and dad and the dog.

Are You Walkin’ On Sunshine? If there’s a medical specialty that can claim this Katrina and the Waves hit, it’s probably the derms – skin cancer incidence is rising faster than an Olivia Rodrigo song on the charts and there aren’t enough dermatologists. Wait times are sometimes 3-4 months and, increasingly, it’s for the PA or NP not the dermatologist. The tele-derm experiment is a potential solution but a majority in our recent poll of 100+ doctors believe it will add cost, not limit skin cancer. But heading into 2022, these practitioners can evolve to impact health system costs in other ways, like staffing a behavioral therapist and figuring out a way to reduce teen acne that has led to a range of emotional and tragic situations for teens.

All You Need Is This: John, Paul, Ringo and George probably could have just been, that’s right, cardiologists, given they sang about love in pretty much every song and when entering their practice they could have just fixed our clogged arteries and genetic issues better than any stent procedure could with a simple rendition of “When I’m 64” from, what else, Sgt. Pepper’s Lonely Hearts Band. Cardiology is one of the Top 5 emerging priorities for both payers and healthcare investors headed into 2022 and interestingly the most “enticing” part of cardiology isn’t the procedure or the office visits, according to investors, it’s the remote monitoring potential.

In Your What? Peter Gabriel’s hit about your eyes was made famous by, who else, John Cusack who made it cool to lift your boom box above your head, but there’s a hidden message here to the vision community – make it easier for patients to get their glasses, contacts and help us figure out a way to see in 15 years when all this technology turns us blind. “It’s one of the underappreciated, least talked about issues,” says ophthalmologist Fran Salita, MD, who says some 20-somethings now in their 40s are “essentially blind” from technology overuse. Companies with an ability to screen and do prevention and follow up visits under a capitated rate likely have an advantage going forward.

Real Fine Place To Start: Sara Evans song is a regular in my home and it’s now the new anthem if you will for virtual health benefit design. United is among those deploying its Optum case managers to be virtual traffic cops under a health plan that allows people to call their health plan, explain their symptoms, then get a referral to the doctor or x-ray, if necessary. How this will ultimately work and whether virtual triage will become so common as to impact the need for in-person care is probably unlikely on a wide scale, but something to monitor.

Eat It: Weird Al was sort of ahead of his time. He must have known that we would be delivering meals on wheels for free to seniors, that food insecurity would become a real thing and that the country would start using healthcare policy and funding to address the problem. But Al was on to something too – it seems that a majority of patients getting these meals have some sort of cognitive issue and thus don’t always eat these meals. Some have serious dementia, some behavioral health issues that limit what they eat. If you’re a social service company, combine personal care, behavioral health and home delivered meals.

Every Breath You Take: Dr. House still best captures the difficulty of the health system in educating the public on how to use inhalers and how to manage asthma. The scene depicting a patient spraying her inhaler into her neck was made famous in the hit TV show and it’s an iconic symbol that we have issues with misunderstanding how to empower people to do good self-care, whether it’s a self-exam to check for potential signs of cancer or understanding how to know when to use the inhaler.  Some practices are doing the right thing. For example, an allergy practice in east Texas is getting an incentive payment these days from a Medicaid plan for giving its highest-risk asthma patients portable spirometers that transmit results back to the physician, help the practice monitor pulmonary function, head off deterioration, and with any luck, see progress.

Don’t Stop Believing: I asked my kids who sang this song and they sadly think it’s Glee. It is of course not Glee and despite my disappointment, Journey carries the torch with what has to be “thee call to action” for families, caregivers, survivors and patients living with cancer. The diagnosis is a game changer. That yellow syrupy stuff that comes from that IV into your veins for 6 months at a slow drip – it is painful, makes you nauseous, shows you who really cares. It makes you fight and for those on the front line, cancer is both your life and your pain – it is tiring, sad, tragic but also gives you joy and hope. Surprisingly, limited private equity healthcare investment has occurred in the oncology space despite what may be the one sector with the greatest need, spend, and potential for innovation.

The Gambler: All Bets Off Kenny Rogers. More payers are covering therapy for gamblers but not in every setting and not as restrictive as you might think. Excellus BCBS in New York state allows OP therapy for gamblers without pre-approval. Residential, partial hospitalization and inpatient services are thought to be investigational.

Lean On Me: Few remember Bill Withers, but we all remember his song, and if there’s a healthcare service that can claim it, it’s hospice. The people who are there at the end, for caregivers, families, and the dying. Hospice nurses have a special place in our culture for those who know them. They bring a certain humanity and grace to the bedside. Most of those working in healthcare – doctors, nurses, nursing homes – would argue that we probably identify people too late for hospice. 80% of health system leaders say they would like to see more use of hospice but there is another societal question – how much families, consumers and our health system are willing to spend for an additional month of life.

Extra Point: Music can be therapy, for kids on the spectrum and moms and dads who can’t find the keys in the morning. It is therapy on Thanksgiving when your dog eats both pumpkin pies and when big Uncle Fred falls asleep on the remote. Music is also therapy for people with an addiction or traumatic brain injuries, and for people like my grandmother Carmella Antonelli who grew up in the mountains of Napoli and made me laugh when she snuck 2 anisette cookies onto my lap for breakfast. I lived with Carmella for a few years back in the earlier 90s in the latter stages of the Alzheimer’s that took her brain, but not her humor. A person with Alzheimer’s knows the pieces of the puzzle are missing …. and they are terrified. Carmella and I would watch tennis on the TV on Saturday mornings back in Fairlawn New Jersey and listen to Frank’s Fly Me To The Moon. She was 82 and I can’t remember a single time we talked about her Alzheimer’s. My friend Eric has. Maybe you know someone who has talked about their disease. Like Carmella, Eric was a young guy when he got the Alzheimer’s. I remember when his son Michael was born, just after Adam Viniteri kicked that ball in the snow to beat the Raiders. Michael talks to his dad here and if there’s a moment that hits home, it’s when the credits roll and the music plays…

40: Percent of coverage policies with step therapy protocols for getting medications, according to a recent study published by Health Affairs. Using data that covers 17 of the 20 largest payers in the US, the study shows that more payers are implementing step therapy protocols for certain diseases compared to previous years, and some payers’ plans may be stricter than needed. Those with step therapy protocols used an average of 1.5 steps but 90 protocols, 3.1%, included as many as four steps and one plan had eight steps protocol. Researchers emphasized “onerous step therapy protocols can add to the complexity and burden of health care”.

Tea, Jam, Bread & Behavior: Earlier this month, CareFirst joined with a global behavioral health company called 7 Cups of Tea to offer free support forums and licensed therapists through a smartphone, computer, or tablet.

Before You Do Anything: Cigna is the latest insurer to launch a virtual-first plan for 2022 and is well positioned to do so, having bought telehealth platform MDLive earlier this year. Cigna will offer virtual-first primary, dermatology, behavioral and urgent care services for employers, beginning with large, self-insured plans, and will offer digital dermatology to its exchange members.

Sliding Scale Care: A new health center, the Dr. Ala Stanford Center for Health Equity, just opened in Philadelphia, offering preventive care, behavioral health, and social services. The clinic grew out of efforts last year to provide care in underserved communities, including COVID-19 testing clinics, led by Dr. Stanford. The center has 8 exam rooms and 5 doctors currently, along with nurses and other staff and will offer care on an income-based sliding scale.

Hospital At Home: In recent weeks the National Nurses United group has argued that hospital-at-home models like those Kaiser and Mayo Clinic have been investing in do not allow for the same level of care a hospital does, and threaten nurse’s jobs. Kaiser’s program is currently operating at two pilot sites in California, using iPads to remotely monitor patients, but it remains to be seen whether this backlash will impact Kaiser’s plans to roll out the program system-wide.

Family Ties: For those who remember, Alex Keaton once told his Uncle Ned played by Tom Hanks that he needed help after Ned downed a bottle of vanilla extract.  Family counseling is making strides in the real world - starting in 2022, Blue Cross NC will provide coverage of family psychotherapy, even without the presence of the patient. This will allow providers to better incorporate the families of those dealing with mental health or substance abuse issues.

Kidney Prevention Partner: Anthem is the latest payer to focus on managing patients with kidney disease, by investing in kidney care startup Somatus with a multi-year value-based care partnership. Somatus will provide clinical services to Anthem’s MA members with chronic kidney disease and end-stage renal disease (ESRD). Somatus has also developed technology that will help Anthem flag patients at risk of developing kidney disease and connect them to the necessary care and resources.

Complicated Feet: Independence Blue Cross is partnering with virtual care management company Podimetrics to care for members with diabetes and have a history of diabetic foot ulcers. Certain members with diabetes will be monitored using the company's cellular-connected SmartMat, which can detect warning signs of diabetic foot complications earlier, allowing for interventions to help prevent diabetic amputations.

Extra Point:  AA is no longer so anonymous and it seems to me to be a good example of a paradigm shift in how we think about and talk about belonging. “Mom, you can’t just go to the AA meeting,” Kristen Wiig’s character said to her mom Jill Clayburgh in the comedy Bridesmaids, only to have mom say, “Well, honey, that’s only because I haven’t had a drink – there’s some really good people in there who need my help…” It’s no longer a place to get help, it’s a place to help. In a conversation this week during a slow jog in the dark at 5:30 (by slow I mean pathetic, like 15 minute mile pace), I bumped into a friend who works for a regional health plan here in the northeast. He says he’s leaving his job and family to go to a treatment center for alcohol recovery and also said the amount of claims related to alcohol abuse are up something like 120% since last year, that’s right 120%. “It’s coming in from all areas – seeing more hospital but a much bigger jump in our own network spend in treatment programs.” The biggest age group impacted – 27 to 35, like my friend. He’s hoping like a lot of us to find where he belongs and how to reset – “I hope to walk out of there with a new purpose … but I am scared,” he said. We’ve always been a culture that likes to put itself into groups and for the longest time we’ve also liked that we know exactly what we’d get out of them. It used to be that if I went to church on Sundays I knew I’d get a 5 minute homily from Father O’Shea on being good, and donuts in the basement, and if I didn’t go to church I knew I would go to hell. But now, the rules are changing. We are evolving in where we belong, what we expect, and how we talk about it. No more hell when I skip church, just limbo and maybe Heaven if I keep holding the door for grandma. In healthcare, there was a time kids, when you’d get sick, take two aspirin and call your doctor but in the future you will go on your support group app to find the fastest urgent care appointment and they will just treat you in the waiting room, because, well, we all know each other’s stuff. We belong to a more connected world, and everything from our peccadillos to our addictions are on display. And maybe that’s okay. Yes, we want to belong to something as Pat Benatar rocked, and we want to get something from it, but we are now finally more willing to share that and to wear our stuff on our sleeves. And if you're anything like Jill Clayburgh’s character in Bridesmaids, you get satisfaction from belonging to something not for your benefit, but for someone else’s.

118: The amount of funding in millions that Workit Health recently raised for its telehealth SUD treatment. The venture funds of BCBS and CVS contributed, indicating continued interest from health plans on novel models for treating addiction. Workit currently offers SUD treatment in 10 states and plans to use the funding to expand to new markets.

Seeing Straight: Arrhythmias and orthostatic hypertension can cause dizziness, panic disorders can lead to blurry vision and acute stress can cause a range of issues, including migraines, and The Department of Defense has put out a range of guidelines and recommendations for these conditions, particularly to assist caregivers and healthcare providers dealing with veterans. The challenge for the health system is these conditions and patients show up at varying stages of risk, and at different sites of service. Figuring out a way to better coordinate and track diagnostics, care and monitoring of these patients is needed.

Risky Business: Teladoc has plans to move into risk-taking arrangements, the company announced last week. Using its new virtual primary program, Primary360, the telehealth company is planning to expand beyond basic fee-for-service arrangements. This will be the first national telehealth platform we’ve seen move into this area, but it’s not entirely a surprise given the success of the many in-person PCP groups performing successfully in this space.

The Next Gene: When actor Gene Hackman said “my team’s on the court” in the classic Hoosiers scene you knew it was an iconic moment, and you knew he’d pay a price for playing with just 4 kids. There’s a new famous Gene emerging in healthcare whose moment is coming amid rising prices. Aetna is launching a network of gene-based cellular and innovative therapies, available in 2022 for the plan’s fully and self-insured customers. The network will be structured like a Center of Excellence program and will include 75+ providers who treat rare diseases. 3 therapies in this field are currently FDA approved - Zolgensma and Spinraza for spinal muscular atrophy and Luxturna for inherited retinal disease - and Aetna expects up to 9 more to be approved over the next 2 years. Gene and cell therapies carry a very high price tag and payers have been working to develop novel ways to cover these treatments, which we reported back in July of 2020.

Into Head Space: Blue Shield of CA will offer their members access to Headspace, the mindfulness and meditation app with 1,000+ stress reduction exercises. This app is among a list of other apps offered through the plan’s customizable digitally based lifestyle medicine and health platform, Wellvolution, provided through collaboration with Solera Health.

Digital Therapy For SUD, ADHD: Digital therapeutic products for ADHD and SUD are considered investigational, but a new Premera Blue policy provides a framework for when these can be considered medically necessary, including FDA approval and high quality-evidence that shows clinically meaningful improvement in health outcomes. A recent study surveying health plans showed that many payers are unfamiliar with prescription digital therapeutics and those who are familiar with them largely do not cover them yet.

Psych Shortage: The shortage of mental health providers is only getting worse, estimates the Substance Abuse and Mental Health Services Administration, with new data suggesting that by 2025 the US will have a shortage of 10,470 marriage and family therapists, 15,400 psychiatrists, and 26,930 mental health counselors. Other shortages will include school counselors, psychologists and social workers. In general, professionals are aging out of these fields more quickly than they are being replaced.

Bone Loss: At Wyoming’s recent P&T Committee, there were questions about a combo medicine used for management of heavy menstrual bleeding associated with uterine leiomyomas. Potential for ~2% bone loss worse than placebo exists in Myfembree, but outcomes are better than relugolix monotherapy. Concerns about long-term effects have led to a 24-month limit on use. The Department of Health will suggest a cost analysis.

Block or Buster?: If you ever rented St. Elmo’s Fire from the Blockbuster you are (a) old, (b) probably still owe late fees or (c) can appreciate the fact that in healthcare there is a lesson to be learned from the buster’s fall from Friday date night grace.  In the next several years look out for healthcare’s next Blockbuster—a model that had its moment, filled a need, but didn’t see the forest for the trees, as a good friend likes to say. In our upcoming 2022 Healthcare Payer Index of Index we will share what managed care veterans think might just be the next declining model—the next Blockbuster of healthcare….stay tuned.

Extra Point: Bet you didn’t know that I have turned to what my dad calls the dark side...It all started when I learned that the single largest referral cost for most Medicaid plans in Texas is, wait for it, POST. Okay, that’s PT, OT, and speech therapy for the laymen. 5 years ago, one Medicaid MCO was spending $27 million a year, but managed to carve it down to a cool $18 million with some good ‘ole fashion utilization management. PT and OT need to be careful about these UM and value-based trends – will they incentivize fewer referrals and change behavior? Will the PCP just do their own therapy? Probably not to any meaningful degree, but it’s worth monitoring. I am going to try to take a page out of the same utilization control playbook here at home. For example, my 14-year-old takes an inordinate number of showers in our bathroom singing We Are The World at the top of his lungs, which is both impressive and makes me a little nauseous, but rather than implement a pre-approval rule or shower cap, I’m just going to just charge him rent. That’ll steer him in the right direction. I might just even capitate it – I’ll pay him say $50 a month, but he owes me $10 for rent, $10 for food, 50 cents for every time he fails to do his own dishes and makes fun of me when I lose my keys twice each morning, so by month’s end he’ll probably owe me! But heck I’m not scrooge - if he does his own stinky laundry and takes showers in the other bathroom, he can keep 80% of the remainder. To be honest, this is part parenting, part my work seeping into my life, and partly to help pay for college.