Behavioral Health Insights

66: On a hunch, about two thirds of parents of children on the spectrum are, themselves, somewhere on the spectrum too, though the vast majority self reported that they were never formally diagnosed, according to a random exploration into ABA and autism diagnostic and treatment spending by Paula Ortiz, a recent college graduate who conducted the study for her Master’s degree in Rhode Island.  Ortiz acknowledges this was just a random sampling of 100 and may not mean anything.  She works two jobs to help pay for her degree, and raises a 6-year-old with significant verbal delays, and “so I obviously figured there was a connection”.  She says she was diagnosed with the neurological condition Apraxia at age 11 – Apraxia can greatly limit a person’s ability to speak but it is treatable, as it was for Ortiz.

Payback For A Less Than Good Outcome:  Lung cancer patients who fail to get to goal on Alunbrig will be part of a new risk-sharing arrangement between Takeda and New England insurer Point32Health, formerly Harvard Pilgrim and Tufts.  Takeda has agreed to reimburse the insurer should the treatment not work. These arrangements have been tricky to build but there have been some strides. Highmark BCBS started reviewing specific pharmacy and medical criteria back in 2018 to determine if COPD or asthma-related symptoms in patients on the drug Symbicort were in-line with clinical trial results. If Symbicort didn’t perform as expected, AstraZeneca provided a rebate.

Here’s The Skinny: Only 11% of dermatologists in our quick poll say they are taking new patients compared to 59% of dermatology PAs and APRNs, including my own appointment with a PA that, wait for it, will be in January 2022.

Unacceptable: So a long-time friend who’s been a network development director for a national managed care company says he sometimes gets a flurry of requests from care management vendors to manage care at home – 120 in one year – “but I would almost rather see another MCO try it first to see if there’s ROI…and I do worry about how these things impact my local docs and our value based agreements.” In some situations, he doesn’t love how the national team will at times “basically force” the local networks to use a vendor.  “We usually are given guidance on what they want the contract to be – what’s acceptable or unacceptable.”  Sounds a lot like my Saturday mornings – mowing the lawn and helping fold with the laundry (acceptable), playing a 3 hour basketball game then heading to the pub (unacceptable).

Social Seinfeld: The comedian used to say he liked soup so much because he was a lazy eater.   Soup kitchens used to be the old model of helping underserved, a kind of symbol of how those more fortunate could assist poor, homeless, hungry. But the science and data around social services, including the benefits of a single bowl of hot soup, are changing behavior. Now, more insurers as we predicted 6 years ago are hiring social workers and an increasing number are designing social service networks to help improve a person’s physical and mental health.  A Michigan insurer, Priority Health, was the first to offer financial incentives to providers who screen patients and submit information on social determinants of health. Physician practices recognized as a Patient-Centered Medical Home can use an approved tool to screen patients and complete the SDOH survey to receive increased reimbursement.

Specialty Care’s New Home: Oak Street acquired virtual specialty provider RubiconMD, allowing Oak Street to expand from just primary care into specialty care, something we’ve been suggesting these value-based PCP groups would (or should) likely pivot to. RubiconMD provides access to specialists across 230 specialties. One Medical, another PCP group focused on risk-taking arrangements, launched a new chronic condition management program this month as well, in an effort to also expand beyond primary care.

Kidney Bean There Done That:  Blue Shield of California is collaborating with Cricket Health to launch a care coordination program for members with late stage chronic kidney disease (CKD) or end-stage kidney disease (ESRD). This program is part of Blue CA’s Health Reimagined initiative and will measure key clinical measures related to CKD and ESRD, including ability to reduce hospitalizations and allowing alternative dialysis sites of service.

Shark Tank PBM: If you have a healthcare business idea, maybe take it to the show. I personally want to create a kind of moving belt system that you can jog on without actually going forward, though something tells me that’s already been done.  Dallas Mavericks owner and Shark Tank’s most well known “shark” is launching a PBM this month that will sell generic drugs at a transparent fixed rate. Others are following—a national employer group with members like Walmart, Costco and Microsoft is launching EmsanaRx for large employers, arguing that employers often “don’t have access to information about drug costs, discounts and administrative fees”.

Patient Communication Lag: “There is a lot of difficulty with providing access and alerts between two practices so sometimes patients get into a crisis, and an intervention is late in coming.”  This from a physician noting challenges with patient and provider communication.  Over half in our Poll of the Week believe patient to provider communication could be improved. Respondents pointed out the difficulty of communicating between the patients’ multiple practices, as most practices do not use the same messaging platform.

Pediatrics Relaxing Authorization: eviCore is actually going to relax what it asks for during the authorization process for musculoskeletal and PT/OT interventions to treat kids with neurodevelopmental conditions. They call these specialized therapy requests.

Extra Point: Strange but true marriages continue to find their way onto healthcare’s alter. The latest in Missouri is a merging of Citizens Memorial Hospital, Bolivar OBGYN and, wait for it, Butterfield Park Pediatrics. Sounds like a page out of Prince Humperdink and Buttercup’s odd coupling in the Princess Bride, but actually combining pediatrics and women’s health is likely an emerging trend. Expect more health systems to expand these service lines and for more commercial insurers to redesign payment to favor these double-specialty practices. The amount of ‘episodes of care’ and clinical efficiencies are significant – just think about an encounter involving a child potentially on the autism spectrum, or a new mom not needing to shuffle between OB and pediatrics amidst post-partem. Even stranger is a dental practice out west that’s talking with an allergy and asthma clinic about merging forces to help the Medicaid population. Patients taking asthma medication are often at risk of tooth erosion or periodontal disease. The marriage bug likely makes its way into home health too – will an Instacart join with a home care agency, will a physical therapy clinic merge with an outpatient psych therapy practice. My own marriage had its own strange start if you talk to my in-laws – a short Italian marrying a tall Irish Catholic. A Yankee wedding a Red Sox. But our marriage probably has thrived on the differences. After 21 years in sickness and health, it’s still working. My dad used to say you ought to be able re-contract every 5 years. I guess I could ask for a fee for service allowance or incentives every time I bring Bridget water or a greater share of the apple pie for risking my life on the ladder, but there a zillion more things she does. This is all to say that some partnerships may seem odd, but that’s just the surface.

850: Pacific Dental Services, the Irvine, CA based dental service organization, hasn’t just opened its 850th dental practice but it has launched a dental-medical practice with the opening of 3 practices - general dentistry, pediatric dentistry, and medical care - all in one Nevada location.

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 allows OP therapy for gamblers without pre-approval. Residential, partial hospitalization and inpatient services are thought to be investigational.

ACT Now For 7%: Molina in Illinois has decided to increase reimbursement rates +7% for assertive community treatment both for individuals or in groups.

Best Buy, Really? The place with all the big TVs has a health strategy if you can believe it, and it’s not too far afield from the biggest trend in healthcare. In 2018, it bought an emergency call service called GreatCall to add to its home-based motion sensor and monitoring technology to help aging seniors. You could see risk-taking super groups promoting such a service and technology, perhaps MA plans too. Perhaps offering discounts on flatscreens or DVDs if they even exist in 5 years. Can’t you just see it – while Best Buy installs the sensor in your mom’s condo, you ask the technician if he has GeekSquad credentials to help reboot your laptop. Now Best Buy is acquiring Current Health, a United Kingdom-based home care platform that focuses on remote patient monitoring, telehealth, and patient engagement.

Yellow Lab: Caution, labs without much scale or utility. HCSC, the parent company of 5 BCBS plans including Illinois and Texas, is launching a new laboratory program for commercial non-HMO members effective January 2022 that we expect may be something similar to what United and Anthem have launched in recent years, including preferred lab providers and possibly a move to better align lab rates across hospital and outpatient locations. Few details have been announced.

It Takes A Village: Walgreens has doubled down on its investment in VillageMD, the home based primary care group. This will allow 600 more Village Medical at Walgreens locations to open by 2025, with a goal of 1000 new spots by 2027, over half in medically underserved communities. Walgreens also recently invested in CareCentrix, a post-acute provider that helps transition patients from the hospital to home, along with Shields Health Solutions, which helps hospitals run their own specialty pharmacies.

Not Your Dad’s Medical School: Mount Sinai’s Icahn School of Medicine is launching the first AI focused department within a medical school in the US. The Department of AI and Human Health will conduct AI research and build an AI framework to deploy throughout Mount Sinai, allowing all physicians at any of their locations access to any new AI-driven tools that are developed.

Price Sharing: Walmart is partnering with Transcarent to offer self-insured employers a new option. The partnership will offer Walmart’s prescription drugs, optical, telehealth, and other healthcare services along with Transcarent’s digital platform which helps patients navigate their health benefits online and find the right sites of care. This new option is the first time Walmart has allowed other employers its prices on drugs and healthcare services, and the option will be open to employers of any size.

Virtual Benefit: United is planning to launch a new virtual primary product by the end of the year, utilizing its Optum physician network. The new product, NavigateNow, will mostly rely on an Optum care team for primary, urgent, and behavioral health services, with UnitedHealthcare's physician network as a backup for any in-person needs. It will initially be available to select employers in nine markets, with plans to expand to at least 25 markets by the end of 2022, along with making it available to employers with self-funded plans.

Did You Know? 50% of all lifetime cases of mental illness begin by age 14 and 75% develop by age 24, according to the National Alliance on Mental Illness.

Sleep It Off: If you like baseball these days, you’re tired. I mean the Dodgers and Braves is a great matchup for the Pennant, but without Vin Scully on the call I’m yawning by the 3^rd inning.  At least we have daylight savings coming so we can fall back to sleep. Bet you didn’t know that sleep disorders like apnea cost upwards of $165 billion a year according to Harvard Medical School’s Division of Sleep Medicine. AIM Specialty is trying to control these costs for insurers. Take Carolina where you need to get pre-approval under a relatively new program led by Blue Carolina for home and facility-based sleep tests plus ongoing orders like for CPAP.

My Gift Is My Song: So you try to show value, and you take your daughter who’s struggling out to supper and blast Ben Platt’s new album on the way. You sing an uncomfortably ambitious falsetto at the traffic light, with the windows down. Not because it sounds good, but because it makes her laugh. Nurse Brenda Buurstra once sang ‘You Light Up My Life’ to Robert Olsen during the older man’s weeklong stay for breathing issues at Bronson Hospital in Michigan. Despite initial expectations that Robert’s lungs wouldn’t hold up, he was discharged home in a week and hasn’t been admitted back. Brenda sang to patients before things like readmission penalties and social determinants were a thing. “I’ve been singing to patients for 14 years,” she told a CBS TV reporter. “It’s just the first time I got caught.” I showed my daughter Sophie Brenda’s video clip last night and while she didn’t get that part in the school play this week, she is now seeing her own voice in a different light. Sure, maybe she’ll be a Bernadette Peters or star as Belle on Broadway, but if not, something tells me there’s another leading role waiting for her bedside. Her song here.

Extra Point: In about a year I turn 50 and this invariably means a major healthcare milestone to prep for….wait for it….that’s right, the senior circuit, as in the tennis tour or maybe even water polo. With my speed and agility I should dominate the 60 and 70 year-olds. Seniors across the US are moving more than ever as part of an effort by more doctors and insurers to promote walking groups and aerobics circa Richard Simmons jazzercise of the 1980s, but they won’t be able to keep up with me. I suppose the only thing holding me back may be my limited talent. I mean I lost the spin in my topspin forehand by the time I was changing 3 sets of diapers in my 30s. Maybe the sports senior circuit isn’t quite right. Maybe I’ll create a Bohemian healthcare for seniors circuit instead. My friends always say I’m part Bohemian. I could do what any healthcare startup does. First, create a following, maybe take my followers and go to insurers touting how my program keeps people out of hospitals. That will definitely be a differentiator. I could use fancy words like “measures” and “algorithms” and when they ask me about my site of care I bet I’ll catch them off guard when I say somedays it’s frisbee at the park, some days painting in a meadow. Very Bohemian. When they deny me, I’ll threaten to go out of network, or well actually I can’t threaten that without a contract, but I could find a temporary code for this sort of new age healthcare and bill that, but something tells me that will raise all kinds of questions. Perhaps I should just design a capitated arrangement in Florida and offer risk groups the chance to pay me out of their PMPM. I’ll keep an eye on their patients after they leave clinic but not so much with remote monitoring as more of a spiritual, laissez faire oversight. As I think more about it, 50 seems like a lot of work if I’m not careful.

76: Percent of high school seniors polled here in my home town this past week who are reportedly going to pursue a career in nursing.

Homeward Bound: SCAN Health Plan is offering a new type of plan for members who are homebound or reside in SNFs or assisted living, called the Embrace plan. The plan, an Institutional Special Needs plan for MA enrollees, will focus on allowing these members to remain in their homes or facilities while receiving care that would typically be provided in a doctor’s office or hospital. Enrollment in Embrace for calendar year 2022 begins on October 15, 2021.

Georgia On My Mind: HCA is selling another Georgia hospital to AdventHealth, months after selling 4 to Piedmont, which means HCA will no longer have a footprint in northwest Georgia. AdventHealth is acquiring Redmond Regional Medical Center in Rome, which also comes with physician clinics and outpatient services.

PAs Come and Go: Beginning January 7, 2022, Premera Blue Cross will require prior authorization for all non-malignant, non-gender affirming hysterectomies. Site of service reviews will also be part of the PA. Meanwhile, Horizon Blue Cross is removing PA and medical necessity determination reviews, either pre or post service, for Psychological and Neuropsychological testing, effective November 1, 2021.

Moving On Up: Molina is buying AgeWell’s Medicaid long-term care business in New York, which will add 13,000 lives to Molina’s NY footprint. Molina has been focused on adding more government lives to its business, buying Cigna’s Medicaid business in Texas in August of this year, and Passport Health Plan’s Medicaid and dual eligible business in Kentucky late last year.

Dark Side of Social Media: Eating disorders are one of the deadliest mental health disorders, and social media plays a major role in promoting potentially triggering content. Large social media companies have been in the news lately with claims that the platforms are aware of their harmful mental health effects on young teens. Click here to read the full report.

Food’s Here: Blue Shield in California has will expand benefits for MA beneficiaries in 2022, including the addition of a new home-delivered meal benefit, which includes up to 22 meals and 10 snacks per hospital discharge with a limit of 2 discharges per year. They are also adding dental benefits to Central and Northern CA plans, which include preventive and diagnostic dental services such as cleanings, exams, and x-rays.

Pop! Goes My Heart: GuideWell backed PopHealthCare, a national provider of home-based and risk adjustment services, launched Emcara Health, a national value-based medical group. Emcara’s offerings include 24/7 Home-Based Advanced Primary Care, transition care, ER diversion, SDoH assessments, and other services for vulnerable seniors and adults.

AirLine Charging For COVID: People that are unvaccinated against COVID-19 may have to pay more for health insurance premiums. Delta Airlines will charge their unvaccinated employees an additional $200 a month for their company health plan due to the high cost of COVID hospitalizations which can cost the company up to almost $50,000 per patient. Delta Airlines is not currently requiring employee vaccination, but this cost may incentivize employees to get vaccinated.

Dental Meet Medical: In our poll of the week, 95% believe dental should be included under traditional health care coverage. Oral health, if unchecked, can contribute to conditions like heart disease and pneumonia, and in reverse, conditions like diabetes, depression, and Alzheimer’s can negatively affect oral health. “Most bacteria from the oral area are the very same bacteria that can infect our heart or respiratory system,” said one respondent. The American Dental Association predicts dental and medical benefits merging will happen soon, saying that “medical plans have a clear or significant advantage over standalone dental insurers in a bundled scenario.”

Extra Point: Dr. Van Norstrom from the clinic once told the receptionist in Seinfeld that he needed Elaine Benes’ chart, because “she’s not going to make it. It’s very bad, very messy.” He was lying, of course, but if you’re burning the candle as I seem to be lately, and as I suspect many of you are if you are somehow connected to healthcare, you start to wonder where the tipping point might be and if you can make it at this pace.  When the work moves you from excitement to exhaustion to sick you start wondering if you need a session with Dr. Van Norstrom, from the clinic. Wherever that is.  I know I hit a wall this morning when I went to sleep during breakfast standing up, which is really hard to do and also painful when you wake up and smack your funny bone, which startles the dog and knocks over the kids gramma.  I also put the hot coffee pot in the fridge, which is probably a good idea in July, but not so much today.  I managed to make my way outside at 7:15 to drive someone to school – I couldn’t tell who because the hood over their head shielded their teenage angst - and then, perhaps still reeling from my funny bone injury - I drove the truck into the garage door. It’s very messy this work-life balance. But on the upside, there’s always those 2-days every week at the end of the week to recharge the batteries, and as will be the case this weekend, fix the garage door.

112M: The cost savings BCBS of NC experienced through its partnership with laboratory benefit manager, Avalon Healthcare Solutions. Since initiating the partnership in 2017, Avalon helped move more lab services in-network and implemented pre-approval to ensure tests were medically necessary.  There’s a growing focus on the “clinical utility” of lab tests.  In 2020, 99% of all lab services were provided within BCBS NC’s network, compared to 86% in 2017.

Good Genes: Beginning January 2022, BCBS Michigan will begin allowing genetic counselors to join their network and receive direct reimbursement. Participating genetic counselors will be able to bill their professional services using codes 96040 and S0265. They can receive direct reimbursement for covered services at 85% of the applicable fee schedule.

The New Social Network: AmeriHealth Caritas is launching a new subsidiary focused on social determinants of health (SDoH). Social Determinants of Life will invest in and support solutions that help people improve their life outcomes. The company’s first investment is Wider Circle, a California-based startup that designs tech-enabled health programs and peer-to-peer social networks. The investment in Wider Circle will allow the company to harness social networks, which research has found can contribute to better health by boosting resilience and leading to improved life trajectories. BCBS of Minnesota is also focusing on SDoH by adding no-cost community health worker services to commercial health plans beginning January 2022. They will be the first health plan in that state to expand use of health care liaisons beyond public health programs.

Doctor, Can You Hear Me?: Amazon Web Services will offer hospitals three new ways to improve communication with patients. Health systems will soon be able to automate outbound calls, texts, and emails with patients via Amazon Connect without the need for third-party integrations with other systems. AWS will also allow providers to verify a caller's identity based on their voice through Amazon Connect Voice ID, potentially eliminating the need to screen each caller manually and speeding up customer service calls. Last, Amazon Connect Wisdom can automatically detect patients' issues and give customer service representatives access to real-time information from in-house databases or third parties using speech analytics to help them resolve patients' problems.

Sweet Home Chicago: Rush University is partnering with DispatchHealth to provide at-home care to patients who would otherwise need to receive care at the health system’s ER or urgent care. After initial triage to ensure a patient should not be rushed to an ER, the typical DispatchHealth home visit involves a nurse practitioner or physician's assistant traveling to a patient's location, treating the condition, and connecting the patient with a DispatchHealth medical doctor, usually through telehealth. The DispatchHealth car carries all the tools for most emergency care needs, including lab tests, medications, and medical imaging equipment. The program began October 7.

Primary Expansion: Group Health Cooperative of South-Central Wisconsin is partnering with UW Health and UnityPoint Health, which adds 19 primary care clinics to GHC’s network. With these additions, starting in 2022, GHC members will have the largest primary care network in Dane County, with access to 38 total clinics and over 300 primary care providers.

Baby Bundles: BCBS of NC will begin offering a Maternity Episode-Based Payments Program (EBP), which includes incentive payments for providers able to keep costs below the average episode cost. During years 1 and 2 there will be no downside risk for providers, but in year 3 downside risk will be introduced with a protection cap.

Hospice Partnership: Pharos Capital is acquiring THEMA Health Services of Arizona to build a new hospice and home health platform. THEMA provides hospice care, routine medical care, pain, and symptom management for terminally ill patients. The acquisition will help THEMA expand its hospice and post-acute care service offerings in rural markets.

Extra Point: Please pray for my son Tommy. He wrote me a text today at 10:30 am saying this – “I hav soar throt. Can you pick me up now? All I have is english class that I’m getting a in doing reely good so can you get me."

1M: Blue Shield California’s community investment to help the California Department of Education expand support for youth mental and behavioral health services within the state’s public school system. California’s Department of Education specifically needs help expanding access to preventive programming, scaling youth mental health training for educators, and creating a statewide Medi-Cal technical assistance guide to help more families access mental and behavioral health services across the state.

Papa Does Preach: Maybe Madonna had it wrong after all. A senior companionship company, Papa, is partnering with consulting firm Milliman to provide a mobile platform called “HealthIO” to help seniors with complex conditions keep track of their health status and recognize urgent issues. Papa will be enlisting their non-clinical companions to help seniors with socialization, technology and housework. Papa is currently in all 50 states and contracts with Medicare Advantage, Medicaid, and employer sponsored health plans.

Smoke Em If You Got Em:  Aetna has expanded coverage for low dose CT lung cancer screenings. People 50 and older who have smoked 20+ packs a year are now eligible, a change from the age 55 and 30+ pack a year minimum.

Imagine All The People: Intermountain Healthcare is, wait for it, launching its own outpatient imaging business.

Playing The Blue Card: Regence BCBS and Intermountain Healthcare are launching a new preferred provider organization (PPO), Preferred Blue Option. It is part of the BlueCard program which means that by enrolling in the Preferred Blue Option network, US companies with at least 51 employees appear as though they will have state-wide access to all of Intermountain’s hospitals and clinics in Utah, including, presumably, its new outpatient imaging centers. The network will be available January 2022.

Strip Mall Senior Care: MetroHealth, the Cleveland-based health system, is opening new senior health sites beginning early next year. The program is known as the Spry Senior Care initiative and so far, MetroHealth has at least four locations identified with a goal to have 20 to 25 locations in the next three to five years. They'll be located not in larger medical buildings but in strip malls or standalone locations. Doctors will see no more than six patients per day and will aim to spend at least an hour with each.

A Network For The Little Guys: Truli for Health, a Florida Blue-affiliated company, is a new HMO being offered in select Florida markets to give small and medium-sized businesses a new option for health care coverage for their employees. Truli’s network of providers includes Baptist South Florida, Cleveland Clinic, HCA Central, Sanitas Medical Centers, Guidewell Primary Care, Guidewell Emergency Doctors, among others. Truli will also use a Center of Excellence program with the Mayo Clinic in Jacksonville.

Recruiting Nurses: To counteract the aging baby boomer population and shortage of skilled nurses in the industry, one company is partnering with a community school district to reach children as young as middle school age about the skilled nursing profession. Bedrock Healthcare of Milwaukee, Wisconsin is creating interest in young pre-teen minds for the career field of skilled nursing, especially in rural areas. The demand for skilled nursing, certified nursing assistants and aides has been steadily increasing over the past 10 years, studies have shown.

Extra Point: I was trying to figure out the source of a leak this morning when I stumbled across an old stack of steno notebooks in my attic. A few were from 2001, and one had notes from an interview I did exactly 20 years ago today with Dave Tofanelli. Dave spent a good part of his years running enterprise-wide network contracting for what was Wellpoint at the time, now Anthem. We were talking about cancer broadly when he said, “We need to change how we do this. I want to see us fly the patient, their spouse or partner or support person to one of the major cancer centers like City of Hope or MD Anderson. Pay for the hotel, the travel, everything. Make them comfortable, allow the doctors to figure out the right clinical protocol, the right drug regimen, and do a call with the local oncologist so that everyone is on the same page. I know we need to do this for cancer and other conditions. Too many things go wrong when we don’t. Wrong treatments, wrong doses. Avoidable hospitalizations.”  Since that time, Tofanelli’s vision has certainly started to play out as more academic centers have expanded partnerships and more payers have expanded their benefit design to include these 1-week treatment kickoffs. Over the next 20 years, I suspect we will see more of this for other conditions and situations, particularly in the severe mental health field. Here’s an example of how this fly out diagnostic and treatment support model worked for one family whose son had been diagnosed and undiagnosed over 5 years with epilepsy, ADHD, autism and in one visit, “too difficult to diagnose.”

24601: Les Miserable fans know this number too well as the mark symbolizing Jean Valjean’s bread stealing moment during the end of the French Revolution, and in a symbolic way this is exactly the number a Medicaid managed care plan’s medical director is advocating the insurer pay per beneficiary per year (well, $24,600 to be exact, but what’s an extra dollar for effect?) to cover housing, health and wellness, transportation, job support and food as part of a social family support concept targeting underserved, typically refugee, populations.

Dose E Doh! Several insurers are looking to reduce doses for non-oncology related specialty medications. The goal is to avoid vial waste. PBMs like IngenioRx will evaluate dosing during the pre-authorization process and will be asked if the suggested dose is clinically appropriate, and likely will be asked to lower it if it is within 10% of the nearest whole vial. Payment is typically linked to the dose, so the review has some reimbursement implications. For now, only Anthem and a few Blue plans acknowledge starting the program this fall.

The New PCP: If you operate a practice with NPs, there’s a good chance your patients have or can start selecting them as their designated primary care provider. Under a new policy set to take effect in December this year, Anthem says it will begin allowing NPs collaborating with PCP groups “to be set up in the system for selection” for applicable plans. Other insurers have done this for years, for NPs and even Urgent Care centers. The insurer is reviewing provider data to identify candidates. It is unclear if the NPs could be eligible at some point if serving in a specialty practice like allergy or endocrinology, or if payment would be at the same level as the physician – odds are the payment would be 85% of the physician’s rate, but contractually some managed care plans will pay the same level and at a minimum being designated as a PCP can open up the NP for incentives tied to clinical quality and performance.

Social Investment: Penn Medicine and the Wharton Social Impact Initiative have invested $750K in businesses that focus on addressing social determinants of health. The money is going to Kinvolved, which has software to reduce school absenteeism, Uptrust, which provides reminders for probation appointments and RecoveryLink, a substance use telehealth platform.

Home Monitoring: Independence Blue Cross and LabCorp are providing the insurer’s Medicare diabetic members with home specimen collection kits they can use to monitor blood sugar levels and screen for certain cancers. The kits will include several tests, including an HbA1c test used to monitor blood sugar levels, an occult blood, fecal, immunoassay test to screen for colorectal cancer and diagnose other conditions that cause bleeding in the digestive tract, and a urine albumin test to screen for early kidney disease in people with risk factors such as diabetes and high blood pressure. The kits are no cost to members, but they do require doctors' orders to get them. Patients will receive kits in the mail and send them back to have their samples tested.

Nurse Shortage Ripple Effect: As the delta variant takes the country by storm, the nurse staffing shortage is becoming an increasingly dire situation. In our poll of the week, about 75% are currently facing a nurse shortage in their hospital or practice, forcing health systems to bring in both costly travel nurses and younger nurses with less experience. A younger nurse in NY transferred off her hospital’s COVID floor over to labor and delivery this month. She’s dealing with the PTSD of her first 6 months on the job and now finds herself in unfamiliar territory - unprepared for handling a stillborn case and a baby coming into the unit without a heartbeat. Some hospitals report needing at least 50-75 more nurses to be at an adequate level. Increasing compensation and benefits will help recruit and retain nurses but health systems say they can’t keep up with travel nurse agencies, some of which offer up to $5,000 a week. Georgia’s Augusta University Medical Center reported 20 to 30 resignations per week from nurses taking travel staff jobs. Recent vaccine mandates have also exacerbated the shortage. One hospital in NY is no longer delivering babies since 30 employees resigned due to the mandate. Some systems are trying to adapt. West Virginia University Medicine is offering new nurses bonuses up to $15k for a three-week work commitment and Monument Health in South Dakota is offering a $40k bonus to intensive care and operating room nurses.

On Second Thought: George Costanza once asked Kramer if he ought to get a second opinion about a rash on his arm, to which Kramer said, “I wouldn’t go outside looking like that until you do!” Perhaps Anthem’s new partnership with Cleveland Clinic could have helped. Anthem members from large employers will have access to second opinions virtually. The Clinic has 3,500 providers available to provide concierge-style service and video consultations. The program may roll out to a broader membership base in the future.

Medicare Coverage Expands, Impacting Drug Prices: The Build Back Better Act would expand Medicare coverage of dental, hearing and vision. In early September, The House Committees on Ways and Means and Energy and Commerce released draft legislation in early September and changes would be paid for largely through drug-pricing reforms. You can find more details here.

Mental Health Day: Employers are beginning to take a step in the right direction to prioritize employee’s mental health by implementing “mental health days.” Companies like Nike, Intel, Microsoft, Marriott International, and others are making changes because burnout caused by depression or anxiety in the workplace can affect not only a person’s personal life but their work performance as well. Studies have shown that working 55 or more hours per week is associated with a higher risk of a stroke and dying from heart disease than just 35-40 hours a week. And this idea doesn’t just affect adults, as studies have shown that children can be impacted by school-life mental strain as well. A new Illinois law will allow students to take up to 5 mental health days starting in 2022.

Extra Point: It’s quite remarkable that a 79-year-old has the patience to write this much over text and not a single lower case letter. Dad’s text this morning is both comical and impressive and for those of you with older folks in your life, you know about these messages – they are your window into the reality of getting old and how often times the kid becomes the parent: BRY!  NEED TO CANCEL COFFEE THIS MORNING. I GOT DIZZY AT STOPSHOP YESTERDAY AND STUMBLED INTO THE FRUIT LOOPS. THEY GAVE ME A CHAIR TO REST BUT DR. B WANTS TO SEE ME TODAY. MOM IS DRIVING BUT HAS HER CARDIOLOGIST APPOINTMENT AT 2. HER TEST CAME BACK WITH ABNORMAL CARDIAC ENZYME TEST. I THINK IT’S THE VANILLA YOGURT SHE ATE. I PUT MY CHOLESTEROL PILLS IN THERE AND SHE ATE THEM! SO SHE’S PRETTY MAD. CAN YOU TAKE HER? IM UP TO 15000 STEPS A DAY AROUND THE YARD BUT A GARDNER SNAKE SCARED ME OTHER DAY SO I’M BACK TO DOING IT INSIDE. THE GIANTS ARE AWFUL. REALLY BLEW THAT GAME. I THINK THE PATRIOTS WILL BE FINE. UNCLE AUGGIE’S FUNERAL WAS GOOD. DID MOM REMEMBER TO TELL YOU HE PASSED AWAY? 99! HE USED TO SNEAK ANISETTE COOKIES TO YOU. WE WATCHED THE SCHITT CREEK THIS WEEK. I DON’T UNDERSTAND IT. IPAD WONT TURN ON AGAIN. CAN ONE OF THE KIDS HELP? I HEAR FROM JACK EVERY WEEK. COLLEGE IS GOOD FOR HIM. LOVE TO JANINE AND KIDS. XOXOXO.

60: “Percent of the time…it works…EVERY time,” or so said Paul Rudd’s news character in Anchorman about his potent cologne, which Ron Burgundy sternly replied in a way that only Will Ferrell can, “Well that just doesn’t make sense” – which is of course logical and funny to say out loud, but Rudd’s stat isn’t so illogical if you think about it. In baseball, 60% gets you in the Hall of Fame, in high school it gets you a diploma and in healthcare it can get you “coverage” for novel treatments and increasingly that better-than-half goal will be part of more and more outcomes-based contracts, particularly for specialty pharmaceuticals that are high cost, like $30,000 or $100,000 a treatment, and even in contracts for physician specialists who can get 60% of high-cost patients to goal faster than peers.

Wal-Mart Charting New Ground: The company classifies specified surgeries performed outside of a center of excellence facility as out-of-network care and covers only 50% of the cost in most cases, according to a benefit design director for the retailer. The company has found impressive results from the care provided at their centers of excellence – including a one-day shorter average length of stay for spine and joint replacement surgery, a big drop in discharges to SNFs for surgical patients – 6 out of every 1,000 for spine patients using centers of excellence vs. 49 out of 100 at other providers, and up to a 3-week shorter period of time off. Additionally, about 50% of patients who went to these COEs never actually underwent surgery because providers told them they didn’t need it.

Unpaid Value Contract: A care coordination company in Urbana, Illinois got a $420 per member per month back in 2017 for managing at-risk youth from a state pilot program, incentives up to 15% of the dollars if hitting 5 cost targets while a Medicaid managed care plan in Kansas paid a family guidance center in Topeka a $20 PMPM for each high-risk patient seen in person, $1 PMPM for following-up with members after 7 days, $1.50 PMPM for eliminating adverse events, $80 for a medication review and other payments for managing youth with a mix of acute behavioral and diabetic conditions. These were some of the first programs to get creative around paying to reduce social costs, but there are lessons to learn from these reforms, namely that the providers had to do a lot of patient outreach and data collection and reporting that wasn’t reimbursed. Make sure to consider this when negotiating value-based contracts.

Like A Game Of Risk: If you’re not partnered with GuideWell, you might want to be. The parent company of Florida BCBS is gaining ground in the south, akin to the way Highmark is gaining in the north. It’s like a game of RISK, both because GuideWell plans to acquire Triple S Management, the BCBS plan in Puerto Rico, the largest health insurer in the territory, giving them 1M more lives, and because recent acquisitions of behavioral health management company New Directions and primary care company Sanitas Medical are indicators that Guidewell is looking to create an integrated risk-taking platform.

Drone Drop: More COVID-19 vaccines may be coming your way, courtesy of UPS Flight Forward, which completed the first drone delivery of COVID-19 vaccines last week to Atrium Health Wake Forest Baptist in North Carolina. The delivery went from the hospital to one of the health system's family medicine practices, about half a mile away. The drone can carry 25 vials each, for a total of 450 doses.

Run Run Run, As Fast As You Can: In my mind there are 5 famous gingers – Rodgers, Ale, Snap, the comedic beauty from Gilligan’s Island and, of course, the gingerbread man, but now there’s a new Ginger on the rise making headway in treating the fast moving mental health crisis. The on-demand mental health coaching and video visit company “Ginger” gives people access to therapists and psychiatrists and has merged with the meditation and mindfulness app Headspace to form a new company. Headspace Health will cover nearly 100 million lives through more than 2,700 employer and health plan customers, plus a direct-to-consumer business.

BurnOut App: Trinity Health is collaborating with Pennsylvania insurer Independence BCBS on a digital and clinical program to help support healthcare workers, many of whom are struggling to look after themselves while continuing to look after COVID-19 patients. The program will address clinical burnout using a self-guided care approach and personalized tools created by NeuroFlow, a mental health software company based in Philadelphia. An app allows nurses to journal and log daily insights and a clinical care team remotely monitors data.

Digital Ups & Downs: In a cautionary tale for digital health, the insurer Medica has decided to discontinue a digital pregnancy and fertility program from Ovia Health due to low utilization. This is part of the challenge going forward for tele and digital programs – payers like them, so do patients – in theory - but there’s a time to ROI, and if you’re not getting uptake the “potential” savings mean little and the program’s become merely a cost. The insurer will, however, start giving members access to Optum’s chiropractic network in 2022. The changes impact individual and family members.

Alzheimer’s Spike: In our poll of the week, nearly 4 in 10 expect an increase in patients with Alzheimer’s disease or early on-set Alzheimer’s due to COVID-19. The Alzheimer’s Association recently reported a link between COVID-19 and the neurological condition. A majority say it’s too early to know: “Patients have a temporary loss or impairment in some cases….but no way to predict if that is permanent.”

MusicMan: If healthcare specialists were assigned a single song, an anthem if you will to define their work and their value, I wonder if OBGYNs would choose Mamma Mia or if allergists would pick Annie Lenox’s Every Breath You Take. Songs matter in healthcare more than you think – they help people recover from illness and have proven at times to reduce the cost of medications, and now there are some interesting developments in coverage of music therapy, which to date has been sparsely covered. Stay tuned for the news and our Top 20 rankings of songs for specialists.

ExtraPoint: There are quite a few things that make us feel old. It starts when your kids stop believing in Santa and gets worse when they start wearing your pants, head off to college, then turn 20. Healthcare has its own aging milestones, like when that Medicare ID card comes in the mail or when you have to turn up the TV so loud the neighbors call the police. I’m having my own bouts with oldness, like getting to enjoy that really tasty colonoscopy prep drink or having to force the parents to drink their juice, or realizing you miss the times when you and dad shared the sports page and a spoon full of sugar over Raisin Bran. There are good milestones, like you can dominate athletic competitions like Izzy Mandelbaum did at Del Boca Vista in Seinfeld, or you can eat the early bird supper at 430 and still have time to work off the cheese cake. There’s also the grandkids. You can hold ‘em, burp ‘em and spoil ‘em, and when they start to kick and scream because you gave them cake for breakfast, you can go home. -BC

41,000: The number of members in health insurer Highmark’s 2019 claims data diagnosed with alcohol use disorder (AUD), leading to more than $4 million in spending and there are assumptions these numbers are rising, and quickly, as recent data suggests more adults than ever are drinking excessively. Highmark is offering its members new ways to treat alcohol disorder. One new option is Ria Health, a technology-enabled telehealth medical practice that focuses on treating AUD by combining medically assisted treatment with digital tools to help members track and record progress. The Ria Health team includes addiction medicine physicians, psychiatric nurse practitioners, psychiatrists, certified addiction counselors, and social workers treating Highmark members.

Poll of the Week: In our poll on behavioral health plan spend, a not-so-surprising 67% report that 4-6% of current commercial health plan spend is related to behavioral health care—higher than many thought it was—but by 2024, nearly all surveyed expect an increase. Some surveyed expect up to 10% of commercial spend on behavioral, others predict 6-10%. When asked what will drive the increase, one respondent said, “I believe the patient can become more balanced and have less incidence of physical manifestation of disease when educated on the overall benefits of good mental health.” Respondents largely expect societal awareness and increased prevalence of anxiety and depression due to COVID as major forces.

Something’s Got To Give: If behavioral spend takes a bigger share of the pie, is there a service that loses out? Since it is healthcare, logic says everyone keeps winning particularly as America ages and deals with epidemics and pandemics, but when we chatted with a few medical directors this week, there was some consensus that behavioral health’s rise may impact one subsector – pain. “I haven’t looked at every claim but there’s a lot we see in medical necessity notes from pain physicians and PTs and chiropractors about mental health, depression, and anxiety – I would think a portion of these patients don’t have chronic pain.”

Lifting The Hays: In Major League, Willie Snipes’ character used to always say “I hit like Mays and run like Hays,” only to prompt his manager to say “You may run like Hays but you hit like s___”. It’s a funny line in a movie about what goes behind the seasons in baseball, and how an underdog takes chances to be a winner. We sit down with healthcare’s version of an underdog, a risk taker with sights on good change for healthcare in the great northwest. Gillian Hays is the new VP of network development for Regence BCBS and she says the insurer is “dedicated to pursuing innovative, value arrangements.” Our interview with Hays is coming soon, but if you’re looking to get attention in the meantime, note that she spends her down-time facilitating an art literacy program for Portland Oregon elementary schools.

Out of Pocket, Out of Style: Geisinger is offering a new billing solution that utilizes artificial intelligence (AI) to help patients pay their out-of-pocket expenses. Up to 75% of patients with out-of-pocket balances often resort to compromising behavior when they owe healthcare providers, like pill splitting or skipping appointments. Patients with more than $250 balances after insurance can choose customized payment plans offered at no fees or interest. An AI-based algorithm analyzes more than 30,000 patient finance data to determine how much they are able to pay monthly. Patients now can complete payments in 60 months instead of the traditional timeframe of 12 to 18 months. That information is merged with provider data to adjust payments based on the likelihood patients will need additional treatment in the future. A pilot was introduced last fall in one of Geisinger's service regions before eventually expanding system wide.

Caregivers Needed: Caregivers are the backbone of America's long-term care system, but these mainly volunteer family and friends are facing declining health issues themselves and now the pandemic has exacerbated these issues and revealed weaknesses in the healthcare system. Solving this underappreciated epidemic is likely to become more important over the next decade and will require more collaboration and solutions from policymakers, advocacy groups, healthcare providers, and families. Our recent report, which can be found here, explores the emotional and physical stressors associated with caregiving as well as financial programs that could assist with this role.

Heads Up Carolina: Cityblock Health and BCBS of North Carolina are collaborating to open five clinics across the state aimed at providing comprehensive care to eligible low income individuals.The model will address physical, behavioral, and social determinants of health and will first become available to low-income members in Charlotte, Greensboro, Winston-Salem, and High Point, and Fayetteville.

Kidney Bean Or Bust: Cigna is expanding its value-based kidney care program through at least 2023. The program, in collaboration with Fresenius, offers Cigna providers who treat members with kidney failure or ESRD additional incentives based on meeting quality metrics while lowering total cost of care. One measure is addressing the high incidence of depression, which can lead to less effective outcomes.

Home Depot Virtual: I went there the other day and felt quite a bit inept, almost invisible – for starters, there’s a lot of paint cans and colors and I never quite figured out the difference between flat, enamel, satin and eggshell, and finding someone to help you feels a bit I imagine like going into a busy hospital ER complaining about a paper cut. But Home Depot is making strides for its employees – an HR director told me that use of telehealth skyrocketed last year, up +265% from pre-COVID, which sounds like a lot, and they are continuing this by offering all employees a single healthcare virtual contact to help them with where to get care, like at an in-network option. Home Depot is pursuing regional centers of excellence partnerships for people who eventually need surgery and “is willing to pay to fly people out of their area” if it gets them to “best quality surgeon.”

Extra Point: I’m all for a good metaphor, like the Yankees 11-game win streak must feel a lot like what I suppose a doctor experiences after going 11 for 11 diagnosing the real reason behind her patient’s pain symptoms. But my colleagues and I are admittedly falling into a bad habit lately comparing the state of healthcare reform to baseball. Everything is either in the 1^st or 3^rd or 5^th inning – I even oddly found myself saying pain management had moved into the bottom of the 5^th the other day, which is both weird and awkward, although perhaps explainable because it was raining at the time and that would mean the game would be over, which some pain practices should be cognizant of if they are over-reliant on certain services and tests. I vote we change the metaphor, maybe to hockey for its 3 periods, although I’m not sure anyone wants to know what sudden death would be to a business or sector, so maybe cross country, which has the same starting and endpoint and, much like healthcare, just runs in circles sometimes, like haven’t we been down this capitation thing before? My daughter tells me golf should work, and I think she’s right – I mean doctors, therapists, pharmacists and nurses for the most part are comfortable when the case is up the fairway. They can see the target and, unless a wind blows like a non-compliant patient or poor concentration, they can hit it. Going into the rough usually requires a special club, ala a healthcare specialist, and going OB usually comes with a penalty, much like what hospitals and doctors have to deal with if they miss the mark on a patient’s diagnosis or treatment. Good golfers get caddies ala a doctor who increasingly rely on assistants and NPs and if you’re fancy like Rodney Dangerfield, with his laser putting technology in Caddyshack, you have special equipment to see the image. Pros like Tiger use yardage books just as doctors now use spreadsheets that tell them just enough about a patient’s history to pick the right treatment. So for our purposes, unlike baseball’s climactic 9^th inning, golf never really ends, and nor will healthcare reform if I’m being honest. Yes, there’s the 18^th, but increasingly in healthcare you are only as good as your last patient or last year and increasingly measured versus the field.

50: The number of new medical centers Anthem is opening in partnership with CareMax, a senior healthcare provider focused in the Florida market. The medical centers will primarily be in areas where Anthem is focused on value-based care efforts, including Indiana, Texas, Kentucky, Wisconsin, Georgia, Connecticut, and Virginia.

Self Insured Strategy: Aetna is rolling out virtual primary care services to self-funded employers across the country. By partnering with Teladoc, the new Aetna Virtual Primary Care service will be available to members at no cost, and includes access to in-person visits if needed, including at CVS MinuteClinic and HealthHUB locations.

ReRun or New Episode? It may seem we’ve heard this one before. Regence’s Episodes of Care program, their first value-based arrangement that was launched a year and a half ago, is adding new providers and employers. Regence’s largest customer, the Washington State Health Care Authority will be part of the program, effective January 2022. The Episodes of Care program so far has driven 16% cost savings for orthopedic procedures and now covers other specialties including cardiac procedures, GI conditions, and maternity care.

Starting A Family: LabCorp is joining the digital health craze, having acquired a digital health platform that provides info and support to individuals looking to start a family. Ovia Health describes its services as helping "women plan for maternity and parenthood through a range of personalized clinical programs." The company's digital platform allows women to monitor symptoms, track potential health risks, and coordinate care with providers. The acquisition will allow LC to further develop new products and services around reproductive health conditions, in addition to the current specialty testing, including genetics, the lab giant currently offers.

Switching Alliance: BCBS of Massachusetts recently announced that it is moving from its current pharmacy benefit manager, Express Scripts, to CVS beginning January 1, 2023. The new agreement is expected to generate cumulative pharmacy savings for Blue Cross customers of between 10%-15% over the course of the three-year contract.

Diabetes Grant: BCBS of Arizona is granting $400,000 to local organizations to help reverse the diabetes trend and its impact on the healthcare system. Arizona based nonprofits, academic institutions, and government entities can request up to $75,000 in funding to further their work related to prevention, treatment, and management of diabetes. These funds can also help these organizations further social determinants of health (SDoH) initiatives for those living with Type 1 or Type 2 diabetes, pre-diabetes, or gestational diabetes.

Breast Detection Boost: Fujifilm Medical and ScreenPoint Medical are partnering to offer providers an AI solution designed for early breast cancer detection, called Transpara, powered by Fusion AI for 2D and 3D mammography. Fujifilm announced that the new FDA cleared Transpara, coupled with ScreenPoint’s AI solution, will display breast screening findings at a doctor’s reading station or PACS system. This is expected to help improve reading accuracy, reduce reading time, and improve workflow. Early detection is crucial to reducing breast cancer mortality rates and this collaboration will offer customers the latest support tools to identify potential breast cancers earlier than before.

Fireside Chat: In case you missed, about a year ago we held a kind of fireside chat with payers and providers featuring stories about 6 patients facing immense behavioral health and psychosocial challenges, including a 28-year-old male with Heroin addiction, a mom of 6 whose youngest had lead poisoning, a 77-year-old widow with dementia and untreated anxiety, a 55-year-old Caucasian female, former athlete with schizophrenia and now alcohol addiction, a 60-year-old woman with major depression, and 20-year-old confronting PTSD. Their stories, the outcomes and how the health system is trying new models and payment reforms to save money, are discussed here in this 2-hour program.

Extra Point: If it wasn’t enough that in a period of 3 days I juggled two trips to help mom with her difficult transition into assisted living, met with the neurologist to review her scan showing significant memory loss from the last scan 10 years ago, made a 14 hour roundtrip drive to Indiana to move the kid into college and had an oil leak in my basement, my vet tells me the dog has a skin infection that requires URGENT attention and, to make matters worse, the market was all out of goldfish this morning. Not sure about you, but when it rains, it pours and if you’re like me there are a whole host of ways to manage the insanity. For me, it’s usually goldfish, a cape codder and season 3 of Schitt’s Creek.

5: The number of new states where Aetna is entering the ACA marketplace in 2022, including Nevada, Missouri, Texas, Florida, and North Carolina. Meanwhile, HCSC will expand its Medicare Advantage (MA) footprint to an additional 90 counties next year, which the company says is its largest MA expansion ever.

Per Member Per Month, And Then Some:  A Medicaid managed care plan in Kansas is playing Oz by setting up a series of multi-level payment per month models for youth behavioral health care. In one design, you can get a $1 PMPM for doing follow up calls within 7 days of IP discharge, $20 for each high risk member you see face to face, $0.75 for screening people with schizophrenia or bipolar for diabetes, and $150 for avoiding adverse events. You can share in savings based on a point system, sort of like school where you earn points if hitting performance targets. There is a maximum payout and providers are compared to peers. In another design, the payment is a flat $425 for more complex cases such as youth who have been in the juvenile justice system and also have mental health diagnosis. Incentive payments are made out of a risk pool, with 5% guaranteed and 10% percent earned based on performance on measures like school functioning. One of the gaps in the program in its first years has been a lack of reporting of findings back to families and a lack of a flow of information on progress. “Too many cooks in the kitchen, not enough sharing of information and lack of ownership…..all fixable things but hard to fix without the right incentives,” said Pete Pfau, who’s 15-year-old son was among those treated under the program. His son is now 18 and out of residential treatment but needs significant services.

Inflection Point: Effective January 1, 2022, Regence will make Inflectra its preferred infliximab product, and coverage for all non-preferred infliximab products, including Remicade, Renflexis, Avsola and Ixifi, will require additional approval. Members who are currently on an infliximab product other than Inflectra will need to transition to Inflectra on or after January 1, 2022.

Union California: Kaiser and Providence are partnering to build a new medical center in California’s High Desert region. The new hospital, to be located in Victorville, will be jointly run by the two very different health systems, and patients of both will be able to receive most services. However, Kaiser members won’t be able to get certain reproductive services at the hospital, including abortion, because of Providence’s Roman Catholic affiliation.

Sleep Time: Some commercially insured members at a handful of health plans starting in October will require prior authorization for lab-based sleep studies. Home-based sleep studies for Commercial members do not require prior authorization.

Quarterback Risk: New quarterly reports for Medicaid and Commercial Episodes of Care will be available starting next week and so-called quarterbacks – those accountable for taking the risk for costs incurred during these episodes – do not have to make a payment back to BCBS of Tennessee in the event they owe risk-sharing payments.

Expensive Genes: Beginning this month, Cigna is expanding its Gene Therapy Program to also include advanced cellular therapies, such as CAR T-cell therapies. Cigna introduced the program in 2020 to help manage the quality and affordability of these novel, expensive therapies. The program steers members toward high quality health systems who have chosen to participate. Recent provider additions include Children’s Hospital Colorado, Connecticut Children’s Medical Center, and Morristown Memorial Hospital.

Imaging Off-Site: Starting in September, Cigna is expanding precertification requirements for CT and MRI scans to include a site of care review for all members covered by self-insured plans. All commercial Cigna members will now have to go through eviCore to make sure imaging is being done at the lowest appropriate level of care. A hospital outpatient setting will only be covered if an alternate site is not available.

Pharmacy Swing: BCBS Texas has new preferred specialty and mail order pharmacies for its commercial members, effective August 1^st. Following several other managed care plans, BCBS TX will move to Accredo for specialty and Express Scripts for mail order for all commercial members whose pharmacy benefits are managed through the PBM Prime. Medicare Advantage members will have these vendors as additional options but are not required to use them, at least for now.

Extra Point: It’s not enough to be talented. I mean there’s a lot of talent out there, but it’s owned by lazy, stupid or essentially boring people. You can’t just be talented. You have to be terribly smart and energetic. You also have to become necessary to people, by working hard and bringing more than your bones and your skin to the project. Don’t just show up. Transform the work, yourself and everybody around you. Be needed. Be interesting. Be something no one else can be – and be it consistently. This hung from a tack board on the third floor on Hereford Street last week, a classroom building Sophia and I toured during her first college visit to the Boston Conservatory of Music. Most of the kids just ambled by to the next tour stop. I fell back along with this guy Fred Hallen from NYC. His granddaughter was interested in the school and there he and I were, total strangers, staring at this Katherine Hepburn classic. Fred turned to me and said – “You know I’m pretty smart and I work hard and bring a lot to projects….but I don’t have a lick of talent….” Then he laughed like a bear probably laughs. Talent is probably overrated, I said, but sometimes it sure can’t hurt. In healthcare, I imagine the most talented are those behind the curtain creating diagnostic and treatment advances, or cardiologists and anesthesiologists who need a steady hand. I might argue that talent is less important for many on the frontlines – that the singing nurse who shows up every day to care for the older lady alone at home is being exactly what Hepburn called for. Needed. Interesting. Consistent.