Behavioral Health Insights

24:  No, not Kiefer Sutherland’s best performance but the portion of seniors who fall due to dehydration, end up in rehab, then fall within 6 months for the same reason based on a study of a cohort of patients with 6 common traits – undiagnosed dementia but significant short-term memory issues, live by themselves, widowed, limited caregiver support, limited social circles and no mention of “daughter” or “daughter or in law” in the medical record. The study, which we did in collaboration with 3 rehab centers in Boston’s north shore, is based on 292 admissions between 2019 and today related to a fall. It’s not surprising that one quarter have a reoccurring event with these common traits, particularly the lack of involvement of a family member. One nurse at Ledgewood Rehab told us that when a daughter or daughter in law is involved there tends to be a higher chance that mom or dad will be set up with more aid at home, including a personal emergency system and a companion to eat meals with. A “7^th” trait was common in about 15 of the 192 patients was they or their families acknowledged that their parent had never fully grieved the loss of their spouse, never saw a counselor, and that this led to a general decline in health and socialization.

Tele Expands: Amwell, the telemedicine provider, purchased 2 digital health companies which it plans to integrate into its virtual care platform. SilverCloud Health is a digital mental health platform that offers cognitive behavioral health programs in Ireland and the UK, including to the UK’s National Health Service, and will help expand Anthem’s reach in those countries. The second company is Conversa Health, an automated health service, which will help Amwell improve care coordination.

Surgical Equity: Penn Medicine recently established a Center for Surgical Health that focuses on improving health equity and access to surgical care for underserved populations who may otherwise seek treatment at an ER. Surgical residents and faculty will oversee the center and expect to provide surgical care to 175 patients in 2021. Most patients will be referred to the surgical center from Puentes de Salud, a nonprofit that serves Philadelphia’s Latinx immigrant population, and the University City Hospitality Coalition, which provides meals to homeless individuals.

Hospital Goes Home: BCBS Michigan is expanding its Hospital Care at Home program, which it jointly runs with Michigan Medicine. The pilot began last year, focusing on commercial members with CHF, COPD, cellulitis, pneumonia and UTIs. The program will now include MA members, and a range of other acute care diagnoses that can be safely treated at home. In related news, more than 50 hospitals will use a new solution from Signify Health to provide Medicare patients with hospital at home services. Through virtual and telephonic clinical and social care coordination, Signify’s solution will support Medicare patients for 90 days following discharge from an acute care facility.

Diabetes Change: The FDA has approved the first interchangeable biosimilar for insulin, which is known as Semglee. An interchangeable designation means that Semglee can be substituted for Lantus automatically by pharmacists without physicians' permission. However, many states have enacted laws in preparation for this approval, and patients will have to be informed they are receiving a biosimilar substitute. The approval of this interchangeable biosimilar has many hoping it will result in more competition in the insulin market, bringing down costs.

Alzheimer’s Niche: Biogen, the company that created the Alzheimer's drug Aduhelm, says the FDA has narrowed use of it after the agency drew sharp criticism for its broad approval of the drug last month without proof of clear benefit against the disease. Biogen is now changing its label to be used only for Alzheimer’s patients with mild cognitive impairment or mild dementia. The new label also says there is no safety or effectiveness data on initiating treatment at earlier or later stages of the disease.

Carolina Integration: Centene announced WellCare of North Carolina will help coordinate physical health services for multiple Local Management Entities (LMEs) for the state’s Behavioral Health and Intellectual/Developmental Disability Tailored Plans in an effort to bring a more integrated member-centered approach to individuals living with significant behavioral health conditions. The changes are expected to take place August 2021.

Nebraska Emergency:  BCBS Nebraska stopped requiring credentialing for ambulance providers, including air ambulances. Ambulance providers will still need to contract with the health plan.

Sports Complex: Peach State Health Plan of Georgia announced a new partnership with Healthy Foundations to assist in the development of the Health Community Resource Village, with the inclusion of a $25,000 donation from the Health Plan to be used for the construction of an outdoor sports and recreation pavilion on the planned community village campus. The community village campus will offer a variety of low-cost behavioral and healthcare services including housing, addiction care, and veteran services.

ExtraPoint: My 17-year-old and I take to the road this weekend for a 100-mile bike ride. I’m already nauseous, probably because I only ride a bike once a year and because I am awfully short and generally consider hills as things to slide down, not ride up. But I am looking forward to the companionship out there as Jack and I try to raise a few more dollars for cancer research and share a few laughs when I fall over at the stop sign. This will be my 11^th year riding the Pan Mass Challenge, but my first time with the kid, and so he will see me at my worst. You see it is awfully embarrassing when I roll slowly into an intersection with 5-year-olds cheering, holding out flavored ice and holding “thank you for saving my mommy’s life” signs, unable to unclick my bike shoes and slowly and pathetically timbering, cursing on the way down, and then crying….but riding a bike is good for your health I’m told. A lot of healthcare companies are now adding spin classes into their set up, some removing the tired waiting rooms and replacing with stationary bikes. Some of the big insurers are buying housing units and revamping them with health services and gyms. A lot of the focus is on inner city Medicaid populations but there’s also a lot of need to support seniors. I did a spin workout this morning with a bunch of 70 and 80 somethings and I suspect if more seniors kept moving as they age that the incidence of falls from dehydration and being sedentary would diminish. When I ride, I tend to think back to those days where I came of age on a huffy. The Huffy was a right of passage for kids of my generation. Before skateboards and 10-speeds, there was this dirt bike that made you feel like you were on Fonzi’s motorcycle. Having it even for a summer meant you were cool and that your parents were cool for getting it. Sure, I may have had a bowl haircut, polyester bell bottoms, and the beginnings of a 5 o’clock shadow, which is rare and awkward for an eight-year-old, but that bike gave me street cred. Bobby Lynch and Ben Elleck, both a year older and 10 inches taller, were suddenly looking up to me. Even Bobby’s older brother, Mike, stopped teasing. “That yours?” he’d say gruffly. Then he’d nod his head, almost to say, “You’re okay Cote.” I decorated my Huffy for the July 4th “horribles” parade around Archie Lane that year, decked it out with cray paper and signs made from oak tag scraps held together with 5-layers of scotch tape. I rode in the center up-front position, Bobby and Ben flanking me, all of us holding red, white and blue popsicles. I put a lot of miles on my Huffy, at least a hundred that summer, I bet. I rode it through the back woods with a walk-man hooked to my shorts, playing track 1 from my Survivor cassette tape (“I Can’t Hold Back” for those who don’t follow the best band ever). We set up jumps over quick sand Mom told us to avoid, crashed into dirt piles, dusted off our cuts and scrapes and got right back on. I went everywhere on that bike. On Sunday this weekend I sort of hope to reimagine that time with Jack, hopefully do a little bit to help people suffering from cancer and, with any luck, fall into a nice bed of grass...

$140M: The amount Anthem and Humana are investing in a new pharmacy benefit manager. With this investment, the plans will hold a minority stake in the new company, DomaniRx. SS&C Technologies, a fintech company, will own the other 80%. Humana will be the PBM’s first customer, as the company “aims to offer payers more transparency into their drug costs and help them better comply with changing government regulations” according to a press release.

Did You Hear About The Detox Fix? A noninvasive treatment to manage opioid withdrawal symptoms recently hit the market. S.T. Genesis looks like a hearing aid of sorts that is applied behind the ear and administers treatment for 5 days helping the patient during the most critical time of detox. This FDA-cleared treatment option could be a way to transition patients with substance use disorder into longer term treatment.

Sleep Before Autism: A recent study reveals that children on the autism spectrum with severe sleep difficulties often suffer behavioral regulation difficulties, impairing their executive function. The longitudinal study was started in 2005 and followed 217 children with autism participating in Pathways in ASD. Parents completed a survey when their children were ages 2-4, and again roughly 3 years later. Researchers also assessed the children’s executive functioning four times from ages 7-12 with another survey to parents and teachers. The research suggests that the sleep problems precede the manifestation of behavioral regulation issues in children.

Appetizing Sight: Warby Parker has refreshed their online marketplace for prescription lenses with a new app called Virtual Vision Test, which has potential implications for the broader optometry sector. The app provides an at-home vision test similar to what you get at an eye doctor, and it can give you a renewed prescription that you can use to buy glasses or contacts. After the app is downloaded, the customer answers a few questions and then a short vision test appears with a letter chart. The person reads aloud the letters with one eye covered and the app records the person’s spoken responses and uploads them to be evaluated by a doctor. Within two days, an ophthalmologist licensed in the person’s state will review the results and move ahead with the prescription renewal or flag it if recommending an in-person examination.

Ride Like The Wind: United will begin offering Peloton classes to some of its members. Starting Sept. 1, as part of UnitedHealthcare's plan benefits, members can enroll with Peloton for access to their fitness classes. New and existing Peloton Members are eligible to enroll.

A New Image For Pathology: A new technology entity has implications for pathology and the broader diagnostic space. Artificial intelligence startup PathAI has acquired Poplar, the management service arm of pathology laboratory Poplar Healthcare. The deal is PathAI's first step into traditional clinical diagnostics. Poplar provides testing services for gastroenterologists, dermatologists, oncologists, urologists, and gynecologists and will be able to use PathAI's AI tools to analyze pathology images.

West Texas Behavior: Two Texas physicians of UMC Health System’s Pediatric Trauma Unit have collaborated with Texas Tech University psychology programs to open the Children’s Behavioral Health Clinic to serve children in the community and those that have received services from UMC. The new clinic will provide mental health support in West Texas through teletherapy services, clinical training to family therapists and conduct research.

Food Partner: Anthem is collaborating with Kroger to offer Medicare Advantage plans in 4 new markets in 2022: Atlanta, Cincinnati, Louisville, and southern VA.

ExtraPoint: Simone Biles doesn’t have mental health “issues”, not that I see. I watched her cheer for her teammates after bowing out of the final competition and to me that showed class, loyalty and mental strength. So what if she didn’t compete in the finals - for students back home at the school where I have taught gym for years, 90% look like Simone and regularly worry about their value and in any given day they are scared, depressed, and think about harming themselves. They are inner-city youth with dreams and obstacles and they rooted for Simone last week, but they also saw someone un-relatable. They couldn’t ever see a way to be so daring, confident, and perfect like Simone. Now they can. She is not perfect, she is just us and she is real. And in leaving the competition, but not hiding, she moved us into a new era in the national discussion. I think we may look back at this as a moment, a catalyst for more states to increase funding for school counselors, for more administrators to change their own mindset and adjust budgets to make counselors full time not ad-hoc like so many still are, and for more employers and insurers to relax restrictions. Our “mental health” is not an issue—nor is it an illness—not in the way many still describe it, but it is easily influenced and impacted by events around us, and by what we see and hear and what we know. And what I see is progress.  -BC

517,000: Cost of medical and pharmacy claims for a small cohort of caregivers one health plan utilization analyst studied this year. The patients “take care of sick relatives, then they get sick from the stress.” The analyst said she’s providing a report to the medical and product design teams in the fall with “stats and case examples” like the 57-year-old who had zero claims cost for the prior 5 years outside of check-ups then a 3-year uptick that led to a heart attack” One idea she’s going to float is a division of labor system that “weans” hours, gradually taking the caregiver “from the most exhausting part of the shift to the less demanding tasks.”

Allergy Market Boom: The allergy immunotherapy market continues to grow, due to the increasing occurrence of allergies every year. Studies show that the occurrence of food allergies increases 10% every year, partially a result of rising levels of pollution, creating a larger demand for immunotherapy. The demand for new, innovative procedures is driven by the continual increase in allergic reactions. Global players in the market are working to improve existing Sublingual Immunotherapy (SLIT) drugs, which are clinically verified against atopic dermatitis, airway allergies, and several food allergies. Health insurers, meanwhile, will prioritize coverage and reimbursement next year with a range of new policies to manage the trend, but improve outcomes.

Kindred Spirit: Kindred is adding acute inpatient rehabilitation units to 3 of its long-term acute care hospitals to help shorten patients’ recovery time. The units, with a total of 33 beds, are expected to start serving patients in September 2021 and will be located in Denver, Melbourne, and Philadelphia. Patients in physical rehab will receive 24/7 nursing care and at least 3 hours of therapy a day for 5 days a week.

TeamWork: Teladoc is partnering with Microsoft to integrate its virtual care platforms for health systems. More hospitals and health systems have adopted Teams to connect with patients via video during the COVID-19 pandemic, the companies said. Teladoc's Solo platform will be integrated into the Teams environment, meaning doctors will be able to access clinical data within the EHR via Solo without leaving Teams, by early 2022.

Social Service, Polynesian Style: Kaiser is partnering with nonprofit health plan AlohaCare and community organization, Unite Us, to launch Hawaii’s first coordinated care network, Unite Hawaii. The network will focus on social services including meals, employment, and housing. The Unite Hawaii network is available to all community-based organizations at no cost to them, offering features that allow providers and care coordinators to connect members to participating organizations and receive real-time data on fulfillment of services.

Northern Exposure: That 90s TV show that featured caribou traipsing across intersections in the fictional Alaska town, but the series was filmed in Washington state where legend has it caribou were the first to deliver mail and now Dispatch Health is taking a page from the past “dispatching” health services to Pierce County, Washington. The company is partnering with Regence BCBS to provide its acutely ill members with physician visits ala Dr. Baker, remote monitoring, prescription, and meal deliveries for up to 30 days after initial treatment. No word on if caribou will be delivering the meals.

Get Authorized: BCBS Tennessee is making some changes to their prior authorization requirements in the upcoming months, the Blues plan will add a PA requirement for 4 musculoskeletal codes, while removing PAs for 18 other MSK codes. Beginning October 1, 2021, some commercial members will require PA for lab-based sleep studies, while home-based sleep studies will continue not requiring a PA.

Consumer Engagement: United recently launched a predictive analytics advocacy program to improve care of patients by working to target social determinants of health (SDOH). This program was created following the height of the COVID-19 pandemic, when approximately 41% of Americans avoided healthcare due to health disparities. Rebecca Madsen, chief consumer officer of UnitedHealthcare, endorsed the program, saying, “It’s really about supporting consumers, driving a different kind of experience, being sensitive to the full continuum of needs, and that every person is different, and they interact with the health system differently.”

Extra Point: I found myself driving by the oak tree last night that took Michael Lynch’s life 40 years ago. Michael was in that coma for 30 days and his mom, Christine, would hold fort at the kitchen table, knitting socks and telling Bobby and I to go ride our bikes. There was an air of pain in that house during that time. Michael, just 16, used to race me, Bobby and Ben Elleck in the Tupperware Olympics. We’d run relays using Christine’s ladles and fill up the bowls with water from the hose. Christine wouldn’t mind – “You’re washing those bowls, Mr. Cote, if you lose.” Michael’s passing hit hard but time healed and Christine spent much of the next 30 years working at the convalescent home, knitting for the residents, making jokes about their health in a way that few can. She was a hot ticket and so her passing this week, on the eve of the Olympic games, sort of hit me. Reminded me that humor is an underappreciated gift in caring for patients.

25: The number of retail pharmacies health system Intermountain is closing, citing declining business and a new deal with CVS Health. Intermountain will keep its pharmacy at Primary Children’s Hospital in Salt Lake City open as a home delivery, retail, and specialty pharmacy. All others will transfer inventory and patient files over to CVS by August.

Spartan Care: Michigan State University Health Care is partnering with Everside Health, a direct primary care provider, to provide employer-sponsored health plans with access to direct and virtual primary care across the state. Employers who choose to participate will pay a fixed cost per employee for 24/7 access to PCPs. The companies say the model is intended to complement employer-sponsored insurance, not replace it.

Onsite Doc Trend: General Motors is opening a new primary care center for its employees on July 19, contracting with Henry Ford Health System to staff the car maker’s Warren Tech Center in Detroit. GM is part of a growing group of large employers who are choosing to bring doctors to or near their workplaces. According to data from Mercer, more than 31% of employers with over 5,000 employees now offer direct primary care services. If you’re a physician practice or outpatient service like a PT clinic, perhaps these major manufacturing companies ought to be on your target list. Build on site, and you’re suddenly exclusive, but keep in mind how insurers will think of these. They may improve access and adherence, but will they lead to overutilization?

Pre-tests Now Included in Payment: Starting this October, Horizon BCBS is changing its pre-procedure testing reimbursement policy and this impacts a broad range of providers, including physicians that own ASCs. Any testing that is done on the day of or within the 72-hour period prior to the day of a patient’s scheduled outpatient procedure, including COVID-19 testing, will no longer be considered for separate reimbursement. This impacts all fully insured commercial and MA members, and covers any testing done for procedures performed in the hospital setting, as well as any ASCs or urgent care centers affiliated with a health system.

Observation an Unsung Quality Measure: Observation in the hospital is one of the key ways physician practices taking risk for admissions can lower total cost of care. When you’re dealing with Medicare patients with chronic disease and other effects of aging, there are going to be events that bring you to the hospital. It’s just a fact. Ensuring more use of observation over actual admissions is important, Michael Yanuck, MD, often told me. “Important to look at your observation status numbers” as a quality measure. Some insurers are adjusting their policies to help.  In Louisiana, the BCBS plan has just increased the payment limit from 30 hours to a maximum of 48 hours. The clock begins when the patient arrives at the hospital for outpatient services, not when observation status begins.

It Takes a Village: Walgreens and Village Medical are making good on their plan to open 600 Village Medical at Walgreens clinics over the next four years. The companies have already opened 46 locations in 2021 and just announced plans to open 29 more clinics in Houston, Austin, and El Paso by the end of the year.

Extra Point: Aunt Theresa took me into Dunkin Donuts one time, walked behind the counter and started pouring two cups of coffee. “Maam. Maam! You can’t do that.”  Aunt Theresa said, “I know I look frail honey, but this old girl still can pour coffee.” She dropped a sock full of nickels on the counter and said, “let’s go.” At Sunday brunch in Fairlawn one time back in the late 70s Theresa’s cigarette ashes fell into my scrambled eggs. “Um, Aunt Theresa, your cigarette….” “Oh, it’s fine dear. Just mix it up like this, it’ll look like pepper.” Aunt Theresa was a housewife for most of her life until Uncle Richard died at 57. “He never passed the meatballs, that was his problem, but boy I miss the ole’ joker.” Aunt Theresa played three sports in high school and worked at a Sunoco to pay her way through community college in the mid-1940s. She sang in the choir for 30 years down at Sacred Heart in Holyoke and used to heckle Father Burns during his homily’s. “I don’t agree with that – that’s not right – no way did Jesus do that” she would holler from the pew. “Let’s move it along Father – I can smell the donuts in hall!” She walked 5-10 miles a day raising two kids and two foster kids, but after Uncle Richard died her health declined and her bad habits picked up. She’s had more than a dozen surgeries in the last 25 years, some for her eyes, some her knees, once on her big toe. But for some reason she’s 96 and still going and on Saturday she fumbled her way to the kitchen with her walker, kicked the dog, cut one piece of blueberry pie, put it on a plate, then grabbed the rest of the pie and took that back to kitchen table. “What?” she said, giving us a look for questioning her greediness. “I figured I’d save a piece for later…..now which one of you is going to lose at Setback?” Managing aging family is awfully difficult these days and for many of us it’s a strain on our families and our own health, but sometimes you get an Aunt Theresa who may have a sharp edge and an abrasive style, but she tells it like it is. And I’m going to miss the ole gal.

42: Percent of kids going off to college in August, according to a poll of my son’s 1,700 Instagram followers—up from 30% recently—who say they are bringing the following to college: a 10-pack of blue iPhone chargers, an old “beat up locker passed down from generations,” and the phone number and text for a mental health therapist. Here’s to something borrowed, something blue, and something new.

Insulin? Aisle 12: Walmart is launching its own brand of insulin, a less expensive version of Novo Nordisk’s analog insulin product, Novolog. The insulin will be under Walmart’s private label and will be known as ReliOn Novolog. It will be available at more than 4,800 pharmacies and Sam’s Club pharmacies by mid-July, with a cost of $72.88 for vials and $85.88 for a FlexPen version.

HomeRun: We’re seeing continued activity in the home health space, most recently with Amedisys acquiring Contessa Health, a hospital-at-home and skilled nursing company. This acquisition will allow the company to focus on serving higher acuity patients in the home setting. Humana also recently announced they plan to acquire onehome, a home health company, following their recent acquisition of Kindred At Home, as the plan doubles down on post-acute care.

A New ER Model Likely Faces Pressure: ProMedica is opening a dual emergency room and urgent care clinic in Toledo, Ohio, through a partnership with Intuitive Health, the health system. According to ProMedica, the new facility will be the first of its kind in the area and will eliminate the need for patients to self-diagnose and determine which level of care is appropriate. From our perspective, these models face some reimbursement challenges, so it will be interesting to see how successful these are. Payers have cracked down in the past on the door #1 vs. door #2 models, particularly in Texas where Freestanding ERs grew up. In recent years, pre-pay review is now emerging from major plans United, Anthem, and BCBS to limit over payment of visits that could be handled via PCPs or as a level 2 or 3 urgent care visit.

Latest PCP Model Goes Country: Main Street Health is a new startup with a goal of bringing value care models to rural areas. The company will help primary care clinics, independent pharmacies, and urgent care centers transform from fee-for-service to value-based contracts with private insurers and Medicare. Main Street’s initial offering, the Extra Access Program, will be available in 30 locations in Western Tennessee and will connect seniors treated by participating providers with a local health navigator and an on-demand care team.

If You Build MA, Benes Will Come: Wellmark, the Blues plan in Iowa and South Dakota, will begin offering MA plans in 2022. The health insurer currently offers only commercial and Medicare supplement plans.

Surprising Episodes: There are some episodes that catch you by surprise, some you see coming. Like I always knew we were moments from a commercial break when 1980s Mr. Roper stared with those glassy eyes into the TV on Three’s Company, but I was floored when Colonel Blake died in that MASH helicopter or when Tom Hanks purposely swallowed a bottle of Vanilla Extract because the Keaton’s were out of Miller High Life on Family Ties. In healthcare circles today, you hear a lot about episodes of care and payment innovation – some are sort of predictable, and I suppose that’s the point. Think Maternity, Hip and Knee. Some may surprise you going forward, and some seem to perhaps miss the mark on who ought to be accountable. A 12-month episode for dealing with drug addiction has promise, particularly Anthem’s, through a home-based provider out of New England, Aware Recovery. There’s a new one emerging that addresses predominantly Medicaid populations in poor housing areas who regularly present with asthma and co-occurring depression in ERs. The idea one PCP has is to use a simple home visit by a social worker, treatment led by an allergist and PCP, and a re-housing plan to either fix the environmental causes or find the patient a new home. United Healthcare is touting these kinds of community-focused models. Problem is, when you look at the traditional episodes of care (link here to Arkansas BCBS’s core list), most seem to put the ‘hospital’ as the principal accountable provider in these. For asthma, while there may be a triggering event bringing you to the hospital, the so-called accountable provider probably ought to be a PCP, a specialist, or perhaps the MSW given the social factors involved. As you build your episodes, try to see what’s coming by finding the right mix of providers and the right person to lead.

Extra Point: DAD IS AT IT AGAIN WITH A STRING OF ALL CAPS EMAILS OUTLINING ALL OF HIS HEALTH ISSUES, HIS SHOT-BY-SHOT GOLF ROUND AT THE LOCAL MUNICIPLE COURSE WITH MY 17-YEAR-OLD, AND HIS DISAPPOINTMENT IN THE YANKEES. ON MONDAY HE DELIVERED FIVE ALL CAPS EMAILS AND ONE TEXT WITH AT LEAST 30 EXCLAMATION POINTS THAT I’M SURE WOULD ANNOY JAY PETERMAN OF SEINFELD FAME. HE USED ONE EXCLAMATION POINT TO SAY THAT THE DOCTOR DID A GOOD JOB FIXING THE WOUND ON HIS FOOT WHEN HE STEPPED ONTO THE HOE SUNDAY, USED ANOTHER TO TELL ME HE HAD GRAPE NUTS AND VANILLA YOGURT FOR ALL THREE MEALS TUESDAY, THEN USED ANOTHER TO SAY HIS HEARING AIDE STOPPED WORKING BECAUSE HE WORE IT IN THE SHOWER! “MOM GOT PRETTY TICKED” HE WROTE, “BUT I COULDN’T ACTUALLY HEAR WHAT SHE WAS SAYING, SO I NODDED AND PUT ON THE BALLGAME!” SOMETIMES I STRUGGLED TO UNDERSTAND WHAT HE WAS ANGRY ABOUT AND WHAT HE WAS HAPPY ABOUT, BUT IT DIDN’T MATTER I SUPPOSE. HE WAS COMMUNICATING, AND I KNOW I’M LUCKY FOR THAT. HERE’S TO ALL CAPS!

5: The number of BCBS plans that have created a new pharmacy solutions company, Evio. The Blues plans in Massachusetts, Michigan, and California, along with Highmark and Independence are behind the company, which will use member data to track how drugs perform. One main goal is to enter into outcomes-based arrangements with drug manufacturers, so the plans are only paying when drugs are effective for members.

Biosimilar Bait & Switch: Cigna is also looking into innovative ways to save on drug costs, by focusing on biosimilars. The health plan is launching the new Shared Savings Program in which eligible patients will be offered a $500 debit card to use on healthcare services or medications if they switch to a biosimilar. The program is opening first to patients currently on the anti-inflammatory drug, Remicade. Two preferred biosimilars will be moved to Cigna’s preferred tier in July.

Virtual Competitor: Starting in July, BCBS Michigan will allow large employer groups to purchase a rider that lowers members’ copays for virtual services. Members whose employers choose this option can see providers virtually for either $0 or $10, depending on their specific plan, which is less than their in-person copays.

Paying For Patient Engagement: Health insurers continue to factor in patient satisfaction into reimbursement rates – some health plans will pay a higher fee to specialists, like allergists, orthopedists, and ophthalmologists for increasing patient satisfaction, “because we know there’s a link between that and a person’s overall outcomes and adherence,” Peg Riordan, a source involved in payment innovation for a national MCO, told us. Several new companies are creating tools to help improve patient experience. In June, health data analytics company, Health Catalyst, said they plan to acquire Twistle, a patient engagement company with software that automates text message, patient portal, and other methods of communication between care teams and patients to support patients as they navigate an episode of care. That will add to Health Catalyst's population health tools, which identify populations at risk for poor outcomes, and will strengthen their offering for customers who are moving to value-based models.

New England Market: The combined health plan formed from the merger of Tufts and Harvard Pilgrim earlier this year finally has a new name: Point32Health. This combined entity will have greater leverage in the New England market, now serving 2.2 million members across the region. Look for more efforts to recalibrate reimbursement, develop more value-based contracts, and shift procedures and services downhill.  The plan’s new name is inspired "by the 32 points on a compass" and "represents the role the organization plays in guiding and empowering its members and making a meaningful impact across the healthcare industry," according to a press release.

Caregiver Decline: The strain on caregivers is an underappreciated challenge for the health system and families across the US, and in recent conversations with managed care plans, many are saying that if your company can help address not only direct patient costs but also the indirect costs of caregiver physical and mental health decline, “you probably have a leg up with us in contracting,” Michael Atwood, RN, a home health network development manager, told us this week. What that might look like is “up to the market to innovate,” but includes emotional support, respite, personal care, and other services that help direct caregivers reduce stress.  As background, in early 2020 we did a poll on caregiver decline that we may be redoing. Read the results here. To discuss, reach out anytime.

Insane Vein: Kim Green has spent nearly two decades battling cancer and, like so many people who go through chemotherapy, she’s had to learn over time to be an advocate in the treatment room. Recently, the Connecticut native needed an IV for a medical issue and told the nurse that the only vein available was in her finger, given years of IVs in other veins. The nurse didn’t agree and tried to get the IV set up through another vein, but failed, then another nurse tried, despite Kim’s pleading. The attending physician came in and dismissed Kim’s preference as ridiculous, but he also couldn’t get the IV set so in the end the staff settled on the finger. Kim was right but it took a lot of unnecessary and painful work to get there. If there’s a lesson here to providers, it’s probably to listen to the patient, particularly for those who’ve had chronic diseases and are forced into being advocates for themselves.

Extra Point: A good friend is in the end stages of saying goodbye to her dad Joel who’s battled several years now with Parkinson’s. Managing the care of someone with this condition takes a village – family, friends, nurses, physical therapists, and increasingly, scientists who are studying ways to address disease cost and quality of life. For anyone who has family with Parkinson’s, Alzheimer’s, and other neurological conditions, you try to find humor in what is a painful condition, and live day to day trying to draw on the memories of the person you know is there but is hiding behind the disease. There is hope in many new studies and treatments and we should honor those who’ve struggled with the disease and their caregivers for helping drive change. Here’s my attempt at honoring Joel and my good friend.

31: Percent of 17 to 20 year-olds in my son’s poll of his 1,379 so called Instagram followers who say they found a mental health therapist recently before they head off to college. “It’s a good idea to get that relationship formed before going into college,” says Ivy Patt, a therapist in Connecticut who deals mostly with private pay teens. Most of these relationships will be virtual and from a managed care point of view that’s perfect, as long as it is privately paid and if through insurance, the encounters make sense to “help with the transition” as long as they are necessary. Therein lies the rub. Payers have started to more closely monitor tele and OP mental health and engage with big telehealth companies like Talkspace to plug them in as options for 17 to 20 year olds like Jack’s buddies, but also adults and seniors. The goal is access, meet network adequacy requirements and help address the growing importance of mental health. But to ensure utilization of these sessions doesn’t go unchecked and adds value, expect insurers to buy these companies for more control – one, Anthem, already has via its acquisition of Beacon which has a college-focused offering – and others like United and Humana likely will. If you’re a mental health practice or one focused on higher levels of care, the short answer is you might want to be thinking about how to tap into the virtual world that kids like Jack live in, and if you’re not careful be prepared for more pressure and competition from insurers.

Pay For Shrinkage: Several insurers are now looking to enter contracts with pharmaceutical companies based on lowering the total cost of care for type 2 diabetics or those with cardiovascular disease. These arrangements look a lot like the early ones the UK built to force drug companies to either agree to good outcomes like tumor shrinkage or send money back. These arrangements have been difficult to create since it’s not easy to agree on the target points and terms, like what’s an acceptable time to shrinkage and how do we quantify failure when maybe the drug added 2 or 3 months of quality life for a patient they otherwise wouldn’t have had. This new era of pay for outcomes in medicine will be led in part by insurer non-profits. What will be most interesting is how this trickles down to prescribers and patients. For successful drugs, it could increase reimbursement for administering the most effective drugs, but it also likely accelerates white bagging in the specialty space. And more broadly, expect insurers to use these findings to inform specialists and patients with chronic disease about what works and what doesn’t, and design new outcomes based arrangements from that.

3rd Time’s A Charm?: Spectrum Health and Beaumont Health are exploring a merger, which would create Michigan’s largest health system. The 2 nonprofit systems combined would operate 22 hospitals and 305 outpatient locations. Spectrum’s integrated health plan, Priority Health, would also be overseen by the new combined health system. Beaumont does not currently have its own health plan. This is the 3rd attempted merger for Beaumont in 2 years, with previous plans for consolidation with both Summa Health and Advocate Aurora falling through.

Too Late: If you have teenagers you know all too well that many are already at the party when they ask to go and Anthem is about to start doing what parents ought to, applying a reimbursement penalty for providers who fail to get pre-authorization when it’s required for commercial patients. The late notification penalty has been in the provider manual since 2019, but Anthem has not been enforcing it until now. Sounds like that parent manual my dad tried to hand me when we walked out of the maternity ward in 2003. “You’re going to need this,” he said, but I never opened it until Jack was at the party. In Anthem’s case, if required PAs are not obtained before services are rendered, reimbursement will be reduced 50%.

Midwest Hub: Big 10 fans may not love this but the largest independent physician groups in Illinois and Indiana, DuPage Medical Group and The South Bend Clinic, are planning to merge, creating a “hub for regional expansion.” DuPage has over 800 doctors but currently has no locations outside of Illinois. By partnering with South Bend Clinic, the group will gain another 170 providers with 11 clinics across Indiana.

Oregon Funding: CareOregon is investing $7.5M in its behavioral health provider network, to make sure members have access to the care they need. The money will go to 25 behavioral health providers who serve 85% of the highest needs patients across the state. Funds are intended to be used for retention bonuses, housing support, or other financial incentives to support these essential workers.

Sooner The Diagnosis The Better: Colon cancer screening kits are now being shipped to certain people BCBS of Oklahoma has identified as lacking access to more traditional screening. A vendor, Home Access Health, sends kids to members and the results are eventually shared with the patient’s PCP within 3-4 weeks. This is one of several emerging value based models the insurer is creating to improve access and incentivize better coordination.

Parkinson’s Challenge: The cause of Parkinson’s is widely unknown with 85%+ of cases classified as sporadic and not genetic and in this piece we interviewed UPMC’s board-certified clinical specialist Chris Childers about the challenges in helping payers understand the need for therapy for this population. Click here to read more.

Extra Point: Sometimes it’s hard to find work, life, balance beam me up Scotty Pippen was a better defender than Michael Jackson’s best song was Billie Jean King beat Bobby Riggs with an old wooden racquet ball is a really difficult sport if you’re slow like a turtle necks are in style for only certain people magazine editions from the 1990s are still sitting in most doctor waiting rooms, but no one sees them anymore since they are looking at their iPhone apps now have a way to show you where to get your colonoscopy, which I have to book soon if I can just stop this run on sentence. I used to volunteer in kindergarten class journaling hour back in 2005, which is where run-on-sentences run free. Kids named Maggie and Connor string together consonants like cheese, without a single piece of punctuation, all the while sniffling and coughing and in some cases falling off their chairs. It’s funny for a 5-year-old, but not so much for an adult whose job it is to communicate with people in a crisis. I was thinking of this yesterday when I read through the medical notes from my Uncle’s cardiologist whose description of why his patient couldn’t get stents or a bypass due to multiple arterial blockages was about as clear as a 5-year-old’s kindergarten journal. Random words. No punctuation. Jibberish to the laymen. I hope teens and 20 somethings coming of age in the era of texting keep this in mind, particularly if they end up in healthcare – slow down, separate thoughts, be simple, avoid semicolons and every once in awhile just stop, listen and use a period.