Behavioral Health Insights

3D: Beginning in April, Harvard Pilgrim Health Care will provide reimbursement for digital breast tomosynthesis (3D mammography) for commercial members in all states the plan covers. Harvard Pilgrim recently merged with Tufts Health Plan, although the two will keep their products separate for the time being.

Lab Disruption: United is planning to launch a Designated Diagnostic Provider program in July 2021 and there is already pushback against the health insurer’s plan. The program is designed for commercial members and will only cover outpatient lab services when delivered by freestanding or hospital lab providers that meet certain quality and efficiency requirements. The American Medical Association says that this could mean members may have difficulty finding qualifying labs and could lead to more surprise bills. United’s new policy says that, “Non-Designated Diagnostic Providers will remain in-network with UnitedHealthcare, but outpatient diagnostic lab services will be denied as non-covered for members with Designated Diagnostic Provider benefit designs and your patients may be liable for charges.”

Skin In The Game: Skin cancer diagnostics company, DermTech, entered an agreement with BCBS of Texas to make its Pigmented Lesion Assay available to about 6 million members. This device allows for early detection of melanoma and will be available as an in-network option for BCBSTX’s Blue Essential, Traditional Indemnity, and PPO/POS members. BCBS of Illinois was the first Blue’s plan to make this device available to its members, followed by BCBS of California, and now BCBSTX.

Raising Arizona: Health Choice Arizona, a subsidiary of Blue Cross Blue Shield of Arizona, announced an expansion of its digital health suite by offering Wellth, a digital behavioral health program, with the goal of improving medication adherence for members diagnosed with Severe Mental Illness. Wellth members begin each month with a rewards balance. To keep their rewards, members must complete daily check-ins by taking a photo of their medications before they take them via the Wellth platform. Failure to comply with medications is one of the costliest problems in healthcare, leading to diminished health outcomes and increased care utilization, which end up costing the health plan more.

Social Service Partnership: Empire BlueCross BlueShield and Montefiore Health System announced a multi-year agreement focused on improving access to quality healthcare for people throughout NYC, Westchester, and the Hudson Valley. The agreement will include new community outreach initiatives including health events, a partnership to support nutrition services for at-risk populations, and a mobile health unit to deliver essential testing and screening focused on improving community health. This demonstrates the evolving role of health plans and systems in providing investments to address social risk. More on this topic in the coming weeks when we release our social determinants of health national research study.

Rx Cover Switch: Blue Cross NC is implementing a new process when submitting requests for drugs under the medical benefit. Effective April 28, 2021, the insurer will shift its medical drug authorization process to CoverMyMeds and the pharmacy call center team. This change aims to improve turnaround times when submitting prior authorizations for medical drugs as well as allowing a more streamlined experience and user-friendly process for providers.

Kidney Bean: Another health plan is focusing on kidney care for its members, this time through an investment in the company Monogram Health. We recently reported that Humana was partnering with the company to provide kidney disease care coordination services in several states and now SCAN Group, whose holdings include SCAN Health Plan, one of the nation’s largest not-for-profit Medicare Advantage plans, has invested in Monogram. This is SCAN’s first outside investment and likely is not the last health plan investment we’ll see in kidney care.

COVID Effect On Surgery Policy: Despite an overall trend in shifting care from hospitals into ASCs, Molina of Illinois temporarily suspended a new prior authorization requirement for surgical procedures in hospitals, due to COVID-19. The new policy was effective January 2021, but Molina put a moratorium on the PA requirement until 2022.

Opt In For Ortho: Orthopedic specialists have until March 1 to sign up to participate in the TurningPoint Safety and Quality Award Program, in collaboration with Horizon BCBSNJ. This reward-based program will provide incentives for providers when their patients experience fewer complications, infections, hospital readmissions and ER visits following their surgical procedures, as well as reduced out-of-pocket costs for patients. Program begins in April.

Extra Point: Unless you’re Notre Dame football, staying independent is problematic in college sports and a bit of a lesson for healthcare innovators. In its heyday, UConn could have joined the ACC or Big 10 but missed its chance and was left without a football conference and its top tier hoop team was relegated to a lower tier conference. Healthcare providers are in a similar pickle – align with a multi-state health system for higher reimbursement and referrals or hang a shingle independently. Many have tried, including many novel start-ups trying to tackle the cost of diabetes, depression and aging with remote monitoring capitation models only to see the big health system march in with their own solution. As you evaluate home based solutions, consider the risk of independence or waiting for the perfect partner, as UConn did. Ultimately, unless you have the ethic of Rudy and a brand like the Irish, be careful - the insurer may like the little independent, but it needs the big health system.

20%: The difference in reimbursement rates for ABA providers now that BCBS of Texas will begin tiering them for ABA therapy, effective April 2021. RBTs, Board Certified Assistant Behavior Analysts or clinicians with a bachelor’s degree will receive the existing rate, while clinicians with less than a bachelor’s degree and no RBT certification will receive 20% less. BCBAs and master’s level clinicians will receive an increase in rate of 20%.

Gender Policy Winners: A new policy on gender surgery is likely a boost to mental health provider volume. Aetna is updating its commercial policies to include gender-affirming surgeries for transgender women, after several members came forward who had been denied coverage for breast augmentation. Aetna worked with a law firm and a nonprofit org representing these women to redesign their clinical policies around transgender surgeries. Under the new policy, the member must have a letter of referral from a mental healthcare provider, offer evidence of their history with gender dysphoria, and have already completed a year’s worth of hormonal therapies before they receive the surgery.

Puerto Rico: Like the game of RISK, payers continue their move into new markets. Anthem will acquire the largest MA plan in Puerto Rico, the plan announced last week. By purchasing MMM from InnovaCare, Anthem will also gain the 2nd largest Medicaid plan in PR, alongside a network of specialized clinics with over 10,000 providers.

Monitoring Parkinson’s: Apple released a new study showing that the Apple Watch can be used to monitor symptoms of Parkinson’s disease. The watch is able to detect the motor symptoms that result from Parkinson’s and by monitoring these movements, researchers can identify the “on” and “off” patterns of a medication’s effects. Physicians often have to rely on clinical visits and self-reporting to monitor Parkinson’s progression; adding something that is relatively low cost and tracks data constantly could be a real help to patients and their physicians as they make healthcare decisions around treatment

Home Run Or Risk: Humana is launching a home healthcare service that includes remote patient monitoring. They are partnering with DispatchHealth to launch the hospital-at-home program in Denver and Tacoma, WA, for patients requiring care management for multiple chronic conditions, with plans to expand the service to Texas, Arizona and Nevada later this year.  One medical director is intrigued by these models but acknowledges the risks – “Reminds me of freestanding ERs – they ended up costing us a lot more by splitting true emergencies like chest pain – how much of this care can really be handled at home?”

Doctor Baker: Straight out of Little House on the Prairie, Heal, a provider of in-house primary care services, including physician house calls, has expanded into Illinois, the Carolinas and Louisiana. Previously, its services were mostly confined to the East Coast. Heal is now available in 12 states and can reach 134 million Americans, the company said. It offers a combination of house calls and telemedicine services on demand.

Dental Switch: Careington, a TPA that also owns and operates large discount and PPO dental networks, is launching a national teledentistry program through affiliate company DialCare, offering 24/7 access to licensed dentists via phone or video consultation. Teledentistry has become a trend over the past year, with more payers promoting these services and more members utilizing them.

Stage 3 Wounds: United’s Medicaid plan Texas has partnered with a wound company targeting patients with stage 3 or 4 pressure wounds. Vohra Wound Physicians will manage outpatient wound care via telemedicine, dispense wound care dressing shipped directly to the member’s home, and prescribe wound related medications or antibiotics.

Extra Point:  I love my mom’s stories about the nursery school kids peeing on her in the hallway. She would take about 3 hours to tell them but boy were they funny when she finally got to the punchline. She always laughed as she shared how little Johnny “made a puddle by the legos.” But mom didn’t always laugh, especially when I used to drop an F-bomb about my below par social life. It was as though she had a bar of Dove soap in her pocket for those moments. If I learned anything about mom over the years, it’s that she may have been behind the scenes, but she was in charge – the President in our house. On Monday, we celebrate the country’s 46 presidents, none of them women. Overall, women make up about half of the U.S. labor force but less than 5% of Fortune 500 companies, as of 2018, had a female CEO. There’s been some progress. In healthcare, Helen Arteaga Landaverde started as new CEO at Elmhurst Hospital in Queens this month and about 22% of hospital CEOs are women today, up from 10% back when I worked for Rosanne Griswold at Charlotte Hungerford Hospital in 1998. I was a nervous pup reporter back then writing publications on the side for the community hospital but I didn’t really blink when I was interviewing her. After all, I was used to female Presidents – my mom Brenda Antonelli, and now today, my

20: Number of primary care centers Humana opens in four states this year, including Atlanta, New Orleans and Las Vegas. Leaning on Humana as your major Medicare payer for your primary care operation brings upside given the company’s investment in risk-based models and in some cases elevated PMPMs, but it also brings this evolving dynamic of competition from Humana’s Partners in Primary Care owned practice.

Staff Boom Or Zoom? Two companies merged in January to become the biggest healthcare staffing firm in Washington state. The joint company, now known as Actriv Healthcare, will employ over 400 nurses and aides and offer services in Idaho, Oregon, California and Washington. Pandemic factors have elevated the role of staffing and shined a new challenge on the system – training physicians and allied providers on how to diagnose on a Zoom.

More Fluoride or Less? Other than Seinfeld’s Tim Whatley who clearly was ahead of his time as a value-based dentist offering patients schtickles of fluoride at every visit, few oral health practitioners even know what value-based means. 86% say they haven’t heard of alternative payment models or know little about them, according to a Dentaquest poll. The study highlights the need to educate dentists about these arrangements, and underscores the potential opportunity for more sophisticated practices to become more involved in pilots and rollouts to demonstrate the impact they can have both on oral health and medical cost savings.

Ride Share: Michigan’s Blue plan is sharing more reimbursement this quarter with ground ambulance providers. Payment (billed with code A0425 and based on mileage) will depend on the number of providers who sign an agreement, but the more providers who sign on, the higher the reimbursement will be. Reach out for details.

Hear This: A hearing aid benefit is now included in Regence BCBS’s medical benefit for employer groups in Washington state with 51 or more employees. The new benefit includes a hearing aid evaluation and hearing aids.

Asleep At The Wheel: Superior Health Plan, Centene’s Medicaid managed care plan in Texas, will begin using a third party to manage certain ENT surgeries (including sinus surgery) and sleep studies beginning May 2021. TurningPoint Healthcare Solutions will process prior authorization requests for medical necessity and appropriate length of stay across all settings, inpatient, outpatient, and in home.

Monitoring Moving Up: In February, CareFirst BCBS starts covering remote patient monitoring for patients discharged from an inpatient facility or emergency room for heart failure, heart failure chronic hypertension, chronic obstructive pulmonary disease, chronic kidney disease, and COVID-19.

Not Your Grandpa’s Gym Class: BCBS of Illinois’ Little Village Wellness Center located on the Southwest side of Chicago is having its grand opening this weekend and although the pandemic prevents the center from launching its full spectrum of in-person low-impact fitness classes and health literacy sessions, the center will host virtual programs including Zumba and cooking demonstrations. The program further illustrates the changing role of health insurers from payer to provider, but also underscores their challenge—Little Village is located around the corner from Pizza Castle.

Extra Point: My Jack looked part Maria von Trapp, part Troy Bolton today hustling from jazz band rehearsal to hoops practice, swinging his trombone case in one hand, his Converse sneakers in another. The 17-year-old senior is doing what no one said he could - juggle the intensive schedule of competing winter activities in a community that says it supports kids who want to do both, but doesn’t really. He’s been trying to convince his coaches and conductors and school system for nearly a decade that he can do both and out of sheer perseverance finally is seeing the rewards. Once upon a time healthcare aired the same movie. Oncologists used to log long hours in clinic and then take unreimbursed calls from home from patients suffering from the effects of chemo. It took data, stories and perseverance to convince the health system that there had to be a better way and now, a decade removed from some of the earliest payment innovation for cancer care, these oncology practices are getting rewarded. If you listen closely, you can hear Jack warming up the instrument these days during our team’s morning call, and like a lot of you with kids who’ve come of age I’ll admit I’m going to miss that next year when he’s off to college. But I will have this as my reward from Jack’s Troy Bolton moment.

29: Percent of primary care practices “hiring” mental health staff in 2021 according to our poll of 567 PCPs, pediatricians, internists and specialty doctors who manage conditions in which depression and anxiety are common, like asthma, crohn’s, cancer, pregnancy and rheumatoid arthritis.

Landing Home: Landmark Health, which focuses on in-home medical care to frail populations, formed a value-based care partnership with Southwestern Health Resources, a clinically integrated network. Through this partnership, the pair will offer multidisciplinary medical care at patients’ homes for approximately 10,000 patients who on average, have between 6-8 chronic conditions. High-risk patients will be assigned a physician or nurse practitioner. Depending on patients’ health needs, they may also be assigned a psychiatrist, social worker, pharmacist or dietician. Patient care will not rely on remote patient monitoring, but instead on in-home medical visits.

Medical Nutrition Scope: Horizon BCBS in New Jersey is implementing a new reimbursement policy for Medical Nutrition Therapy. As of April 15, 2021, these nutrition services will only be considered for reimbursement if billed by a registered dietician, nutritional professional, or a hospital that has received assignment from a registered dietician or nutritionist.

Kidney Disease Shift: Monogram Health is now providing kidney disease care coordination services for Humana members in Alabama, Tennessee, Louisiana and Mississippi. The program offers medication, treatment compliance and monitoring of comorbidities to ensure early detection of chronic kidney disease and end stage renal disease. BCBS of Texas is another insurer creating per member per month payment options for care management companies able to do CKD prevention.

Out of State Protection: BCBS of Nebraska is making a change to help patients who go out of state for care. Starting in mid-April, if a preauthorization is required but not obtained for an out-of-state member, providers will be held responsible for the denied charges. Prior to this change, the member was held responsible. This change means that providers cannot hold out-of-state members responsible for charges that are denied when preauthorization is not obtained.

Pilot For COVID: WellCare is piloting a national at-home COVID-19 testing and flu prevention program for Medicare Advantage members who are symptomatic or have been exposed to the virus. All test collection kits are being offered as a one-time benefit to select, eligible MA members. Each kit includes a PCR test, 20 disposable face masks, hand sanitizer, and an oral digital thermometer to help prevent spread and exposure.

Cigna Behavior Change: A mental health outpatient program called Catasys OnTrak was not reimbursed by Cigna in 2020 but will be for Medicare HMO members with a diagnosis of anxiety, depression or substance use disorder this year.

Extra Point: Please pray for my daughter today. The 19-year-old has an open-book, 48-hour-to-complete, all-multiple-choice anatomy exam this afternoon. The physical therapy major needs a good grade to stay above a 3.0 in her sophomore year and on pace in the rigorous 5-year college program. Back in our day we had 30 minutes and unless we were Lenny Duppee and wrote the chemistry answers in blue ink on our left hand, we had to just know it cold. “But I’m really nervous – I never know if it’s a, b, c or d.”  Um, that’s sort of the point kiddo. Maybe pray for my son instead? By tomorrow Jack will know if his dream college picked him, a long shot given his grades and SATs are below the typical accepted and he’s competing against kids who got deferred by Harvard. Probably best to pray for people like 77-year-old Charlotte Stamos. Charlotte came to our house 5 times yesterday to ask when her vaccine appointment was. She was a hospital and nursing home social worker for 34 years and told us yesterday that the independent living facility denied her application because she failed her memory and psych evaluation. Charlotte is in many ways the picture of aging in America – a widower battling a lonely home, a bad hip and a brain that can remember the name of her first-grade teacher, but not that she had her vaccine on Wednesday.

7: The number of additional physician organizations BCBS of Michigan is adding to its risk-sharing payment model, Blueprint for Affordability. In total, 21 organizations are participating, representing roughly 38% of Blue Cross’ total commercial membership and 42% of the Medicare Plus Blue membership. The new physician organizations joining include ACOs and multi-specialty provider groups.

Bundle This: A maternity MAT initiative kicks off this month for all OB/GYNs and maternal and fetal medicine doctors in Blue Michigan’s physician performance program, this one focused on addiction. Providers who participate will receive initial funding of $10,000 and will then be eligible for $1,000 per patient treated with medication assisted treatment in 2021.

Health Disparity Study: Parexel and Signify Health are collaborating on a series of clinical trials to identify relevant social determinants of health. Parexel says to correct disparities in healthcare and drive more inclusion in clinical trials, first a more holistic understanding of non-medical factors that influence patients’ lives is crucial. The first pilot is set to launch this year.

Tough Break For Virtual Payment: Tufts Health is implementing some changes related to virtual services. Effective this year, Tufts will no longer routinely compensate for interprofessional telephone or internet consultation if any face-to-face service has been billed on the same day or within the previous 14 days. Tufts Health Plan will limit online digital E&M services to one combined unit within a seven-day period and will not routinely compensate online digital E&M services when billed within seven days of certain other E&M services.

The New Age HMO: Doctor on Demand is partnering with Community Health Choice to launch an HMO plan on Texas’s ACA exchange focused on virtual primary care. The plan targets Texans who do not qualify for Medicaid and Medicare and may otherwise fall into a coverage gap. Members will have access to video visits for preventive and urgent care, along with behavioral health. In the wake of COVID-19, we’ve seen a rise of virtual focused health plans and will be watching how these impact care over 2021 and beyond.

Cancer Care At Home: Coram, CVS’s infusion business, is collaborating with Cancer Treatment Centers of America to administer chemotherapy at home for some patients. Patients will begin their first cycles of chemo in a hospital or outpatient center and if tolerated well, will then transition to receiving the infusions in their homes. Coram nurses will provide in-home care, and patients will have access to telehealth visits and digital therapeutic check-ins with the rest of their care team.

Extra Point: If you look closely, the man pictured here donning a light gray winter cap, brown jacket and khakis was about to be turned down for a dose. On MLK day this week, the man didn’t know he needed an appointment, he just saw the big signs for vaccines here in Hartford, had heard the AM radio talk about it, so the man walked 4 blocks and waited in line. The nurse coordinator gave him a website, a phone number and an apology, but then with 100 circling the building, did what she had to do I suppose. That man is 83 and against my better judgment, I left my spot to find him. Wasn’t too difficult if I’m being honest, since each step took him great effort and obvious pain, plus I was already feeling out of place amidst the 75 and up crowd, even though the state had okayed part-time teachers. That man and I found a lonely bench and with the magic of the iphone and a little patience, I registered the man for an appointment for an hour later at the Pratt & Whitney drive-up location. The man didn’t have a car anymore and as he quipped in the moment, “What do I have to do today,” so I gave him a ride and changed my own appointment slot. The man had his wits about him but admitted he had felt overwhelmed lately. He talked about how “my Janie would do all this,” his angel until passing away 5 years ago to cancer. The man cried a little when he said that, but he smiled telling me how she used to make the best monte cristo. “I can still taste it,” he said. The man told me the story 3x on that ride. But I didn’t mind. The man, Jerry Wilder, thinks he retired in 2006, same year as my dad. He grew up in Brooklyn on Franklin Street but spent most of his adult life in greater Hartford. He and Janie had 3 kids and 5 grandkids who mostly live in the Midwest, but his daughter is nearby but busy. “She teaches the kids who have the special needs, autism, not sure which grade. I think it’s kindergarten.” I asked the man what he used to do. “I was a neonatologist. Was actually a pretty good ball player back in the 60s….had a call-up with the Kansas City Athletics, but I couldn’t hit the ball out of the infield enough." So you became a doctor I said. "I guess so," Jerry said. That man was my Moonlight Graham on Monday, on MLK day, when we think about dreaming a little and not about what is but what can be, and sometimes what was. I’m glad I left my spot to give him a shot. Was my gain.

3: The amount of free PCP visits Blue Cross NC members will have through a new feature designed to encourage their members to go to the doctor’s office. Effective January 1, 2021, select Blue Cross NC members have no copay for their first 3 visits when visiting their PCP on file. Benefit available to ASO, fully insured, and fully insured individuals under-65 with a copay for office visits.

Kidney Care: Beginning this month kidney care management company Somatus launched a pilot to better integrate care for CareFirst BCBS patients with chronic kidney and end-stage renal disease. 250 members in commercial, fully insured groups with policies issued in Washington, D.C. and Northern Virginia are part of the pilot at no additional cost to the member. Patients get connected to a Somatus care team including a nurse care manager, community health worker, renal pharmacist, renal dietitian and social worker.  We assume this model is paying a PMPM but what we need to understand is the effect on nephrologist and the impact on the dialysis companies.  At a minimum, this is another example of the trend toward disease focused care management partnerships.

Scaling Social Determinants: CareSource is partnering with Healthify to build a network of community based organizations across Ohio, which will provide members of the Medicaid insurer referrals to address social determinants of health. The network will be made up of community organizations that provide a range of services that address SDoH such as food insecurity, lack of transportation, unemployment, inadequate housing, and financial instability. In Michigan, Priority Health is launching a new web presence that will focus on SDoH and health inequities by providing visitors with educational background information on SDoH, among other content. Payers are increasingly recognizing the importance of addressing SDoH for their members’ overall health. Stay tuned for a special report on SDoH from the Managed Care Friday team, out later this month.

HIV First: A new health system in the Pacific northwest includes the first skilled-nursing and outpatient chronic care management program in the US designed specifically for people living with HIV/AIDS. The Bailey-Boushay House is part of the newly formed Virginia Mason Franciscan Health system, which boasts 300+ sites, 11 hospitals and 5,000 providers.

Scripted: Iowa was once only famous for the great Moonlight Graham and that small ballfield in Kevin Costner’s backyard, but now Wellmark, the BCBS plan here, is building its own field of dreams - a new preferred drug strategy for drugs covered under the medical benefit will make Biosimilars the preferred drug without prior authorization for applicable cancers, asthma and rare diseases under a new policy taking effect fully by April this year. Wellmark is joining the many health plans who are looking to help control drug spending by making biosimilars the first line choice.

Change Up: UnitedHealth’s Optum is buying Change Healthcare, a technology company with an array of services including claims processing and data analytics. Analysts say the goal of the acquisition is to leverage the amount of data both companies control in order to help improve care and lower costs. We saw at least one other health insurer buy an analytics firm in 2020 and it doesn’t appear this trend is going away anytime soon.

Extra Point: Mom and dad still use a rotary phone, keep a checkbook balanced to the penny and if they’re lucky Dr. Blume will come by the house to check their BP and run a rapid strep test. Some days I think they are straight out of Little House on the Prairie, others I think they are just brilliant. House visits ala Dr. Baker are now becoming the norm in SNF and hospital at home models and primary care like Village MD. It’s a trend you could see coming as I discussed here 6 years ago when I had a bit more hair.  Ma’s heart condition fueled by 18 some years eating Italian in a village near Napoli and dad’s age – just about 80 now – have both of them in line for a vaccine here in the nutmeg state. I’ll be driving both to the convention center on MLK Day – first to get their Covid vaccine and then to get my own.  I’m not exactly tier 1, but in Connecticut, since I coach sports at an inner-city middle school, that puts me on the list. Part of me feels like I’ve cut the line like I used to do at Vecchitto’s Italian Ice shop in Middletown, but I hope that by getting vaccinated it will protect the kids, many of whom have lost a relative to Covid, all of whom are part of a state free lunch program and none of whom think of things like college or gym time as a right, but rather a hope. It’s not lost on me that MLK himself once said that “of all the forms of inequality, injustice in healthcare is the most shocking and inhumane”. Hopefully we move into a new phase soon that equalizes healthcare and raises our collective health. I am hopeful – for more house calls by doctors like Pete Blume, vaccines for those in need, and maybe a cell phone for mom and dad.

2.2B: The amount Centene is spending to acquire Magellan Health in an effort to strengthen its mental health business. The deal will add 2 million pharmacy benefit members and 16 million medical pharmacy members to Centene's portfolio, the company said. The deal will also bring Centene 18 million third-party customers of specialty health services, which includes physical medicine and rehabilitation to people with disabilities.

Acne: “I’m not sure if we’re missing an opportunity to reduce depression, alcoholism, violence and suicide by adding payment incentives to encourage dermatologists to work with teen therapists more regularly – it’s this kind of care coordination that’s value based.” – Mindy Carpenter, a payment transformation leader with a western Blue company.

Specialty Rx Revamp: Regence Blue Cross in the upper northwest is transitioning their preferred specialty and home delivery vendors from AllianceRx Walgreens Prime to Accredo and Express Scripts Pharmacy, effective April 1, 2021. Accredo will be the preferred specialty pharmacy and ESI will be the preferred home delivery pharmacy for Regence commercial members in Oregon, Utah and select counties of Washington who have Specialty Select. These members must fill their specialty drugs at Accredo or get them delivered by ESI to be covered by the health plan. Accredo and ESI will be new in-network options for all MA members and Idaho commercial members, where they have the option to use these but will not be required.

Consumer Choice: Beginning in March, the doctor finder and transparency tool “Find Care” in Anthem BCBS’s online directory will be available to search by procedure type. The sorting option will use algorithms based on a patient’s medical conditions and demographics to display the best physicians or providers. Surgeon-facility pairings, cost efficiency measures and the volume of patients treated by disease and outcome-based quality measures are factored into the algorithm.

PT Quality Measure: Worker’s Comp insurer The Hartford prefers to refer and partner with Select Medical for physical therapy, not because they have a lot of locations but because unlike a lot of PT practices they train therapists on how to ID addiction and other behavioral disorders. My dad, now 77 and himself getting at home PT for his 3rd fall, says he wished he was trained in this during his years as an athletic trainer. “Took me 2 months to figure out knee pain was really masked by an eating disorder in an athlete.” This is not a new concept, as we studied here 6 years ago, just an important component of figuring out what PT and orthopedic quality look like.

In case you missed: 81% of 1,612 consumers in our healthcare poll say they did not go to the doctor in 2020 and 79% say they have “significant amounts” of unused health savings dollars left over. One issue is a majority say their employers didn’t adjust their FSAs to allow them more time and flexibility to use the savings for medical care in the year ahead. A majority polled say they are moving from FSAs to HSAs in 2021 or were considering. Look for full results in our consumer poll briefing coming in January.

Boston Link: We had more than a feeling that these two health plans would sync up and as of January Tufts Health Plan and Harvard Pilgrim Health Care have merged in what will be a new nonprofit serving 2.4 million members across 5 New England states. A new name is expected. My 13 year old’s suggestion – Fenway Care, so you know where his allegiance lies.

Extra Point: I slid the old Peter Gabriel cassette into the boom box last night, rewound for 10 seconds, flipped the tape, hit PLAY then STOP then flipped and rewound 3 more times and alas there it was, In Your Eyes. I held it high like Lloyd Dobbler, stood atop the coffee table and told my kids “this was a quintessential 80s moment” epitomizing an era of persistence, optimism, big hair, great songs and surprising yet perfect marriages like Lloyd’s with Diane Court. When we rewind healthcare in 10 years I suspect we may see the same thing – partnerships that come out of left field but oddly work: Walgreens and Village MD’s primary care outfit, dentists and allergists teaming to treat gum disease in those with asthma, and autism therapists and gastroenterologists linking up to address prevalence of GERD in kids on the spectrum.  Dermatologists and teen therapists to halt acne-induced suicide attempts, health centers revitalizing community hospitals and fall-detection alert devices helping seniors dealing with vertigo. As Diane told Lloyd, “No one really thinks it will work, do they?”  No, said Lloyd. “You’ve just described every great success story.”

15: Percent increase in reimbursement starting in February for physicians who do certain procedures in ASCs rather than hospitals under a Michigan Blue plan policy. The change applied to PPO membership, as HMO patients are "managed" and use ASCs more often already.

Penn & Tella: This is how my brother-in-law from Boston’s north shore pronounces the magician pair but it’s also a new telehealth program from Penn Medicine that has reduced rehospitalizations 75% among patients who’ve had hip or knee replacements. The program, Home Connect, gives patients wearable devices and text messages to help them monitor pain levels. According to researchers, only 3% of those using the connected care platform returned to the hospital within 45 days of their surgery to deal with complications, compared to 12% of those in standard care.

Raising Arizona: Magellan Health continues its move into care delivery, acquiring a 70% interest in Bayless Integrated Healthcare, an integrated outpatient behavioral health and primary care provider in Arizona.  We expect more benefit managers, insurers, and health assessment companies in 2021 to continue to add services to their models or try to. Bayless has 175 providers across eight locations in central Arizona and will serve as a growth platform for Magellan to enter new geographies as a partner to, or a provider of, integrated primary care and behavioral health.

Lyft Off: The transportation company is continuing to expand its presence in the healthcare field, this time by launching a nationwide campaign to provide rides to vaccination sites for those in need. By partnering with United Way and Anthem, Lyft’s goal is “to provide 60 million rides to and from vaccination sites for low-income, uninsured, and at-risk communities.”

Big Apple Medicaid: Starting in March, Medicaid beneficiaries enrolled in several of United Healthcare’s New York plans will need a primary care provider to make a referral for them to see certain specialists, like cardiologists and dermatologists, although a specialist who has arranged to act as a PCP is exempt. The referral must be in place prior to the specialist visit for the specialist claims to be paid. Several situations do not require referral – HIV screening, dental care, women’s health, behavioral health, maternal depression screening, some eye care, and ER and inpatient hospital consults, like anesthesia or radiology. This applies to United Healthcare Medicaid beneficiaries in a Family, Wellness4Me, or Child Health Plus benefit plan.

The Florida Effect: Florida-based risk-taking primary care provider, ChenMed, owns Detroit-based Dedicated Senior Medical Centers and, starting summer 2021, the centers will partner with Michigan’s Blue plan under a model to reward physicians for health outcomes improvement. Six total centers will open in the Detroit metro area.

Waste Not, Want Not: 81% of 1,612 consumers in our healthcare poll say they did not go to the doctor in 2020 and 79% say they have “significant amounts” of unused health savings dollars left over. One issue is a majority say their employers didn’t adjust their FSAs to allow them more time and flexibility to use the savings for medical care in the year ahead. A majority polled say they are moving from FSAs to HSAs in 2021 or were considering. Look for full results in our consumer poll briefing coming in January.

Extra Point:  I just saw that Modern Healthcare is looking for nominations for the best places to work. I’m no expert in this area but here are my top 5 nominations. (5) My parent’s attic, because no one is there and in between meetings I can line up the Smurfs and GI Joes for battle. (4) My deck, because it’s the only place where I can get Vitamin D and catch the neighborhood teenagers sneaking into our shed. (3) My basement, because I can do a few loads of laundry while drafting emails. Clearly important, given the extent of my wardrobe right now—sweatpants, gray shirt, brown socks, repeat. (2) Front seat of the wife’s car but only when she’s home from school and I can say “I heard something weird coming from the engine so I’m going to take it to the shop” for several hours, which gives me bonus points, peace and quiet, and a smidge of guilt. And (1), the bathroom floor because for some reason it has the best reception. Today I woke up at 6am and started work in #1 but, for a change, felt a bit less like Groundhog Day’s Phil Connors. Sure, the lab was chewing another N95 mask and, yes, there are no New Year’s Day Italian meatballs at Uncle Cosimo’s to look forward to, but 21 has finally edged out 20 like a George Blanda extra point for Chicago’s Bears. Groundhog Day’s hold on us is breaking. Happy – and of course healthy – new year to you and your families. -BC

49: The percent of Medicaid, Medicare, and commercial payers who named this their top priority for 2021 in what is a bit of surprise but an indication of how the health system continues to evolve.  The new #1, the full Top 20 priorities and what moved up and moved out since last year will be reported in the 15th edition of the Healthcare Payer Index coming out soon. Stay tuned.

Alternative Pay: 31% of surveyed payers say they are thinking about the next generation of payment models and one model, likely developed by some insurers, will target severely mentally ill populations. But creating the right model, price, incentives, and PMPM, as well as finding a network provider able to have success is going to be difficult given the significant variation in patient diagnoses and needs, from schizophrenia and bipolar to eating and panic disorders. Still, in 2021, expect more insurers to tackle these alternative concepts and either pilot or partner with a kind of care management company able to manage treatment, avoid hospital cost and improve quality of life.

Anesthesia Cometh In: BCBS of Texas and U.S. Anesthesia Partners signed a four-year agreement that allows BCBSTX members to continue receiving services from the national anesthesia provider at in-network rates. The agreement covers more than 2,500 clinicians in Texas and expands the relationship to include BCBSTX Medicare Advantage members.

Crowded House: If you’re a fee-for-service primary care practice in Louisiana, South Carolina, Ohio, or North Carolina, get ready for a new value-based competitor to come into the market as Oak Street is expanding their footprint into these states in 2021.

Specialty Pharmacy Integration: Centene plans to acquire PANTHERx, a specialty pharmacy focused on rare diseases and orphan drugs, by the end of the year. PANTHERx will operate independently as part of Centene's Envolve Pharmacy Solutions, their drug management program that includes PBM services and specialty pharmacy solutions. This is another example of consolidation in the specialty pharmacy space, as several payers in recent years have acquired them or formed exclusive partnerships.

Surgical Stake: Tenet Health signed a deal with SurgCenter Development to acquire up to 45 ASCs across nine states. The centers will be operated by Tenet’s ambulatory surgery unit, USPI, and will bring their total number of ASCs up to 310. Tenet will have up to a 60% ownership stake in the centers, with the rest owned by physician partners.

Humana Expands Value Models: Humana has been busy over the last month, announcing new expansions, partnerships, and a new value-based model. First, Humana is strengthening its value-based partnership with Vancouver Clinic by opening a second neighborhood clinic, Evergreen Place, in Washington. Like their previous venture Vancouver Plaza, this one will feature a mix of providers and will offer preventive care and telehealth services to all Humana Medicare Advantage members, along with Humana Dual Eligible members. The health insurer also signed a new agreement with Prime West, effective January 2021. Under the agreement, Humana MA members in Nevada who pick a direct network option will have access to an additional 120 providers at 42 Prime West locations starting in January. Last but not least, Humana is launching a new primary care value-based model called Primary Care First for MA members in HMO and PPO plans across 48 states. It will build on the CMS model.

Gene Therapy Payment Model: Earlier this year, we published a report on the ways payers are trying to address the high cost of these treatments. Check it out here.

Extra Point:  Maria Sanchez has had a tough go of it this year, losing her parents to COVID and her 51-year-old husband, a factory worker who didn’t get to his doctor quick enough this year and missed an early diagnosis of cancer. But on Thursday afternoon, after a 12-hour shift at a Hartford hospital, Maria, a nursing aide by night and mom of two by day, hopped off the 62 Bus line, maneuvered through a few slush puddles and saw her kids doing snow angels out in front of their apartment building. Jayla, just 5 years old, and Xiel, 12, don’t quite know what loss feels like to their mom but they know mom has been sad. Maria walked over to the kids and started crying. “The kids haven’t had a chance to just be kids much this year.” Xiel has become the man of the house this year – shopping, cooking, and taking care of his sister. Internet is spotty here in the four-story building, often making it difficult to be online for school, so Xiel has relied on a neighbor to help him with reading and writing. “He’s so smart but I worry about all that I put on him.” Maria wiped away her tears with her mismatched mittens and dropped her backpack into the snow and fell backwards into snow angel position. Jayla jumped on her and giggled. “Ma ma, I love you – can we have hot cocoa?” Maria smiled and exhaled all at once. It’s been a tough year for sure, but moments like these give her hope. -BC

40: The number of additional onsite primary care clinics Walgreens and VillageMD are opening in 2021 through their partnership, focused on sites in Texas, Arizona, and Florida. Physicians, nurses, and pharmacists will staff the clinics, and an app will allow patients to also utilize virtual and telehealth services. Walgreens has stated its long-term plan is to open as many as 700 of these clinics over the next five years.

Moving to the Pharm: BCBS of Michigan is moving two drugs from the medical benefit to the pharmacy benefit because “they can be safely administered in the member’s home.” Skyrizi, for plaque psoriasis, and Tegsedi, for hereditary transthyretin-mediated amyloidosis (ATTR), are covered under the pharmacy benefit as of October 8, 2020. The drugs will be available through specialty pharmacies, lowering the drug cost to the plan, and increasing patient convenience.

Texas Hold ‘Em: The Center for Cancer and Blood Disorders in Texas is using artificial intel to help patients avoid unnecessary ER trips. The AI program helps providers predict which patients are most likely to go to the ER in the next 30 days and then recommends actions the providers and case managers can take to prevent this. The center is one of three practices piloting an AI platform from Jvion that uses 25 different variables to identify risk, including social determinants.

Best Buy Health Play: Next year, members enrolled in a Regence Medicare Advantage plan will have access to Lively Mobile Plus, a PERS (personal emergency response system) offering from Best Buy Health. The device offers a 24/7 connection to trained staff that can help in medical emergencies and non-emergency situations, along with built-in fall detection technology. The Lively Mobile Plus benefit can also help Regence members navigate social risk factors like transportation concerns, social isolation, and food insecurity, helping maintain their overall level of health.

Infusion Biz Adds Vaccine: CVS Health, through its infusion business Coram, will administer COVID-19 treatment in patients’ homes and in long-term care facilities. The treatment, manufactured by Eli Lilly, requires an hour-long infusion and administering the treatment at these sites of care will allow patients to avoid hospitals during the latest surge. Hospitals, PCPs, urgent care centers, and long-term care facilities can refer patients to receive a home infusion, starting in seven markets in the initial phase, which begins mid-December and will expand over the next few months.

In Case You Missed It: We released the latest version of our Healthcare Investment Index on Thursday. Check it out here and reach out with any questions.

Extra Point: I had a Carl Spackler moment during Tuesday’s managed care panel. My internist was tuned in and texted me about the same time I was peppering BCBS Chief Pharmacy Officer Dr. Mona Chitre about why virtual clinics have become a disruption in western New York. “Bryan – set up zoom session. Your eyebrow has a growth that looks to be getting bigger.”  Talk about real time diagnostics - and I didn’t have a copay for the unsolicited consult! So, I got that going for me. Which is nice, as Bill Murray’s Spackler would say. In truth, I find Dr. C’s point about virtual clinics a fascinating paradox – they are fresh, offering choice, fancy apps, and data, and are lowering A1Cs, giving self-funded employers a way to cater to younger employees and those with chronic conditions. Very Gen X, or is it Z? But they disrupt the progress a health plan is seeking with its physician network. They add another cook in the kitchen and they go against the tide of integrated care, to say nothing of the challenges they may create around attribution, data sharing, outcomes measurement, and value pay. As the former greenskeeper Spackler might say…gunga galunga.