Behavioral Health Insights

Social Service Payment: Identifying the social factors of health is part of a new program from a Michigan health plan. Starting in January, the plan will provide financial incentives to healthcare providers if they screen patients and report back these social risk factors. Click here to read more.

Extra Point: At about 11:45am on Tuesday the 8th, one of our panel discussions will feature Mona Chitre, the longtime chief of pharmacy and VP of integrated clinical strategy for Excellus BCBS, the head of healthcare strategy and payment transformation from Blue Carolina, Troy Smith, and a pair of behavioral health leaders, Ish Bhalla MD and Stephan Young, trying to reshape payment policy for SUD, SMI, and broader mental health for their health plans. I suppose it would have been more dynamic to do this from bar stools down in DC but ce la vie. I’m only 30% confident what I’ll ask, 50% certain what they may say, but about 90% certain you will hear my kid’s trombone and my daughter’s Julie and the Phantoms CD during the one-hour panel, plus probably a few “who stole my charger” and at least one “Dad! Zaggy pooped on my laptop again!” And because there are six of us online mid-day Tuesdays, there’s at least an 83% chance I’m moderating from the backseat of my 1997 Volkswagon, wearing a winter coat and an Italian cap. But if we’re to learn anything from this week’s feature about Priority Health’s brave move into paying doctors for, of all things, identifying social determinants of health, it’s that sometimes we need to adjust and do things differently. So on Tuesday, maybe, just maybe, I’ll shave, put on a tie and try to let the panelists steal the show…

$100M: The amount Ochsner Health in Louisiana committed to spending over the next five years to build community health centers in underserved areas. Louisiana consistently rates in the very bottom of US health rankings and the health system aims to increase their ranking by opening 15 centers across the state. They will be located strategically in rural and underserved areas, providing more alternatives to patients who frequently use the ER as primary care.

Interception: An adult and pediatric practice in Nevada says Anthem’s teledentistry partner has “picked off some of the patients we typically would have seen for pain-related issues,” as dentists face a new competitor. The teledentistry movement is more likely a maneuver to improve access but could become a hurdle for unsophisticated practices who rely on low acuity “complaint visits.” Pediatric dentists are also being denied operating room access due to COVID cases deemed more medically necessary, concerns about aerosol generation, and lack of protective equipment, a Health Policy Institute study has learned. The American Dental Association and the American Academy of Pediatric Dentistry are working together to address the issue, even as the oral health industry tries to make a comeback in Q4.

Proton Beam of Light: Philadelphia-based University of Pennsylvania Health System and Southern Jersey’s largest health system, Virtua, are extending their collaboration to open a proton therapy center in South Jersey. Construction of the center began this past summer at the Virtua Voorhees Hospital and is expected to open in 2022.

Amazing: News about Amazon beginning to sell and deliver prescription drugs through its own online pharmacy is not a surprise and 83% of 712 consumers we polled this week say they will likely consider it, particularly given most – more than 600 – already use Prime for a range of products. Prime members will be eligible for up to 80% off generic drugs and 40% off brand name medications, even without using insurance. Amazon Pharmacy shoppers will be able to input their insurance information directly to see if their price is lower through insurance or their Prime discount. Discounted prices will be available both online and at 50,000 participating physical locations. InsideRx (formerly Express Scripts) will manage the benefit. Insurers have started to piggyback on the Amazon experience. Several insurers now have dedicated portal pages on Amazon to allow their commercial members to buy eligible supplies using HSAs and FSAs.

Heart Beat: iRhythm Technologies, the maker of the Zio patch, released data this week showing that its wearable technology increased the rate of atrial fibrillation detection and reduced cardiac events. Aetna helped back the study, which included about 1,700 of their members who were deemed at moderate risk for atrial fibrillation.

Coming Soon: We sat down with Kimberly Harrison, VP of network engagement for Priority Health in Michigan, to talk about a new program starting next year to provide certain physician practices financial incentives if they screen patients and report back social risk factors. The full story in our next edition.

Extra Point: MAYBE IT’S JUST ME BUT IT SEEMS LIKE ALL THE SENIORS IN MY LIFE ONLY EMAIL IN ALL CAPS.  I DON’T THINK THEY ARE ANGRY. IT’S MORE LIKELY THE SAME PROBLEM THEY HAVE WHEN LEAVING THE LEFT BLINKER ON FOR 12 BLOCKS – THEY EITHER DON’T REALIZE IT’S ALL CAPS OR DON’T KNOW HOW TO CHANGE IT. AS MUCH AS IT MAKES ME LAUGH, IT IS A TAD BIT ALARMING TO READ AN ALL CAPS VERSION ABOUT UNCLE AUGIE’S ELEVATED LIVER ENZYMES OR THE EAR WAX DAD’S PCP FOUND THAT MAYBE, JUST MAYBE, WILL CURTAIL HIS VERTIGO PROBLEM. -BC

59: Percent of dentists reporting increasing prevalence of stress-induced oral health problems like bruxism or teeth grinding, chipped and cracked teeth, and temporomandibular disorder symptoms like jaw joint pain.

As CMS Goes: CMS will begin paying doctors to use two different AI systems, one focused on diagnosing diabetic retinopathy and the other that alerts specialists when a brain scan shows a patient may have suffered a stroke. MA and commercial plans may also provide coverage, though the parameters around reimbursement may vary. Both products were approved by the FDA back in 2018, and will now finally be reimbursable, allowing more widespread use in the medical field.

Buying Risk: Centene is buying health analytics and risk adjustment company Apixio, which analyzes sources of patient data like physician notes and medical charts. The move is designed to complement Centene’s existing data analytics products and help ease the transition to more value-based care arrangements, which heavily rely on accurate patient data.

Biosimilar Boost: Wellmark BCBS is launching a new drug strategy program in the first half of 2021, focused on promoting preferred biosimilars. No prior authorization (PA) will be needed if the biosimilar does not have a PA in place today, and for those that do have one in place, no PA will be required for 12 months. PAs will be required for non-preferred products. The fee schedule will not change, in order to encourage the adoption of biosimilars.

Blue Light Ahead: Dependents under the age of 19 years old who are enrolled through employer-sponsored plans may now receive anti-reflective coating on eyewear at no additional cost under new benefits from United Healthcare. The coating helps reduce exposure to blue light, something that many young people have seen an increase of over the past several months, thanks to remote learning.

Home Addiction Model Q&A: Tufts Health Plan is expanding an in-home addiction treatment pilot for substance use disorder through a partnership with Aware Recovery, which works off a PMPM model. Tufts is the first health plan in Massachusetts to cover this treatment. To hear our interview with Aware, click here.

TelePsych Expansion: Aetna is expanding its mental health partnership with Inpathy to include members in three new states, Illinois, Texas, and Florida. Inpathy connects members with therapists and psychiatrists via online video sessions and has partnered with the plan since 2016. A recent meta-analysis indicates that remote therapy can be more effective than face-to-face in treating some mental health conditions.

Extra Point: A game of two-on-two hoops went south last weekend when I dove (okay, awkwardly tripped) trying to win a loose ball on the blacktop down at the park. I jammed my big toe into the court like a hammer, essentially breaking it. My teammate, who works in medical HR at Aetna, says I was fouled, even though no one was near me. Seven unanswered points later, we lost the game and my big toe swelled up, but I did get the skinny on Aetna’s new efforts to hire a new chronic conditions solutions executive director. The title isn’t as interesting as the responsibilities, which include operating and managing the diabetes solution program, overseeing commercial and government plans and PBM clients, and designing and launching pilots that improve health, reduce medical spend, and enhance experience. I asked if solving chronic losing was a possible pilot.

4: Stage of cancer one of my friends has. He found out the other day. Colon cancer spread to the body. Missed his annual checkup in the office but had a tele-encounter with his PCP. If there’s a cautionary tale here, it’s that my friend had no symptoms but didn’t get to the lab for an annual lab test his doctor ordered.

700: Percentage increase in addiction-related hotline calls during the pandemic, according to the Indiana Family and Social Services Administration. Sudden stoppages of in-person therapy or group sessions of Alcoholics Anonymous can have major impacts on addiction, including higher mortality rates.

AWP Out: Starting in February 2021, CareSource will base prescription drug reimbursement for small, local pharmacy chains on National Average Drug Acquisition Costs. Using this reference-based pricing will decrease some of the volatility that comes with AWP-based models. The new pricing methodology is the latest initiative by CareSource, a Medicaid payer, to change the pharmacy reimbursement environment, allowing pharmacists to focus on taking care of patients. Earlier this year, CareSource launched a value-based reimbursement program to incentivize pharmacies to target medication adherence and patient outcomes. They also began reimbursing pharmacists for clinical services provided to Medicaid patients in Ohio.

Cancer Path: Cigna is launching an oncology clinical pathway program in January 2021 designed to make sure patients are receiving appropriate and cost-effective therapies. The program will be available for specific cancer types and stages and will provide oncologists with evidence-based data to help select the best chemotherapy regimens. If a provider requests a regimen that is not part of the pathway program, they may have to work with eviCore medical oncologists to get the regimen approved.

Virtual Psych: Magellan will start using Kaden Health’s virtual behavioral care platform to help patients with substance use and those who need psychiatric consultations; the move toward tele-psych continues to accelerate and represents both opportunity and risk for outpatient therapy practices.

Work Comp Changes Behavior: A national worker’s comp insurer is targeting behavioral health as it reshapes its PT networks. Roughly 40-60% of injured worker claims are for patients with at least some psych issues that could complicate recovery, the insurer has found. In an interview with their western claims manager this week, we learned that they are using Healthy Systems, a kind of benefit manager with its own preferred network, to direct injured workers to services like physical therapy, including one large PT practice that screens patients for psycho-social issues, such as depression, and trains its PTs to deal with these patients. We’ve long discussed the importance of a PT practice adding behavioral health capabilities. This will be an important component for PT practices to “fend off reimbursement pressures” and become preferred providers for commercial, worker’s comp, and Medicare Advantage insurers.

Renewal Insight: CVS has a new at-home contact lens prescription renewal tool, QuickRenew, that aims to make re-ordering contact lenses a breeze. The tool is available on the CVS Optical website and customers can renew their prescription in just a few minutes. Independent ophthalmologists review the vision tests and confirm prescriptions, which can then be used anywhere to purchase more contacts.

Not Playing by Ear: Widex, a hearing aid manufacturer, is using artificial intelligence to help optimize hearing settings. The system uses algorithms to help create personalized hearing settings and the company said the process would take more than two million tests if they did not leverage AI, compared to around 12. The settings can then be securely stored in the cloud to help enhance the hearing experience of other users.

Radiation Therapy Innovation: Mayo Clinic and Google Health have launched their first research project together, building AI and machine learning tools to optimize radiation treatment plans for cancer patients. The project will focus on creating an algorithm that can automatically distinguish tumor margins from healthy tissue. They are starting with cancers of the head and neck, which can be particularly difficult to manage, given the many anatomic structures in narrow spaces.

Closing Health Disparity: COVID-19 has made health inequities across the country highly visible and BCBS of Illinois is launching a new provider program to combat this issue. BCBSIL created the Health Equity Hospital Quality Incentive Pilot Program to support hospitals serving the highest concentrations of BCBSIL members who are most at risk of contracting COVID-19. Long term, the program aims to improve healthcare outcomes in minority groups and will focus on reducing racial and ethnic disparities in care. BCBSIL will provide $100M in funding to participating hospitals, including Memorial Health System and UI Health.

Baby Bundle: AmeriHealth Caritas Louisiana is expanding its PerformPlus value-based care program to include a new pregnancy-focused option, Bundles for Babies. Providers will be evaluated and compensated based on the episode performance and delivering timely prenatal and postpartum care, along with STI screenings for pregnant women. The health plan will provide data analytics to help participating providers. Women’s Clinic of Acadiana is the first to sign on.

Extra Point: We played futbol with the middle school kids last Saturday over a frost on the muddy lawn at Bushnell Park. The girls brought their inhalers and little brothers, some brought their moms, none wore cleats, and only one had shin guards. My bride brought the hot cocoa, my daughter the Halloween candy, and after a few whiffed kicks and a dozen falls, we all wore a thick layer of dirt and a thicker smile. Those 50 kids live in 4^th floor apartment buildings that breed asthma and limit hope, and this year have in some cases taken their families – the 75 year old aunt who brought them to the states or the 45 year old dad who was on time every morning at the factory for minimum wage and a COVID infection. This school is trying to reverse the story. It now starts school online at 10am, not because the kids need sleep but because they are up late paying bills and up early making breakfast, running laundry, and teaching their little brothers how to use an inhaler. Since the change to the late start and weekend futbol, there’s been a 60% drop in depression, a 50% drop in ER trips, and an increase in attendance and test scores. These changes don’t yet change the trajectory for these teens, but they hold the line. And for those of you trying to make sense of social determinants and how to build or scale social service businesses, this is your population – inquisitive, young, struggling to breathe, burdened by circumstance, but motivated to elevate their health and their families.

$50: The cost of a new 12-week Embrace Wellness program offered by Carroll Hospital in Maryland for people going through cancer treatment. Participants have access to self-care activities, nutrition education, wellness classes, and weekly exercise classes. The program runs through November 24, 2020 and costs $50 per person. Coordinator Bridgette Bostic says the program has been successful despite COVID-19.

Cleveland Rocks: University Hospitals, based in Cleveland, formed a joint venture with digital health company, ValueHealth, to create a high-value network of ASCs. The centers will focus on orthopedic surgery, specifically hip and knee replacements, but will also include clinical services like urology and cardiology. UH will be one of over 30 health systems partnering with ValueHealth for their Ambulatory Centers of Excellence program.

Smoking, Diabetes Fix in Carolina: Blue Cross NC is launching no-cost virtual programs to help their members quit smoking and reverse Type 2 diabetes. Starting in November, fully insured group members will have access to Carrot Inc’s tobacco cessation program and Virta Health’s diabetes program. Both programs use digital health tools to help members choose better behaviors, and Virta Health’s program can be used by PCPs to integrate into care plans.

Live From Zoom: Cigna is partnering with MDLive to offer members who rarely interact with the healthcare system virtual wellness exams. The partnership aims to get people into the healthcare system through an easy first step and after meeting with a MDLive physician virtually, members can be referred to other sites of care. If you’re a PCP or urgent care provider with significant Cigna exposure, this represents a new gatekeeper in the mix, and perhaps volume pressure.

Western Outcomes Model: L.A. Care Health Plan and Inland Empire Health Plan are participating in the California Right Meds Collaborative, an initiative founded at USC that is focusing on empowering pharmacists to help improve health outcomes in their communities. Pharmacists in the program who provide clinical services to members with uncontrolled health conditions, like diabetes, high BP, and asthma will then receive payments from the health plans.

Michigan Referral Changes: Priority Health in Michigan is the latest payer to offer a telehealth-only plan. My Priority Telehealth PCP will assign members a PCP through Doctors on Demand and all visits will be virtual unless the PCP refers the member to a specialist that needs to be seen in person. The plan offers the same benefits as traditional plans, including coverage for preventive care and chronic care management, and access to reduced co-pays on prescription drugs, along with discounts on gym memberships.

Amazon Links Up With Big Payer: Horizon BCBS members now have the option to have their medications delivered at home, thanks to an alliance between Horizon’s PBM, Prime Therapeutics, and Amazon’s PillPack. Members have two options for receiving meds: a 30-day supply of pre-sorted packets for each day or a 90-day supply in a standard bottle, which PillPack notes may lower the member’s out of pocket costs.

Fit for a Benefit: Moda Health is integrating Fitbit benefits into its plans in January 2021, offering more than 64K Individual, Small Group, and MA members across the Pacific Northwest access to Fitbit devices, programs, and health coaching. As plans continue to emphasize preventive care, digital health platforms make sense to incorporate and we expect to see more collaborations like this.

Extra Point: Please pray for my oldest son this weekend.  Jack, on the eve of his 17^th birthday, has a serious case of senioritis. He is already into at least one college, is pulling a solid D- in AP statistics, didn’t study for his test last night, and didn’t budge on going to school today, so we grounded him. It will no doubt be a difficult weekend for him alone in his messy bedroom watching college football, eating pizza, and sleeping in late. Say a little prayer, as Aretha would sing – one for Jack, one for you, and one for anyone out there this weekend alone, grounded by circumstance and who would give up their left arm for a hug and a Hail Mary.

1.1B: The amount of money Highmark's True Performance value-based reimbursement program saved in healthcare costs. The savings were related to ED visits and hospitalizations and were generated from 2017-19. About 2M Highmark members see a primary care doctor through the True Performance program. Payer results in value-based care vary - one Blue plan told us they lowered cost of care by about 3%, Aetna and Cigna somewhat less, while United has saved more (7-9%). In one example the plan saved $1.5M via value-based design (which they describe as not a lot of money), keeping about $1M of that.

And the Winner Is...Humana’s MA members receive more preventative care and experience fewer hospitalizations and trips to the ER when they see primary care physicians participating in value-based arrangements compared to both traditional Medicare models and non-value-based Humana arrangements, according to a recently released study. As of 2019, two-thirds of Humana’s individual MA members receive care from primary care physicians in some form of value-based arrangement, with almost 20% assigned to PCPs participating in a global value model. Although the percentage of members assigned to doctors participating in value-based arrangements held steady over the last few years, the total number of members seeking care from physicians in these arrangements grew by three quarters of a million.

Stella or Stellar: In Massachusetts, my in-laws would call it Stella, not the beer but the new tech platform that pushes insights about patients and their conditions to physicians in Harvard Pilgrim Health’s network. Stellar Health is helping the insurer move more successfully into value-based models, tracking quality outcome measures.

Clover Care Turns to Walmart, UHC Expands: Walmart is expanding its push into healthcare, this time by partnering with insurance startup Clover to offer Medicare Advantage plans in Georgia. Members will have access to the new Walmart Health centers recently opened across the state. Both plans will offer free primary care, and one of the plans will offer $0 premiums. Members in the co-branded Clover Walmart plans will also receive a $400 a year benefit for OTC health expenses that can be used at Walmart’s physician stores or website. UnitedHealth Group, meanwhile, will expand its MA offerings to seniors in 291 new counties next year and in three new states, Michigan, Delaware, and Mississippi. Some features include $0 MA premiums in 2021 for 2.5 million members and almost all will see stable or reduced premiums; $0 copays for telehealth visits, labs, routine vision and hearing exams, colonoscopies, mammograms, and cardiac rehab; and a monthly cap on insulin at $35.

MD Burnout Fix:  A new program from the United Health Foundation and the American Academy of Family Physicians will train physicians to improve their well-being and reduce burnout. COVID-19 has presented healthcare providers with additional challenges and stressors. 81% of nursing home staff say their stress and anxiety are elevated, compared to 69% among hospital staff, and 61% of clinic staff. The goal of the program is to foster a movement in family medicine that changes the culture, policies, and systems to better support clinician well-being. The program will initially train 200 family physicians and begins in January 2021.

Pharm Land: Kroger Health and its family of pharmacies, Costco, Publix, and HEB, are joining Humana’s preferred stand-alone Medicare Part D pharmacy network for 2021. This will add more than 9,000 pharmacies to Humana’s current preferred network of around 5,000 Walmart and Sam’s Clubs pharmacies.

UnShare: David would not share the one yogurt with his sister, Alexa, during a classic sibling argument in a Schitt’s Creek rerun this week. Sharing will be a big topic of debate in managed care circles over the next five years. In a straw poll of payment innovation directors for managed care plans, a majority say they will need to re-evaluate the share of savings in value-based arrangements during the next contracting period. “It’s either we adjust what we share or change the target – particularly around surgical episodes, but perhaps other conditions, particularly as more providers beat the goal.”

Extra Point: A basketball season is underway in my community. Parents are pushing for it because they want their kids to play sports. Our own kids may participate, I may or may not coach, and I can’t see how we get through one or two games without having to shut it down, but maybe I’m wrong. I hope I’m wrong. Our high school senior, Jack, starts varsity hoops in November. He has zero chance of playing college sports but also has an inflated sense of self and thinks he can walk on at Indiana or Michigan, so for his sake I hope he gets a chance to play this winter. On a Zoom with middle school parents last night, a dad shared his concerns about the contact on the court. “I mean, when the kids play defense that’s bound to be a problem,” he said. I nearly fell off my chair because his kid hasn’t played any defense ever – he stands roughly 10 feet from anyone, including his own man. So, dad’s concern, while understandable, is somewhat overstated, I think. If I coach our 8th grader, I feel good about our chances. Leave one kid basket hanging on offense, two kids in the middle of the court to pass him the ball, the other two on defense as interceptors. No dribbling, spaced, masked, modestly COVID compliant. Think ultimate frisbee with a round ball. It may be risky, and we may just lose every game, but it may be the only way to keep the kids healthy.

68: Percent of older adults exactly one year ago who said the quality of care during a telehealth encounter would not be as good as a face-to-face visit, according to a University of Michigan poll on aging, with half saying they did not feel personally connected to the healthcare professional and four in ten reporting difficultly seeing or hearing. The poll asked a national sample of 2,200 adults, ages 50 to 80, about their ‘tele’ experience and, welp, things sure have changed. By May, according to our own poll of 1,362 adult parents aged 35-55, 51% preferred virtual over in-person as compared to urgent care, although when we peeled back the answers, it was clear telehealth had its limitations too. Just 34% liked it for discussing pain symptoms in May, compared to 42% in April. Many said they found the diagnostic capabilities of the NP or physician limited over the virtual platform. 77% of moms said they prefer in-office for themselves, but a slim majority would likely make more use of virtual for their younger kids—better “than toting around my kids.” The question for the payment system is how to adjust to the new telehealth boom, value it, and pay for it, and if recent reports from our interviews with health plans are any indication, how to monitor for abuse too. “We’ve had a decent wave of companies billing so much telehealth it adds up to more than what would be possible in a day—a good amount of abuse of the system,” a source said. These developments don’t mean reimbursement reductions per se but likely mean a re-adjustment on how to ensure appropriate payment.

Eye of the Tiger: Eye care practices around the country are seeing an increase in the number of LASIK procedures over the past few months. Several surgeons in major cities like Los Angeles report a 30% increase, mostly driven by younger adults. Some health analysts think this is because people are spending less money on travel and entertainment, and possibly because people can recover at home while continuing to work.

Injectable Target:  Look out for pre-payment reviews and post-payment auditing of medical injectable drug dosage and prescribing, as nearly half of payers in 2021 will use third party help to dig into claims for injectable drugs administered in the office setting. These companies will hone in on how many units are administered for the patient as well as average wholesale price information to ensure that claims are coded appropriately.

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 the underserved, a kind of symbol of how those more fortunate could assist the poor, homeless, or 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 than we predicted six 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 will reportedly be the first in the Wolverine state to offer financial incentives to providers who screen patients and submit information on social determinants of health. Beginning in January, providers who are recognized as a Patient-Centered Medical Home can use an approved tool to screen patients and complete the SDOH survey to receive increased reimbursement. Click here for a story on another leading insurer’s policy.

Extra Point: Tommy was pulling in a solid C- in social studies last month, which was both disappointing and perplexing. I mean, some subjects like English can be difficult because of all that tension between the past, present, and future, and all those double-meaning words like ‘lie’ and ‘lead’. But social studies? It’s not about what will be but what already was. Easy peasy. After a few civics lessons over undercooked flapjacks at supper, I got Tommy to understand culture, poverty, checks, balances, and how a bill becomes a law. By last week, he had pulled his grade up to an A, although a not-so-solid 68% on a recent quiz probably will hurt. “I didn’t know the test would be today Dad!” That’s called a pop-quiz kiddo. Get used to it. The A is a popular letter in the history of healthcare. There was the BBA, the MMA, the ACA, the AIDS epidemic, and more recently a wave of conditions like autism and addiction—and now anxiety. The CDC lists about 41 conditions and diseases starting with the letter A, though it understandably doesn’t feature all, including only those that have critical or broad relevance to public health. For instance, I couldn’t find apathy, which I would like to lobby to be added to the list. At a minimum, it seems to be a re-occurring condition in both our boys and as COVID continues on, may become a bigger problem than we want to admit.

2021: Cigna will offer telehealth services to all Medicare Advantage members next year, including virtual visits with behavioral health providers at no cost. They will also offer a $0 premium plan next year.

Biosimilar or Different?: Regence Blue Cross in the northwest is implementing a new step therapy program for medications covered under Medicare Part B in 2021, like biosimilar Zirabev. What’s interesting is that Pfizer launched it earlier this year at a wholesale acquisition cost of around $60 for every 10 mg, which is nearly 25% less than its reference product Avastin, a Pfizer spokesman confirmed. The biosimilar is for colorectal cancer, non-small cell lung cancer, and metastatic cervical cancer, among other conditions. Regence will also promote Pfizer’s Ruxience for Hepatitis B, leukemia, and lymphoma. The kicker? They are allowing a 100-day medication supply for their Medicare Advantage members who previously received a 90-day supply. The 10 extra days are free. These trends of incenting patients to use biosimilars are increasing nationally, and not just to benefit patients but physicians too, as more payers are sticking pre-authorizations on the branded drugs and offering doctors incentives to use the biosimilars.

Blue Devil Dermatology: Scans of photographs of dermatology patients’ skin let clinicians more rapidly slot them into appropriate treatment pathways for faster care under a new algorithm built by a team of Duke sociologists and anthropologists. Duke’s time-saving tools include an algorithm that spots urgent heart problems in patients.

Concierge Is Back: United is launching a new concierge-style health plan that will offer members access to free urgent and primary care services. Through a partnership with Canopy Health, United’s California Doctors Plan, members will also have access to 24/7 telehealth services. The companies estimate that members will save up to 25% compared to other health plan premiums.

Tale of the Tape: Athletic trainers will have the opportunity to participate in Blue Cross Blue Shield of Michigan’s commercial networks starting in 2021, reimbursed at 85% of the fee schedule within the scope of their license, minus any member deductibles and copayments.

Extra Point: Dad would get a kick out of the Tale of the Tape this week. 39 years ago, Phil Collins’s people were on the rotary phone with him to help the Genesis pop legend tape the ankle he rolled in time for his show one cold October night at the Hartford Civic Center Mall. Dad, who was athletic trainer and tennis coach at the University of Hartford for nearly four decades, treated Phil like any student-athlete. My sister came along for backstage ankle taping – Collins offering dad a pair of front row seats to hear him belt out his “Can you feel it in the air tonight” number, his #1 hit back in 1981. I wanted to go desperately, but Dad picked my sister and, while I was bummed at the time (okay, I was mad), I get it now. Flash forward to one year ago this month at Madison Square Garden in New York – Collins, now in his 70s, hobbled on stage with a wobbly cane and a broken foot and admitted to the sold out crowd he probably wasn’t going to be skipping around stage or beating those drums, that his ‘messed up’ foot, bad back, and a number of other health issues would keep him stationary, but, against all odds, he was going to sing a few songs…His teenage son played drums and my bride and I, neither having ever seen Phil in concert, sang “Follow You Follow Me” like we were still 10 years old next to the scratchy record player in our parents’ living rooms. It is remarkable how pain, injury, and surgery don’t have to mean you stop. You just have to adjust. I think back to that night when the phone rang and how my mom dropped the receiver on dad’s foot and nearly choked my sister with the phone coil as she frantically stretched the phone over to dad’s ear…. I think back to how dad showed me the next morning how he taped Phil’s ankle like an artist in his own right, and I wonder if the pop star would remember that moment. If he’d remember dad. The athletic trainer.

$200M: The amount Blue Cross NC is giving out in health and wellness retail cards to fully insured members during October and November. The cards will be pre-loaded with between $100-500 and members will be able to use them to purchase anything over the counter. Blue Cross in Tennessee mailed rebate checks to 143,000 members in September because their health insurance costs were lower than originally anticipated. Members who purchased individual health insurance coverage through the Federally Facilitated Marketplace in 2019 qualify.

Which Specialty? A new report by Doximity shows that radiologists and psychiatrists are most interested in telehealth, while anesthesiologists and surgeons are least interested, not surprisingly. Other increasingly popular telehealth services include telestroke (neurologists), dermatology, pediatrics and infectious diseases. Many specialists are increasingly interested in using telehealth, particularly to treat their patients with chronic conditions who may need more frequent check-ins and management.

California Dreamin’: SCAN Health is bringing AmericasHealth Plan and Clinicas del Camino Real into its provider network in an aim to support the Hispanic population in Ventura County of California with high quality care. Clinicas del Camino Real is an FQHC with 15 sites, serving approximately 40,000 patients enrolled in Medi-Cal or Medicare plans This collaboration takes effect October 1, 2020, and will focus on older adults.

Ro the Boat: Telehealth startup Ro is expanding its partnership with Pfizer’s generics division to offer generic versions of commonly prescribed blood pressure and cholesterol medications through Ro’s virtual mail-order pharmacy. Generic versions of Lipitor and Norvasc will be made available through Ro’s $5 per month prescription drug service, which launched earlier this year and does not take insurance.

Mental Health Illuminated: Researchers at the University of Illinois Chicago are testing an artificial intelligence virtual agent called Lumen that will be used to broaden mental healthcare access for people with moderate depression or anxiety. Using the same technology as Amazon’s Alexa, researchers are developing an app that will act as a virtual mental health coach, leading patients through strategies and following a validated treatment protocol. The National Institute of Mental Health is funding this five-year project.

Trick or Treat: If you took last week’s quiz, you’ll know it was not easy – three value-based stories, only one true. But the truth is, they were all true. A $90 fee is in fact provided to a dermatology group by a commercial payer for diagnosing depression in teens with serious skin conditions, A Medicaid plan in the east is now near the end of its first year paying a skilled nursing facility an additional $230 a day for helping manage and treat substance use disorders in its residents, and an additional share of savings for lowering hospital admissions below a baseline target. And an MA plan has set a target bundled rate of $13,900 for hip arthroscopy, inclusive of two months of post-op physical therapy and pain management, and after a year, the average total cost for the episode was indeed $11,500, so the plan has decided to lower the target and change the share of savings.

Extra Point: My oldest is home from college this week, her college dorm shut down until at least November, so like any parent worth their salt I made her help me stack the wood, rearrange the pantry and poll 134 students. I need an assistant from time to time and who better to ask kids about the future than one who had to escape her homeland to make hers.  The students, age 11 to 17, are all current and former pupils at my wife’s school in inner-city Hartford, all young girls trying to rise at a time and in a world that makes it difficult for them. We asked them what they want to be when they grow up and 94 of them said things like “I’m already grown up – I take care of my sisters,” “I pay the rent,” “I talk to the doctor for my mom,” and “I read the label on the inhaler for my lil’ brother.”  We asked them if they weren’t in school and had a job, what they’d want to do, and half said a singer like Lizzo or Taylor or Beyoncé and about 50 of them said a doctor or a nurse, maybe a “baby doctor” or “cancer doctor,” like “that woman who saved my uncle” or the nurse “who took my blood pressure,” or maybe “a therapist because my friends say I’m a good listener.” None of them want to be a surgeon, two of them want to be Michelle Obama and one wants to be Kamala Harris, and one – just one – said she wants to be her mom – brave, working two jobs, sacrificing, “but always making time for me.” We asked them what it would take to be a doctor or a nurse and most said go to college. None of them have a parent who graduated college, but they all said they “dream about being the first in my family” to do that.  I asked my oldest what she thought about that and she said, “I have that same dream…but right now, it feels impossible.” Hang in, I said, the glass is half full…. now go help your sister with her chem homework.

12: Percent of hospitals receiving incentive payments for reducing cesarean sections and meeting quality goals related to episiotomies, early elective deliveries, and maternity care under a pilot from Tricare set to conclude in March 2021. Tricare, which provides healthcare coverage to 9.6 million uniformed service members, retirees, and their families, has several value-based initiatives underway. 3,640 hospitals participated in the maternity pilot.

Asthma Device: Anthem is pairing with UC-Irvine to study whether smart devices can help asthmatics predict an asthma attack. Anthem members will be part of the study. Smartphone-based technology is now being used to treat a variety of conditions. Results could be used as part of clinical and payment redesign. For example, an allergy practice in east Texas is getting an incentive payment these days from a Medicaid plan for giving its highest-risk asthma patients portable spirometers that transmit results back to the physician, help the practice monitor pulmonary function, head off deterioration, and with any luck, see progress.

Pharma Outcomes Pay Model: Highmark, which is now expanding its membership in the Northeast, has entered into an outcomes-based agreement with drug manufacturer AstraZeneca for Fasenra, a maintenance treatment for patients with severe asthma that around 500 Highmark members currently take. The agreement will apply to both commercial and Medicare members and is the second agreement between the health plan and manufacturer. They previously signed a similar deal for asthma and COPD treatment, Symbicort, and last year, announced that they had demonstrated positive results in improving health outcomes.

Rebrand: On the surface, Cigna’s rebranding of its health services division this fall as Evernorth may seem more marketing than healthcare, but if you pull back the curtain, the services under the new brand indicate how the company is going to try to manage care, shape networks, and redesign payment. Evernorth will include PBM Express Scripts, specialty pharmacy Accredo, and medical benefit manager eviCore along with other existing and new products like Healthy Ways to Work, a return-to-work program for health plans and employers, the fertility program FamilyPath, a gene therapy program called Embarc, and mental health platform inMynd. These connected companies will be able to share medical, pharmacy, and psychosocial data and offer a more comprehensive benefit than we have seen from insurers.

Addiction Outcomes: Anthem announced they more than doubled the number of members who are receiving whole-person treatment for opioid use disorder across Medicaid, individual, and employer plans. Four years ago, Anthem pledged to increase the number of members receiving both drug therapy and counseling treatment and the numbers show they attained their goal. The combined percentage of consumers across plans with opioid use disorder receiving both therapies went from 22% to 56%. Medicaid plans alone increased from 24% to 65%. On our behavioral health roundtable earlier this week, two companies--Aware Recovery and Eleanor Health--shared case studies about their value-based PMPM models that center around whole-person care.

Health System Maneuvering: Two Blues plans are partnering with providers to offer additional health plan options next year. Horizon BCBS in New Jersey is launching a new Medicare Advantage plan, Braven Health, through a partnership with Hackensack Meridian Health and RWJBarnabas Health. Braven Health is the first payer-provider owned health plan in the state, and will be available starting next month, going into effect at the start of 2021. In Wisconsin, Anthem and Ascension Wisconsin are teaming up to offer ACA health plans in five Wisconsin counties in 2021. The Anthem plans will feature Ascension Wisconsin’s 24 hospital campuses, 110 care locations, and more than 1,300 physicians, including Children’s Wisconsin for pediatric care.

Diagnostic Cost Variation: A new study published in the Journal of General Internal Medicine shows that COVID-19 diagnostic tests range from a penny to more than $14K. The study reviewed a sample of 182,149 diagnostic testing claims from 764 providers in 46 states and the District of Columbia. All claims were submitted between March 19 and July 19. Independent labs were the most common facility type for diagnostic tests and also had the highest prices.

The Purple Kit: CVS Health is sending all Medicare members “Caring for You” kits in preparation for flu season and the pandemic that include over-the-counter items to help members stay healthy. The purple boxes will include a thermometer, hand sanitizer, and two Aetna-branded facemasks, as well as other items. This will be a one-time benefit and will affect members who enrolled before August 1, 2020.

Vision Meets Dental: MetLife plans to acquire Versant Health, which owns Davis Vision and Superior Vision, by the end of the year. Through the deal, MetLife, a national dental insurer, will gain access to Versant Health’s 35 million members, and MetLife’s existing customers will gain access to Versant Health’s extensive provider network, which is one of the largest in the vision industry.

Think About It: A bookstore is one of the only pieces of evidence we have that people are still thinking. This is Jerry Seinfeld’s opinion, not mine, but it makes sense and when you’re looking at whether a healthcare business has a population that could potentially hurt your ability to effectively take risk, just think about all the evidence you can find stored in your data, or the plan’s data. Look for the number of address changes in the prior year, or gaps in insurance enrollment, or if you can tell whether the patient was “auto-assigned” to the primary care practice or “self-selected”.  These psychosocial data points can be “high predictors of non-adherence and bad outcomes,” says Barry Lachman, MD, who’s heading up a community development program in Dallas to address the effects of poor housing and food insecurity on asthma incidence and overall health. And if the data is aggregated effectively, it can help practices help their health plan partners figure out who will fail, before they fail.

Extra Point: If I were to tell you one of these were true and two were false, what would be your choice? (a) A $90 fee is provided to this dermatology group by a commercial payer for diagnosing depression in teens with serious skin conditions, including significant acne, while another group hired a pair of psychologists to help counsel teens with significant skin issues. The health plan is contemplating an enhanced reimbursement rate for both groups as part of a 2021 initiative to support investment in specialty practices doing value-based care. (b) A Medicaid plan is now near the end of its first year paying a skilled nursing facility an additional $230 per diem for helping manage and treat substance use disorders in its residents, and an additional 50% share of savings for lowering hospital admissions below a baseline target, based on the facility’s prior admission rates. The nursing facility hired a team of SNFists to help provide coverage, particularly on weekends that accounted for 75% of admissions in 2019, and as a way to limit what the plan calls ‘avoidable admits’, like for a patient with a 101 fever. (c) An MA plan sets a target bundled rate of $13,900 for hip arthroscopy, inclusive of two months of post-op physical therapy and pain management, and after a year, the average total cost for the episode was $11,500. Under agreements, orthopedic surgery groups are the accountable providers and get a 35% share of savings below the target but with total costs below the benchmark, the plan decides to lower it to $12,000 and change the share of savings to 50-50. Which of these is true? Email your guess to be entered into drawing for a complimentary gift card. Answer next week.