Behavioral Health Insights

74: Percent of medical directors from 103 plans we polled who say imaging studies for uncomplicated low back pain are a consistent problem, often ordered unnecessarily with the first month of diagnosis. Health plans like BCBS of Illinois say they have to collect and report this type of data to the National Committee for Quality Assurance.

Like Pulling Teeth: A Midtown Manhattan dentist’s practice is thriving, despite being almost completely shut down for a few months during the peak of the pandemic. Why? Tooth fractures. The dentist, Dr. Tammy Chen, wrote in The New York Times that she’s seeing, “at least one a day, every single day that I’ve been in the office. On average, I’m seeing three to four; the bad days are six-plus fractures.” Dr. Chen points to COVID-19 related stress, poor body positions while working from home, and insomnia leading to teeth grinding at night. She advises we all pay more attention to our posture during the day, along with our teeth positioning, and find ways to stretch out and relieve tension.

Musculoskeletal Interference: Pre-authorization will now be required for lower extremity small joint surgeries under a new AIM Specialty medical review policy taking effect in November. Surgeries include total joint replacement of ankles, correction of hallux valgus, and hammer toe repair. AIM, which handles all Anthem reviews and pre-authorization for other payers, says they will evaluate both the medical need and site of surgery.

Newest Episodes: This used to be a thing in the 70s, huddling around the RCA, holding up those bunny ears to avoid the static so the whole family could watch the latest MASH event. In healthcare circa 2020, new episodes are huddled around events, too - the Coronary Artery Bypass Grafting (CABG) Episode-Based Model and the Total Shoulder Specialist Rewards Program are the latest episodes from Humana as part of its expanding Medicare Advantage value programs. The CABG model has six participants across six states and will cover the entire episode of care including surgery and post-discharge care. The Shoulder program is Humana’s first orthopedic payment program and will offer additional payment for realizing better health outcomes or attaining lower costs through site of care selection.

Pre-Authorization: The Illinois Blue plan now will use eviCore, not Prime, to handle medical review for chronic infusion drugs like IVIG and Avastin.

Rural Addiction Treatment: The Utah Center for Rural Health at Southern Utah University started a new program that will allow specially selected people to receive expert opioid addiction treatment without even leaving their homes. One of the program’s primary benefits is how little it disrupts a person’s life. In rural communities, where specialized care may be limited or nonexistent, participants will no longer have to relocate when seeking help.

Drone Care: Wake Forest Baptist Health in North Carolina is using drones to ship equipment, including PPE, to providers and patients at distant sites. Using drones to ship items, like specialty infusion medicines, will help make sure patients get these costly, time-sensitive medications when needed. Wake Forest is partnering with Matternet and UPS FlightForward for this program. The two companies previously partnered with another North Carolina hospital, WakeMed, and have since coordinated more than 2,200 deliveries using drones.

Skilled Care Connectivity: Northwell Health is launching a telehealth platform that will provide on-demand care to two SNFs in the Bronx and Long Island. The SNFs will be connected to the health system through telemedicine carts that enable SNF staff to connect with critical care nurses, intensivists and hospitalists for emergency care and supervision. Northwell hopes to expand the platform to include additional facilities in the New York area.

Extra Point: Kathleen Sarnes sings to hospice patients in Staten Island, part of a quietly rising movement in healthcare, like those first 16 seconds of Pearl Jam's Wish List. The influence of song as a cure should not be mocked or muted. There's more evidence that music can reduce pain and anxiety, lower heart rate and blood pressure, improve care plan adherence and extend life quality. Sarnes says her grandmother told her to remember that the people she sings to weren't always sick. Music therapy is covered by some insurance, including Medicare, though typically for severe situations and usually as part of a mental health plan, not as any sort of lead treatment. Its pitch to healthcare payers will be a difficult one but studying music's effects on neurological diseases and on slowing disease progression is worthy, in my opinion. My daughter Sophia was singing at a nursing home on weekends before COVID closed that door. Just 15, she says it seemed to "perk up" people with Alzheimer's or cancer, or "people with a lot of sickness." I asked my colleagues here on our team this week for the music that is their therapy, a so-called soundtrack of their life. Their response was a sign of the times, but also a testament to who we are. We have a daydream believer among us and someone who won't stop believing. We have different strokes and a little Joni Mitchell to help us to see both sides. There will be growing pains ahead as we march through what seems like another pandemic wave but as music writer Kelly McCartney says, "we each have all the truth and wisdom we need inside us, and the more we look outside it for answers, the further we get from it." We are closer to fine I suppose and, I guess if I have a wish it might be the same as Eddie Vedder's, that "I wish I was as fortunate, as fortunate as me."

80: The amount of new counties Cigna is adding individual plans in for 2021, increasing their ACA market size by 27%. Key benefits included in some of the plans are no copay for virtual visits, including behavioral health providers, a new diabetes care plan that includes no copay for diabetes equipment and supplies, and increased coverage for nontraditional healthcare services, like acupuncture.

Oral Health Uptick: Kaiser Permanente and Delta Dental of Washington have partnered to launch Health360, a medical-dental plan focused on better overall outcomes and a lower total cost of care. The plan is aimed at midsize employers and provides a single point of contact for many aspects of the medical and dental plan administration, allowing members to more easily receive the total care they need.

The New Center of Excellence: The Association of Blues plans will have its own health plan—its first in 25 years—launching in January and it will feature providers across 55 markets that will essentially be promoted to members as high value, high performing centers. This is an important development since the plan will direct patients to providers based on their quality and cost. Out-of-network coverage will not be available. The local Blues plans are helping to select local health care providers based on quality measurements.

Genetic Test Check: Horizon BCBS is the latest in a string of insurers to start aggressively monitoring genetic and molecular testing utilization. Starting in October, the New Jersey plan will start to require pre-service medical necessity reviews for molecular and genomic testing done in a physician’s office or clinical lab. Through eviCore, all fully insured and ASO members will need these medical necessity determinations completed before any testing can take place.

Pac-12: The Western athletic conference famous for UCLA’s Lew Alcindor and beach volleyball has signed an agreement with Quidel Corporation, a diagnostics company, to secure testing supplies for student-athletes. Testing machines and related tests are expected to be available at all 12 schools by the end of September. The ability to have rapid results may allow sports to come back sooner, even though the conference has currently postponed athletic contests until at least January 2021.

Rx Exclusive: Starting January 2021, AllianceRx Walgreens Prime will be the exclusive specialty pharmacy provider for Blue Cross Blue Shield of Michigan commercial members. This does not affect Medicare Advantage members, but commercial members will be required to use AllianceRx Walgreens Prime for all specialty medications.

Joint Effort: Tennessee will have one of the nation’s largest orthopedic groups, thanks to a three-way merger between Tennessee Orthopaedic Alliance, Tennessee Orthopaedic Clinics, and Mid-Tennessee Bone & Joint Clinic. Combined, the group will have 105 physicians and a staff of more than 800, with 27 locations in 17 Tennessee counties.

Disparity Gap Closing: Sinai Health System and DePaul University are partnering to build a community-driven research institute that will work to mitigate health disparities in Chicago. The agreement includes providing shared education programs for students and researchers, jointly pursuing research and grant opportunities, sharing expertise and data, and supporting sustainable community and academic partnerships aimed at reducing health disparities.

Caregiver Decline Addressed: Harvard Pilgrim is launching a new telehealth program to help caregivers take care of themselves while caring for others at home. Harvard Pilgrim will work with Ceresti Health to create a platform with education, coaching, and support programs for caregivers in Massachusetts and New Hampshire. The content will be organized to address how to take care of children, adults, spouses, and those with certain chronic conditions. A study on caregiver decline back in the spring indicates the impact of caregiver health: click here to read more.

Readmit Model: Unity Point Health in Wes Des Moines Iowa started a SNF at home model a year ago to provide in-home nursing level care to patients, just as VillageMD has developed primary care physician services at home. 78% of payment innovation and value-based strategy teams at commercial and Medicare plans we polled this summer said these are the kinds of models getting their attention.

Florida E/M Change: Starting in October, the Florida Blue plan will no longer pay for multiple evaluation and management (E/M) services reported on the same day for the same patient by more than one physician in the same specialty and the same group. Think two neurologists both billing for E/M. Only the first claim received will be paid.

Extra Point: Not sure about you, but my kitchen was like a Jack Klugman warzone this week, straight out of a Felix and Oscar episode from Neil Simon’s Odd Couple. At one point on Tuesday, there are five Zooms going on simultaneously, wires crossing, the dog eating egg scraps and Cliff bar wrappers, then barking every time he hears a bark coming from a computer, startling my daughter who spills her milk, which starts flowing under laptops like the Mississippi after a rain storm. There’s laundry in the sink and toothpaste in the freezer. My wife starts playing Perry Mason, challenging the kids about who stole her charger. “Not me”, they all say. Her voice carries from the living room as she teaches 65 students about hand washing protocols for the first day of class, as I sit frozen on a PowerPoint slide, staring at a bar graph that makes no sense, gripping my chipped ‘DAD IS #1’ coffee mug like it’s the only thing holding me together. It’s only 8 am but Tommy and his sticky syrup fingers start playing a video game on his phone while his French teacher figures out for 10 minutes how to share her screen. “Sois patience,” she keeps saying. My dad bangs on the door then barges in as he usually does but this time stumbles on one of Zaggy’s squeaky toys, loses balance, and head butts the wall like Rocky charging at Apollo. He drops and so I frogger my way through the power cord maze to help him to the couch, clean his wound, and call the doctor. There’s a bit of angst as we MASH unit our way around dad, but my daughter, in true Radar O’Reilly fashion, brings over some gauze before I could say “we need gauze.” Dad is a bit dizzy and still feeling effects of the vertigo, but he is going to be alright. By 9 am, I’m three Microwave reheats of my coffee into the morning and ready for conference calls. My 16-year-old senior? He’s oblivious, huddled in a corner, ear buds blocking out sound. “Papa fell and hit his head so I’m going out to urgent care – can you take out the trash and help your sister with that Algebra,” I said. “Wait, what, papa fell?”

3: The number of Walmart locations that the company is replacing with Oak Street Health clinics in the Dallas-Fort Worth area this fall. Newly public Oak Street has a network of 60 value-based primary care centers and the three new centers will offer preventative primary care and urgent care services focusing on patients of all ages.

5 and Dime: Payments focused on improving patient outcomes will be five to 10 times larger than what is contained in a typical outcomes-based, risk-bearing agreement under a new Blue Cross Blue Shield of Minnesota multiyear pact with Allina Health, a Minnesota health system. The provider and payer intend to cut the cost trend for care by 10% over the next five years.

Model T: In what could be the next vital healthcare innovation, Henry Ford Health System has launched a new health plan called Pivotal, which offers virtual services for in-network visits. Pivotal has over 6,000 physicians and 3,500 ancillary providers through Henry Ford.

$0 Copay: Aetna launched a new health plan, Aetna Connected, which will allow its members to make appointments at its parent company, CVS’s MinuteClinics and HealthHUBs, with no copay. The plan will also offer free at-home prescription delivery and discount on health-related items at CVS. The plan is launching next year in Kansas City, focusing on employers with more than 100 employees.

Advantage, Medicare: Like Bud Collins used to say when McEnroe got the advantage over Borg, it’s clear health systems with Medicare Advantage plans are getting ahead in the healthcare game. Sentara Healthcare and Cone Health, two nonprofit health systems each with their own Medicare Advantage plans, are merging in a value-based care model focused on digital and virtual care options in order to increase access to care. Oscar, meanwhile, is partnering with Holy Cross Health and Memorial Healthcare System to launch a co-branded Medicare Advantage plan in South Florida. Broward County residents can enroll in the new plan starting October 15, pending regulatory approvals.

On Second Thought: Michigan’s Blue plan has an agreement with 2nd.MD, which gives self-insured groups access to personalized second opinions by video or phone from medical specialists at top institutions, and, starting mid-2021, for all fully insured members.

Extra Point: A 28-year-old male from Carolina says he “wants to give up heroin but still wants a beer with his buds on the weekend.” At 16, he begins using pain pills and by 24 gets a severe illness leading to loss of job, home, and his fiancé. He moves back home with his folks by 25 and starts the cycle, back and forth from hospital emergency rooms, crisis stabilization for heroin overdose, and at one point a 28-day rehab. It’s astounding to me that more than 50 healthcare professionals talk to him during a five-year period in and out of facilities, but none treat his anxiety. At 26, one clinician’s lab workup diagnoses him with Hep C but he’s never connected to treatment after discharge. This spring, he’s alone, shut off from outsiders, trying to recover, avoiding his elderly parents to limit coronavirus risk. How this male begins to recover, the total costs of treatment and how a value-based payment model is turning his story around will be one of six case studies discussed September 22^nd, during a live two-hour forum kicking off at noon eastern. Stephan Young, enterprise mental health leader for Ohio health plan Caresource, will lead off to share managed care’s view of these risk-taking solutions, including an innovative SNF program, a telepsych model, a social service program, and a pair of addiction treatment capitated models. I’m excited to host a lineup as stellar as the ’27 Yankees. Register by clicking here or reach out with questions. Registrants will also receive results from a summer healthcare consumer research poll.

23,500: The number of Blue Shield of California members reporting weight loss, reduced stress, and even chronic condition reversal, under a program from non-profit digital app platform Wellvolution. In the program's first year, nearly half of diabetics who signed up for a digital app like Digbi or Betr experienced disease reversal, like normalized A1C. Emily Morales, 33, an intake therapist in Pasadena, stopped eating a meat-heavy European diet after getting gut-biome and genetics results. Elementary teacher, Abebi Bain, 47, says she was eating foods that were aggravating her asthma and allergies until she started using the Betr health app.

Cleveland Still Rocks: Singer Ian Hunter is the voice behind the 1980 hit “Cleveland Rocks” - an anthem Hunter wrote to change public perception about his favorite city. 40 years later, one of the most well-known national healthcare providers, Cleveland Clinic, is changing perception by launching an accountable care organization and health insurance plan for certain fully-insured and self-insured employers in northeast Ohio. Cleveland Clinic will receive rewards, from Aetna, for meeting quality and cost goals and Aetna commercial plan members nationwide will have access to virtual second opinion services from Cleveland Clinic providers, as well as a Cardiac Center of Excellence program.

Capitated Pay at Home: Aetna is partnering with WellBe Senior Medical to deliver primary care services to about 10,000 high-risk seniors in their homes. The program began in Atlanta last month and is now available for certain seniors in the Chicago area. Eligible seniors will have access to at-home care 24/7. Aetna assigns eligible high-risk patients to WellBe, which is then responsible for managing their care and receives capitated payments from Aetna. Those eligible are typically seniors in their 80s with multiple chronic conditions, including diabetes, heart failure, osteoarthritis and dementia.

Specialty Pay per Episode: Since last week’s piece about global-risk primary care medical practices setting up episodic payment arrangements with one referral partner per specialty as a way to limit cost and improve outcomes, we’ve had a flurry of inquiries from PCPs about how to determine which specialist, and what to pay. “I’d like to create my own network, not rely on the insurers,” lamented Mary Horton, an administrator for a medical group in Massachusetts. “If it’s a specialist we need who might need to see the patient several times and monitor care, it makes sense for us to create an episode, say 30 or 60 days, and figure out a payment based on that, and make them our exclusive partner,” said Paula Riordan, executive director of a PCP practice in the Atlanta area looking to establish this for a range of conditions—pain, orthopedic, GI, skin, and respiratory issues, like asthma. “If it’s more repetitive care, like for mental health, then I think we’d consider a per patient per month amount with a partner or telepsych vendor.” Specialty doctors we have been interviewing and polling in the last three years lament their limited role in value-based care. “It’s not for us and I’m unclear where we fit,” Greg Thisis, MD, an ophthalmologist, told us back in 2018. His concern is legitimate for certain specialties, but not all, and Riordan is essentially laying out the opportunity.

Uber Expands: Uber is further expanding its move into the healthcare space, this time by partnering with NimbleRx to deliver prescription drugs. The initiative launched in Seattle and Dallas, and with Nimble already in use by more than 700 pharmacies in 34 states, the partnership has plenty of room to grow.

Google’s Latest Play: Google is investing $100M into telehealth company Amwell as part of a multi-year partnership. As telehealth shows little signs of going back to pre-pandemic levels, this partnership will focus on improving access for patients through Google Cloud artificial-intelligence and machine-learning technologies to assist patients and front-line workers with intake, inquiries, and triage and providing natural language and translation services for non-native speakers. Several health insurers use Amwell as their primary telemedicine vendor.

Fertile Ground: In Vitro Sciences (IVS), a network of fertility centers, is partnering with InVia Fertility, a reproductive services clinic with multiple locations operating in the greater Chicago area. This partnership will allow IVS to expand its current footprint in the Southwest and Northeast to the Midwest.

Tackle Depression: A new law in New Jersey requires kindergarten to 12th grade schools to teach mental health and for behavioral health companies, the trend represents a potential growth market, particularly now that schools are scrambling to find therapists as more students self-report depression. In New Jersey, football coach Bill Kvaleim started clothing company Tackle Depression to promote anti-stigma messages on hats and hoodies. Parents can find a mental health directory for the state, or volunteer, on the “Tackle” website, similar to Shatterproof’s directory of addiction treatment centers. Coach Kvalheim was diagnosed with depression and anxiety but he’s not alone. High schoolers and college athletes are a new mental health population these days, given the lack of team sports. The Athlete Mental Health Index has tracked the connection between playing sports and mental health since 2010. Read the details here.

Autism Treatment, Until Further Notice: Michigan’s Blue plan has started allowing direct‑line applied behavioral analysis interventions through telemedicine. They developed a set of informal guidelines to help providers think through which members may benefit most from telemedicine interventions and they will allow providers to provide these services “until further notice.”

Cross Country: Back in April, we reported how a team of medical professionals from Intermountain Healthcare in Utah were deploying to NYC’s Northwell Health to help combat COVID-19, and now Northwell Health is returning the favor. 10 ICU nurses arrived in Utah earlier this month, and though the state is not experiencing a surge in the virus, the medical team is there to support ICU teams at Intermountain as they cross-train and share best practices with one another while treating COVID-19 and non-COVID patients.

Disparities: Centene’s new task has 12 members dedicated to helping close gaps in healthcare disparities. Given its reach into underserved populations, namely Medicaid, Centene’s group could have a big impact. Read the details and view taskforce members by clicking here.

Extra Point: Joel once bought a horse with his daughter Jen and they traveled across the I-90 West to go watch that horse race at the Fairgrounds in Saratoga. He was Old Stewball meets Black Stallion – fast, raw, a fairytale. But Joel and Jen didn’t buy that horse for the money or fame. Before their horse retired, they took their winnings and bought a horse of a different color, this one much slower and often injured, seemingly on his last leg, but on race day it poured like the rain in Spain and, wouldn’t you know it, that aging horse mucked her way to a win, like OId Rosebud circa 1916. The last time Joel and his daughter went to the races was August 2016. Joel’s Parkinson’s has sidelined those summer trips to the Fairgrounds and kept Jen from watching dad’s excitement down the stretch. On Saturday, amid a Kentucky Derby-like downpour, Jen married Craig, with 12 others by her side, but dad wasn’t there, held up at the nursing home, crippled by a disease that is pulling away his cognitive function, his movement and speech. But a day later, Jen took the cash from her Aunt Linda’s Hallmark and bought a couple cups of coffee and a few anisette cookies and popped a squat with her dad on the nursing home grounds. Joel didn’t say much but it didn’t matter. The disease may have won yesterday, but not on this day, and if stem cell researchers continue to find ways to stop deterioration in Parkinson’s patients, maybe, just maybe, Jen and her old man will have another ride around the track.

134: The number of physicians who have begun to offer medication assisted treatment (MAT) for opioid use disorder in Michigan, under a plan’s new initiative. At least one new primary care provider is delivering MAT in 31 Michigan counties since the program started last fall.

Specialty Pay per Episode: We are starting to see more examples of global-risk primary care medical practices setting up an episodic payment arrangement with one referral partner per specialty as a way to limit cost and improve outcomes when they have to refer. “If it’s a specialist we need who might need to see the patient several times and monitor care, it makes sense for us to create an episode, say 30 or 60 days, and figure out a payment based on that, and make them our exclusive partner,” says Paula Riordan, executive director of a PCP practice in the Atlanta area looking to establish this for a range of conditions—pain, orthopedic, GI, skin, and respiratory issues, like asthma. “If it’s more repetitive care, like for mental health, then I think we’d consider a per patient per month amount with a partner or telepsych vendor.” Specialty doctors we have been interviewing and polling in the last three years lament their limited role in value-based care. “It’s not for us and I’m unclear where we fit,” Greg Thisis, MD, an ophthalmologist, told me back in 2018. His concern is legitimate for certain specialties, but not all, and Riordan is essentially laying out the opportunity.

At-Home Lab Boost: At least three payers are partnering with home care companies to test patients at home. In Illinois, at-risk members of BCBS of Illinois who have not been screened for colorectal cancer may qualify for an in-home testing kit, at no extra charge, to encourage screening. The insurer will notify members that they will receive the test kit and that using it is voluntary. The member then submits the test for processing to Home Access Health Corporation. Premera Blue Cross in Washington state is partnering with Home Access Health to offer in-home test kits to Medicare Advantage (MA) members for colorectal cancer screening, diabetic blood sugar control, and diabetic kidney disease screening. Humana launched a similar initiative for their MA members at no cost, through September 2020.

BMI Link to Alzheimer’s: Are your medical practices evaluating body weight and the potential impact on brain function? If not, they should, as BMI has an astounding impact on brain function and ultimately Alzheimer’s disease, according to a new brain imaging study in the Journal of Alzheimer’s Disease. All regions of brain activity lose activity and blood flow with a higher BMI. Scientists analyzed 35,000 functional neuroimaging scans to measure blood flow and brain activity. The temporal and parietal lobes, hippocampus, posterior cingulate gyrus, and precuneus areas of the brain are vulnerable to Alzheimer’s disease and were found to have reduced blood flow along the spectrum of weight classification from normal to overweight, obese, and morbidly obese.

Pregnancy Link to Guess What?: A recent study found that women who used cannabis while pregnant had a 50% increase in the risk of autism spectrum disorder in their children, according to a report published in Nature Medicine. The data was recorded with 500,000 Canadian mothers and the question of whether cannabis affects the fetus’s neurodevelopment had not been explored much beforehand. Children were followed for an average of seven years, during which 7,125 were diagnosed and the in-utero cannabis exposure was 2.2%, compared to 1.4% for mothers who did not use cannabis during pregnancy.

15-30: This is not the score three points into an epic Borg-McEnroe tilt but a new BCBS of Louisiana policy taking effect in one year that will stop payment in situations when a patient is readmitted to the same hospital for the same or similar condition or complication to the original condition within 30 days of discharge. The current policy denies payment when this occurs within 15 days. COVID-19 has delayed implementation of the 30-day rule.

Site of Care Stop Sign: A national MCO expanded precertification requirements for CT and MRI scans to include a site of care review, effective August 1, 2020. eviCore will handle these reviews and determine if the appropriate site of care is being used; outpatient hospital settings will only be approved when deemed medically necessary.

Angel En Route: A Los Angeles MCO has funded a van and partial nutritionist salary as part of a new program to help the underserved. Read the full story, from our correspondent Lauren Stroger, by clicking here.

Extra Point: An allergy practice in east Texas is getting an incentive payment these days 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.  As many of us send our kids back to school next week, to college clusters, crowded high schools and recess yards, I think we could all use a spirometer too. Something to help us monitor and to help us breathe easier. Mine came Wednesday when our oldest came home armed with a giant roll of bubble wrap. “Packing up boxes?” I asked her. “No, it’s for my bed at Springfield,” Mukue said. “The egg crate thing.” Of course – she didn’t know the difference, a light moment that in an oddly reassuring way makes me feel at ease about sending my oldest girl off to Springfield College next week. I’ll breathe easier knowing our kid—the same one who once scored six times on her own team and only eats Frosted Flakes for supper—will at least rest soundly at school on a bed of popping bubbles.

200K: The number of Medicare Advantage members across 23 states who will receive a free monthly membership to home delivery service, Shipt, through its new partnership with WellCare. 

Going Downhill: Like an Alberto Tomba race, more insurers are pushing volume down and out of hospitals. BCBS Minnesota will require that certain hernia, gynecology, and orthopedic arthroscopy and foot procedures be performed in a non-hospital outpatient setting, as of October 2020. The insurer already established this policy for ENT and upper and lower gastrointestinal endoscopy procedures in 2019. There will be geographic exclusions for any members that do not live within 25 miles of an in-network ASC or physician office that can perform these procedures. The insurer is also moving injectable drug treatment for hereditary angioedema (HAE) from their medical policy to a pharmacy benefit. Any members taking these drugs will now go through Prime Therapeutics for a prior authorization for the self-administered drugs.

Pharmacy Shift: Cigna will end its contract with CareCentrix for home infusion therapy in February 2021. Accredo, Cigna’s specialty pharmacy, will take on most of those services, with eviCore assisting members who require non-specialty infusions. In other home infusion news, Empire BCBS in New York is requiring commercial members move their oncology drug administration to the home for certain immuno-oncology treatments, including Keytruda, Opdivo, and Yervoy, among others. Effective August 1, 2020, members are no longer permitted to receive these infusions in the hospital outpatient setting.

Northern Exposure: No, not the strangely interesting Alaskan TV series, but a strategic effort by Arizona's Banner Health to acquire Wyoming Medical Center. While not final yet, the deal would include a $100M investment by Banner into the medical center’s “facilities, technologies, programs, people, and operations over the next 10 years,” including telehealth capabilities.

Hill Street Blues: Avera Health, a health system in South Dakota, is using a $1M grant to launch a telehealth program that will connect police and court officers with mental health experts to help assess and treat people in crisis. The Virtual Crisis Care Program will cover 23 counties and aims to use the connected health platform to increase the level of care that can be provided at the scene.

Virtual MA Plan: Alignment Healthcare is launching a virtual Medicare Advantage plan in 2021, which will feature digital, concierge-style services for both primary and specialty care. The plan will incentivize members to use digital solutions, but will also cover in-person visits when necessary. Another MA plan, SCAN, is also using technology to improve healthcare for members, by launching artificial intelligence predictive models to help avoid hospital admission.

Extra Point: Like the healthcare system pushing surgeries out of hospitals, my wife and I are chasing the kids out of the house in two weeks, taking two to college, one to tour Midwest universities, and two others back to public school chaos. Needless to say, this fall comes with mixed emotions, to say nothing of the price tag ahead and uncertainty over COVID. I’m a bottle of stress: yelling at my daughter for burning the waffles, working when I should sleep, sleeping while driving. Might explain why on Monday I woke up on the couch at 1am to a man standing in my kitchen. For the full story, click here.

50: The reimbursement rate increase for child psychiatrists agreeing to be in the BCBS of Massachusetts network. This is a big deal - we only see these hikes when traditionally out-of-network service providers perhaps agree to come in-network for a deal, and even then, they can be rare. Child psychiatrists are in high demand throughout the US. Meanwhile, primary care doctors who "integrate" mental health into their practice here will be eligible for incentives. Question is whether integration will include using telepsych platform and whether PCPs will be effective at this, given the length of time it can take to diagnose and assess mental health. "If you think the checklists are effective, you're mistaken," says Prudence Fry, an RN who works at a pediatric practice in Massachusetts. 

Down in the Bowels: While Don Draper might have made the midday cocktail iconic in 1960s ad agency life, 2020 drinking due to the pandemic is having a downstream impact on health risk.  Nearly 4 in 10 GI doctors and internists we polled report rising incidence of symptoms related to irritable bowels or constipation, and some are proactively addressing it. Click here to read more.

ABA Win Out West: No, this is not a headline from the 1970s basketball league, it’s the latest victory for autism providers; effective this September, Regence Blue Cross will remove pre-authorization requirements for applied behavior analysis for any members 17 years or younger. Regence is making this change to better establish parity between behavioral health and physical health services.

Schtickle of Fluoride: Tim Whatley used to give his patients “a schtickle of fluoride” and send them on their way during Seinfeld-era dentistry, but if the comedy aired today, Dr. Whatley might first bring the patient over to the PCP. That’s right - the integration of dentists and primary care practices is increasing. CareOregon was already working to integrate dental care into primary care in the state and COVID-19 has sped this up, as dental staff from Virginia Garcia Memorial Health Center were redeployed to the primary care side early on in the pandemic. CareOrgeon has now invested $2M across five clinics in the Portland area, including Virginia Garcia, to help dental and primary care staff integrate their services.

Heal at Home With PT: Humana invested $100M into a primary care startup that focuses on in-home care for Medicare and Medicare Advantage patients. Heal offers in-home primary care and telemedicine visits, and recently expanded to include teletherapy visits. It currently operates in eight states and may potentially add on services like physical therapy.

New Health Plan: AllWays Health Partners, a commercial health plan in Massachusetts, is working with Newton-Wellesley Hospital and Mass General Brigham to launch a new integrated health insurance product, Allies. The product’s model will focus on members receiving primary care at the hospital and those with more complex conditions seeing physicians at Mass General Brigham centers. Allies members will reportedly receive savings of up to 20% of AllWays’ traditional HMO plans.

In-Home Lab Draw: Oscar Health is launching a new virtual primary care benefit at no cost to their members that includes unlimited virtual visits with PCPs, and some members will be eligible for free at-home vital monitors and in-home lab draws. The program rolls out first in Florida, Texas, California, Colorado, and New York.

Extra Point: I’m going fishing with my youngest son on his 13th birthday. My buddy DWalter says fishing with his dad and brother was part of coming of age. “I love those times,” he says. Last time Tommy and I fished, I hooked my wife by casting in a kind of bizarrely pathetic boomerang motion. I’m hopeful this fishing expedition will be less stressful and painful, but I have low expectations. One time I fish-hooked my buddy Troy when we were skipping school and his dad had to bring him to the ER. The problem is fish hooks have a rigged shape, so the ER doctor couldn’t just rip off the hook like you would out on Golden Pond; otherwise Troy’s scalp, yes his scalp, would bleed a lot. Medical costs due to fishing injuries are unlikely a major problem, nothing like viruses and mental health and diabetes. But if you’re in my boat, maybe take cover.

61: The percent of college students who will forgo school this year, according to our random poll of 417 incoming freshman and sophomores. Read what they’ll do instead and how it may impact healthcare by clicking here.

David Gets a Win vs. Goliath in New Pay Model: BCBS of Massachusetts is launching a new payment model for small practices that will combine value-based care and support payments. The model is designed for practices with 1K-20K members and will incorporate upside risk. The pilot does not launch until 2021, but immediate support payments will go out to any provider participants starting in 2020, once they sign the value-based care contract. More payers are entering into value-based arrangements with physician groups, like BCBS North Carolina, on which we reported back in June.

Hurricane Health: While it’s unclear if college athletics will be returning in the fall, the University of Miami is moving forward with a program to monitor the health of their student-athletes remotely. The university is the first in the country to partner with Tyto Care, an Israeli telemedicine company that makes the TytoHome telemedicine kit. The kits will allow the university’s healthcare providers to gather biometric info from student-athletes and remotely examine them, including measuring their temperature and blood oxygen levels. Another initiative in Florida will also make use of TytoHome kits. Baptist Health, a non-profit health system, is partnering with homebuilder CC Homes to provide the kits with every new home purchase. They’re aiming to capitalize on the trend toward home-based connected health.

Grassroots Delivery: DoorDash, best known for food delivery, is partnering with Walgreens Boots Alliance to deliver OTC medication and other drugstore products to patients’ homes. More than 2,300 products from Walgreens will be available for delivery through the program. The service will start in Chicago, Atlanta, and Denver, and eventually expand to other locations. DoorDash previously teamed up with CVS Health in June for a similar model.

Substance Use Partnership: Highmark announced that its commercial, ACA, and Medicare Advantage members in Pennsylvania and Delaware will have access, as of April 2020, to a comprehensive, technology-enabled opioid-use disorder program from Bright Heart Health. Members are able to meet, on-demand, with medical staff and counselors through a smartphone, tablet, or computer, and care teams will be composed of a therapist, physician, case manager, and a wellness coach. The goal of the program is to stop abusing opioids without experiencing powerful drug cravings or severe withdrawal symptoms. Highmark will pay providers through its value reimbursement program.

Kidney Care: Humana is partnering with REACH Kidney Care, a non-profit company affiliated with Dialysis Clinic, Inc., to provide kidney disease care coordination services to commercial and MA members in Alabama, North Carolina, South Carolina, and Tennessee. REACH Kidney Care nurses, pharmacists, and dietitians will work alongside the patients’ PCPs and nephrologists and offer patient education and medication assessments. Amal Agarwal, Humana’s VP of Transformative Home Solutions said, “This whole-person approach to treating chronic kidney and end-stage renal disease provides greater choice and flexibility, including for some the option for in-home treatment.”

Community Health System Resurgence: Optum is partnering with Boulder Community Health (BCH) in Colorado, its second partnership with a health system. Optum will help BCH with back-office type functions, developing risk-based contracts, population health, and negotiations with payers, while BCH will continue to make clinical and strategic decisions. Last year, Optum signed a similar deal in California with John Muir Health. As hospitals, particularly small, independent ones, continue to struggle, exacerbated by the pandemic, look out for more of these unusual partnerships.

Extra Point: Angela Wilmont’s mom, Penny, hasn’t been in the hospital at all this year, not once. In 2018, Penny, now 77, was in 13 times due to complications from heart disease, a hip fracture, a dizzy spell from a drug dosing mistake, a fall, skin infection, dehydration, and chest pain. But help from a who’s who of home care has halted the revolving door. There’s Alexandra, her home health aide, Alexa the Amazon system, Johnny the cardiac trainer for seniors, Bill’s senior rides, a new geriatrician, Tamara, an RN who comes in for medication and BP checks once a week, and Liv from the companion company, who helps Penny shower. “I credit every one of them – they have saved mom’s life and mine.” Angela found her own health declining. “I didn’t exercise, my anxiety skyrocketed. I was shaky, depressed, angry, and gained 15 pounds.” She calls her mom’s care team her own “saving grace,” as she now is much healthier. I asked her how she lined them up all up and she said that a nurse from her mom’s Medicare insurer visited the house in February 2019, about three days after her last hospital trip. “She put it all together for us – the insurer pays for it.” What struck me when I dug a bit deeper is that each one of Penny’s clan of caregivers had an agreement with the insurer and, in nearly every case, they all say their service prevents hospitalizations. At least four of the six get a bonus of some kind for proving they do this. No one can argue that they each had a hand in changing Penny and Angela’s life, but who is really keeping Penny at home? One has to wonder how these bonuses will play out over time, if that insurer will look for more evidence from Liv or Johnny and decide to redistribute the dollars, or if they’ll see the total value in ‘family terms’, now that Angela is healthier. Even though Angela has different insurance.

700: The amount of primary care clinics Walgreens is planning to open up in the next five years through a partnership with VillageMD, the home-based primary care group. The clinics will be called Village Medical at Walgreens and will integrate digitally with Walgreens to simplify the prescription process. The first clinics will be opened in Texas and Arizona, and more than half will be in government-designated medically underserved geographic areas.

Match Game: Like a page out eHarmony’s book, a former teacher we chatted with this week has plucked 24 college kids in New England, started training them in applied behavioral analysis, and created a school service targeting the cash-paying population of families who are bracing for a full year of at-home education. Like a dating match site, the entrepreneurial educator will match the parent’s need with the college kid’s skills. Seeking a male who’s got some base training in working with kids on the autism spectrum but also can help an 11th grader with SAT prep and show a 6-year-old how to paint like da Vinci? We got that. Need a female with basketball experience who’s strong in algebra and essay writing? We got that. Zoom meet-and-greets will be used, and then a discussion about whether the college student will educate “remote only,” visit the family daily or 3x a week, or perhaps “live in.”

Telehealth Avalanche: UPMC, the Pennsylvania health system, averaged about 9,500 telehealth visits a day by the end of April, up from just 250 a day before then. A separate study found that about a third of tele-visits during the crisis have been specifically for mental health reasons but in discussions with pediatrics, geriatricians, and other PCPs, the real number is probably closer to 70%. “I can’t think of a visit this week where my patients haven’t talked about their mental health, depression, mood, and anxiety in some way,” Ally Tiascentino, PA, told us in an interview. “It’s no longer the PHQ-9 that is driving our discussion.”

Ohio Behavioral Model Emerges: Managed care plan CareSource is partnering with Child and Family Health Collaborative of Ohio to develop a new model of community-based behavioral health care for children in Ohio, including enhancement of telepsych services. The focus of the partnership will be on keeping children and their caregivers engaged in behavioral health services during the pandemic and into the 2020 school year. In Ohio, more than half of CareSource Medicaid members are under 18 years old. Tia Marcel Moretti, CareSource Ohio Director of Behavioral Health, says “combining forces will allow us to explore new, creative ways to achieve better health outcomes.”

Long-Term Care Gap: Funding decreases in recent years have left nursing homes poorly equipped to handle the pandemic, according to a panel AARP convened earlier this month. Dr. Rachel Werner, Executive Director of the Leonard Davis Institute of Health Economics at UPenn, says many nursing homes in poor neighborhoods receive less funding and were thus less equipped to deal with the pandemic while Dr. Morgan Katz, a Professor of Medicine at Johns Hopkins who focuses on infection control, says new policies enacted for nursing homes really need to be guided by available resources. “No mandate that is given should be unfunded.” Dr. Grace Jenq, who specializes in geriatric and palliative medicine at the University of Michigan, says nursing homes affiliated with academic centers “stand a better chance of being able to test rapidly.”

Women Rise Up: Getting mammogram results while still at your appointment is one feature of a new comprehensive women’s health center in Michigan opening at the end of August. Spectrum Health Women’s Health & Wellness Center will include a broad range of services, including preventive care, pelvic floor concerns, incontinence, menopause symptoms, bone health, preventive heart health, nutrition and breast health. The center will support virtual visits and will have space for classes on topics like health eating and managing stress.

Walk the Line: Independence Blue Cross in Pennsylvania conducted a nine-month study of over 460 employees from six Independence employer groups that shows an enhanced walking program led to weight loss and improvements in mood, energy levels and overall feelings of well-being. Independence offers a variety of walking and weight loss programs to employer groups, including “Maintain, Don’t Gain!” — a program to help employees avoid weight gain during the holidays, and “Losers R Winners,” a weight loss challenge program that includes cash or other prizes. Earlier this year, we reported that several Blue plan executives say they are appointing Chief Executive Officers who will head up more initiatives like this.

Gene Therapy Innovation: These therapies offer hope for many patients where previously there was none, but it comes at a steep price. Zolgensma’s price alone was listed at $2.1 million per treatment, making it the most expensive drug in the world. But there are a range of value-based models emerging from Cigna, CVS, Harvard Pilgrim, Aetna, Anthem, and manufacturers to help figure out a path forward. What’s interesting is to see so much creativity in payment models out of the gate. It usually takes years, decades even, for the health insurers and health system to collaborate like this. The full report comes next week.