Behavioral Health Insights

12.6: The percentage of high schoolers who reported they used tobacco products in 2023, down from 16.5% in 2022 according to the CDC’s National Youth Tobacco Survey. E-cigarette usage also decreased from 14.1% to 10%. The trend mimics a similar drop in length of stay for SUD cases in hospitals, down from 10.1 to about 7.5 from ’21 to ’22 according to one commercial plan. The trends are promising but given the potential for so many high costs and recurrence in SUD, the “work is far from over” according to experts at the CDC.

GLP Changing Employer Policies: More union plans are starting to cover the weight loss drugs and for more than just those with type 2 diabetes. Policies set to roll out in 2024 are part of an effort by unions and self-insured employers to recruit and retain employees. The coverage expansion of what is a $10-16K a year medicine is noteworthy and perhaps the market disrupter of the year.  Pre-authorization is required and will remain in place for foreseeable future, but the medicine has potential to have a ripple effect, on cardiovascular disease prevalence and management, potentially depression and anxiety and maybe on pain and productivity. One national union health plan we interviewed last week spent $150K on GLP-1s alone in 2022 for a small group of its members, compared to the $1.6M it spent overall for weight loss, an $840K increase vs. 2021. There are many new GLP-1 drugs in the pipeline, so plans expect to see use increase year over year. “The big question is ‘to what end,’” said utilization analyst Wendy Abraham on our conference call November 10^th. “Down the road, we may work it out so that members may also need to enroll in a program of counseling since these drugs may be lifetime usage.”

Home Care Victory: BCBS in Massachusetts will remove 14,000 prior authorization requirements for home care services beginning January 1. The payer says this is in response to capacity-related stress hospitals in the state are facing, which is not unique to Massachusetts.

Point For MA: A recent study by Harvard and Inovalon comparing outcomes data for Medicare beneficiaries found that MA members had lower rates of high-risk medication use, fewer avoidable hospitalizations and fewer hospital readmissions overall. Past studies on this topic found more modest differences across the two populations but Harvard and Inovalon said their study used a larger sample and a broader set of quality measures than those studies.

Instantaneous Meal:  Instacart Health has signed a partnership with Mount Sinai Solutions, the employer arm of the New York City-based health system, to offer $110 in fresh grocery stipends for post-op and post-partum patients. The program will launch in early 2024 and includes the creation of a virtual storefront with local and national grocers through Instacart. Like we predicted back in 2014 when we suggested grocery delivery service Peapod ought to add nutritionists and partner with healthcare insurers and hospitals, nearly a decade later the grocery delivery service Instacart continues to make a move into healthcare. Its health division started working with WellCare of Kentucky and digital health company, Good Measures, to make food prescription programs available for Medicaid members. Good Measures’ dietitians work with members to create a nutrition plan for them, which is accessible via Instacart. For low-income consumers, Instacart allows people to use their Temporary Assistance for Needy Families benefits as well as Supplemental Nutrition Assistance Program assistance funds.

Insulin Access: Optum Rx is moving 8 insulins to preferred formulary status which means they will be available with the lowest out-of-pocket costs for commercial members whose health plans use the pharmacy benefit manager beginning in January 2024. The insulins are currently either on tier 3 or not covered at all, which leads to access issues and higher costs for patients. The PBM says that, in 2024, 98% of all their customers will have access to insulin for $35 or less a month. In related news, BCBS of Massachusetts recently removed prior authorization requirements for continuous glucose monitoring and supplies for Type 1 diabetes.

Reproductive Policy Change: The White House announced the nation’s first initiative for women’s health research, led by First Lady Jill Biden. The initiative will target both reproductive health care research, perimenopause, and menopause. These topics, along with the exploration of increasing payer focus on women’s health, were explored in our recent women’s health whitepaper read here.

Extra Point (From The Archives): Phil Collins’ people were on the rotary phone 42 years ago to call my dad of all people to help the Genesis pop legend tape the ankle he rolled in time for his show on a cold November Friday night at the Hartford Civic Center Mall. Dad, who was an athletic trainer and tennis coach at the University of Hartford for nearly four decades, treated Phil like any student-athlete. Collins offered dad a pair of front row seats to hear him belt out his “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 four years ago at Madison Square Garden in New York. Collins, now almost 70, 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 the 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, surgery and anxiety don’t have to mean you stop. You just have to get some help and 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, if not excitedly, 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.

46: The percentage of veterans who have self-reported PTSD and depression in a recent poll, a slight decrease from the same poll in 2022. The U.S. Defense Health Agency has a transition program available to all service members and veterans regardless of how long they’ve served and connects them to those services using coaches. “What’s great about the program is we are diagnosis agnostic, meaning you don’t need a diagnosis or to already be in care to participate,” says Nicholas Polizzi, a psychologist who works at the DHA. “We are come one come all. If you’re experiencing stress about the transition you can talk to someone or if its comorbid depression and anxiety we can help figure that out. Our mental health coaches know all about it, they are generalists. Our goal is to help the individual get connected to care with their next therapist.”

Walmart Moves In: The retailer has announced its first deal with a health system, Orlando Health in Florida. Ambetter from Sunshine Health, a Centene plan, will be part of the partnership in which the trio aims to better improve care coordination between Walmart’s 23 health centers in the state and Orlando Health. Walmart’s centers will become preferred providers in seven counties in Ambetter’s Value Plan.

Retail Switch: Walmart will also be adding daily “sensory friendly hours” in which the retailer will lower the lights, turn off the radio and change their TV walls to a static image. The hours, targeted to those with sensory processing issues like autism and PTSD, will be from 8am-10am every day at all stores across the country.

AI Up & Down: Virtua Health, a New Jersey-based academic health system, is incorporating AI chatbots to provide behavioral healthcare to patients amid the provider shortage. The chatbots, created by Woebot Health, are referred to patients with mild-to-moderate signs of depression or anxiety. A number of digital health companies are utilizing voice and text-based AI during patient visits, but not all are proving successful. Olive AI, a digital health company that developed AI-based technology to help providers and insurers automate the revenue cycle, went out of business and sold its remaining assets last week, despite raising $832 million in funding since 2020.

Infection Surveillance: With cold temperatures approaching, the CDC is expanding its infectious disease surveillance program at four major US airports to screen for more than 30 pathogens, including flu, RSV, and COVID. The surveillance program was launched in 2021 to combat COVID-19 at seven airports. The four airports where the program will be expanded are JFK, Boston Logan, Dulles and SFO.

Sales Cycle: Allstate, the home and auto insurer, also has a health insurance division which it recently announced its intentions to sell. It will be interesting to see if any of the larger name health plans are interested in acquiring it. Meanwhile, Cigna is exploring selling its Medicare Advantage business. The health insurer has never had as much volume in that line of business compared with competitors like United and Humana, with MA revenue for Cigna coming in at only 4.4% of its 2022 total.

Make It Count: Starting in February 2024, Anthem will implement a new policy restricting some genetic tests to once in a member’s lifetime. Reinterpretation of the genetic sequence will be allowed as needed but will not be separately reimbursable.

Rate Cut Delay: Aetna will lower reimbursement rates for physical and occupational therapy assistants to 85% of the allowable rate starting March 1, 2024, a delay from its initial plan to start the policy in December.

Inhouse Infusion: Cigna will expand its Pathwell Specialty program in 2024 to more than 4 million additional commercial members. Members will need to use Pathwell Specialty designated providers when receiving specialty infusions.

Izzy Mandelbaum Healthcare: This Seinfeld icon once barked at Jerry that ‘it’s go time,’ a plea from the Lloyd Bridges character for the weaker, unhealthier comedian to shed some pounds. Managed care organizations are in a bit of their own go time these days, juggling the rise in weight loss drugs and trying to figure out the pros and cons, like adverse events of depression and anxiety that we’ll discuss during today’s forum on behavioral health at noon (Pre-register here). At a minimum, expect more MCOs to require patients on these medicines to be part of “programs” in the future. One managed care medical director in Indiana once talked to a medical group there that turned an old apartment building into a basketball court and gym for patients who needed more activity – office visits and check-ups took place at the facility. The health plan, Welborn, paid a PMPY to track BMI, obesity and other measures, including presenteeism in school and work. ‘This is the sort of thing that gets my attention – rather than come in saying you want a 10% increase because you added a clinic, show me how you’ll change the course of life for these patients.’

Extra Point: Unions are striking back with apparent wins for auto workers, actors and healthcare workers just this month that put organized labor back on the map after a two-decade downward trend. It’s interesting that the Screen Actors Guild negotiated protections against artificial intelligence, which no doubt will be a recurring theme of future healthcare labor union negotiations. I wonder how these developments will impact access, shortages, reimbursement rates for healthcare workers, quality of care, and investment.  Labor remained the #1 concern of 127 healthcare investors according to our annual poll due out next month, mostly due to the rising cost of labor. There are many famous unions – there’s the one for students on college campuses, there’s the marital one, that Duran Duran song with the snake, and of course the state of the union. I’d argue that all of these have had some trouble in the last 30 years losing some of the cache they once had but, like a lot of things, they are making a comeback. Bruce Springsteen, perhaps the one musician most connected to the struggles of the average worker, may need to hold a reunion of the E Street Band to cut a new version of his 1978 song Factory. Perhaps that can be the new anthem for the current labor movement.  I suppose the union resurgence is a good thing for those in the gig economy like my own daughter, an aspiring actress and singer, who sometimes finds herself singing to patients at hospitals or nursing homes. It’s plausible that she could be part of both the actor’s guild and maybe a healthcare union one day, or maybe a new union for singing nurses.

Editor’s Note: At noon today, I’ll interview a long-time worker for a union health plan when we’ll dive into issues largely around behavioral health utilization, but also interesting challenges like weight loss, medications and mental health. Pre-register here.

Behavioral Health Expert Discussion: Register here for my live interview next week, Friday, November 10th, with Wendy Abraham, Utilization Analyst, APWU Health Plan, and Ish Bhalla, MD, Medical Director of Behavioral Health Value Transformation, Blue Cross NC as we discuss the complex behavioral health ecosystem.

67: Percent of physicians are concerned about the use of AI in healthcare decision-making, according to a Medscape survey. Most are more supportive of it as a tool to help with administrative tasks like scheduling and note-taking, but worried about it being used for more involved tasks like diagnosing and treatment planning. Interestingly, older doctors, those 45-64, were more supportive of AI. Some specialists are also more supportive – particularly those already using it in some capacity like radiologists. Earlier this week, President Biden signed an executive order directing HHS to develop a program to better regulate AI tools already used in healthcare.

Burnout: Around 56% of nurses and 47% of physicians reported burnout during the COVID-19 pandemic, and high rates of burnout have continued into 2023. The CDC recently launched an initiative for hospitals to address employee well-being and offers training for leadership.

Goodnight, Sweetheart: California has experienced a 19% increase in men taking paid family leave since 2020, signaling a shift in the perception of parental leave from both employers and employees. Research shows that when fathers take leave, mothers tend to have better health outcomes, according to an associate professor of health policy at Stanford. Residents of most states have access to 12 weeks of unpaid, job-protected leave. Thirteen states and DC have enacted a paid family leave law, although some have yet to take effect.

Gene Therapy: The FDA is reviewing a one-time therapy that uses gene-editing to treat sickle cell disease. The blood disorder causes severe pain and organ damage and most with the disease die by 50-55. But the exa-cel therapy would mark the first time CRISPR gene editing will be used in a clinical setting and the first curative treatment for sickle cell, which affects around 7 million people worldwide including 100,000 Americans, most commonly Black or African Americans. The FDA has until December 8 to decide about whether to approve the therapy.

$1,000 For Doula Care: Walmart is expanding access to doula services for all employees, expanding a pilot program originally offered in four states. The expanded benefit will cover up to $1000 for doula services during pregnancy and is part of Walmart’s Life with Baby program.

Menopause Business: Memorial Hermann Health System is partnering with a virtual provider focused on menopausal care. Women in Texas will be able to access the Midi Health services directly through the company’s platform or through a referral by a Memorial Hermann provider. After meeting with a provider specializing in menopause care, patients receive a personalized care plan that can include hormonal or non-hormonal medications, behavioral health coaching, evidence-based supplements and integrative therapy.

Price Gap: The first study looking at federally mandated price transparency data from health insurers shows that health plans negotiate widely variable prices for the same procedures, depending on where in the country they’re performed. Research published in JAMA looked at Humana’s rates for seven different procedures for about 1 million members with commercial insurance – even though the health plan is exiting the commercial market at the end of the year. Higher rates tended to be paid in the Upper Midwest and Southeast. Prices varied from $69-$114 for an office visit and from $348-$528 for a colonoscopy, presumably for the professional fee only.

Onsite: Smaller employers are starting to follow in the footsteps of larger ones by offering onsite healthcare clinics, and a Mercer survey found more employers are offering deductible-free health plans to their employees, as about 25% of employees report they can’t afford their healthcare needs without help.

Extra Point: Dad says he “deleted the internet” again last night and somehow disabled use of his phone “because it was talking Spanish,” forcing him to walk over to Gerry’s house to call me about the time change for today’s 129^th echocardiogram this year. He really loves these echos, obviously. I think he’s going for the record. Dad is repeating this story as we sit here early Friday morning waiting for the sonographer to call him in. “You know I think your mom had something to do with it – she was watching the your tube when it happened.” You mean You Tube dad? I said. “I don’t know whose tube it is…I just know she is probably to blame. But don’t tell her I said that. She’s making her spaghetti tonight.” It’s interesting watching my folks navigate life in their 80s, learning how to live in what must seem like a foreign world at times, holding on to familiarity like the tinker bell held onto her Reese’s on Halloween this week – it’s not unlike our kids navigating life in their 20s, on their own in a big city, grub hubbing Chipotle with the $13 they have in their account like they did when they were 15, feeling part lost, part over their head but doing best they can. I suppose my bride and I may not be much different in our 80s as things like artificial intelligence force us to God only knows what…take a George Jetson style helicopter to the actual clouds to see our sonographer? I guess until then we’ll just have to enjoy the lighter moments of coming of age, and aging.

16.8: The percentage increase in hospital admissions in 2022 related to these diagnoses, representing the second biggest driver for a national union health plan with more than a quarter million members. We’ll give you a hint – it’s a famous Joe. That’s right, GI or gastrointestinal conditions are an increasing driver of hospitalizations, namely stomach, intestine, and pancreas related conditions – and drove more admits than lung, pulmonary, musculoskeletal and mental health. Save the date: Friday, November 10^th, at noon ET for a ~30-minute live conversation with this union plan.

61: The portion of all mental health disorder related hospital admissions in 2022 for a national union health plan that were attributed to “dependents” of the plan’s primary adult beneficiary.  Dependents were typically teenagers.  39%, by comparison, were tied to the primary beneficiary.

54.9: The percent of Black medical students who plan to work in underserved locations, compared to 24.6% of white students and 23.1% of Asian students, according to data collected across 48,000 medical students between 2019-2022. We’ve heard from many behavioral health providers recently about the lack of providers who look like the diverse populations they’re treating or those willing to practice in more rural and underserved areas. Research indicates that increasing diversity among doctors tends to lead to better health outcomes – it seems like at least some of this next generation of doctors are trying to make that happen.

59.99: The maximum cost of a monthly membership with nutrition and wellness company GNC who’s partnered with ReviveHealth to offer virtual primary care, urgent care, mental health, physical therapy, medications and eventually virtual weight-loss care, all without insurance.

55: The number of FastMed urgent care clinics that Blue Cross NC is purchasing in hopes building the clinics “back to pre-pandemic" levels.

2: Dual eligibles, those who qualify for both Medicare and Medicaid, will have a new benefit starting January 1, 2024, from BCBS Tennessee. The Blue Care Plus members will get health food, over the counter supplies and housing utilities. Previously, these benefits have only been available to those who meet Special Supplemental Benefits for the Chronically Ill requirements.

1972: The year when the FDA determined that a product called Trypsin was less than effective as a debriding agent and so they rescinded approval, but not until about 40 years later did it find that some products approved by the agency contained the ingredient. A popular topical treatment to handle wounds in nursing home residents lost its own FDA approval because it contained the ingredient and about a month after that FDA decision, Part D plans that covered the wound care product stopped covering it. “Nursing homes complained, particularly since some were concerned about readmission penalties and relied on it for preventing wounds from going from stage 2 to 3, preventing pressure ulcers,” SNF clinical director Barbara Keller said at the time.  What’s past is somewhat prologue. CVS is the first big pharmacy chain to announce a voluntary recall of a product called phenylephrine used in many popular decongestants. A month ago an FDA panel determined that phenylephrine is ineffective. CVS will pull many products containing the ingredient from its shelves.

20: Did you know that this portion of calls into the 988 crisis line go unresolved, largely because there’s no local option to direct the person to? A lot of people in crisis still call 911, but only some of those responders are trained and knowledgeable enough to transition the person over to 988. As with any new system, this should improve. In Houston, a 911 and 988 crisis center co-locate responders, and this is having better results.  Read more details about the ever-changing behavioral health ecosystem in our special report by clicking here.

What’s The Over Under? Is it at all possible drones from Amazon will drop off prescriptions and pizza directly into the Texas A&M’s Kyle Field football stadium during this weekend’s home game vs. South Carolina? Amazon will begin testing prescription drone deliveries in College Station, Texas, and patients there can now get scripts delivered within one hour of placing an order. They’re focusing on medications for illnesses like the flu or pneumonia, where starting medications quickly is particularly important. They won’t be delivering any controlled substances and, despite what seems like a good idea according to college students, no pizza pies.

Extra Point: Watching the Patriots game on an iPhone over pancakes last Sunday in NYC – yes, late afternoon pancakes are delicious – I asked our 18-year-old Sophie what an extra point is worth. “Wait, that’s the kick, right?” Yes, I said, it’s the kick. “Oh well, that’s easy. It’s 3, obviously.” Her answer made me smile and reminded me when she was just 6 and she made a list over pancakes of all the things she would need if we ever had to go to a hideout, and high on her list were 3 pairs of tights, or as she wrote it, “3 ti_s” (that word George Carlin said we couldn’t say on television!). Webster could not have seen that one coming, right? But I’m not so sure what was funnier: the spelling or the 3? When I told her that she was close but had spelled “tights” incorrectly, she chuckled and snorted the way kids do. “Oh yeah,” hee hee she giggled, “there’s no ‘s’” It’s a strange set of emotions when the kids leave the nest and go out on their own. You begin to feel yourself age, and not necessarily physically. Your brain just instantly becomes older. You find yourself staring out windows and getting emotional just looking at that picture frame made of popsicle sticks she gave you for Christmas. You start to randomly choke up thinking about those moments when you could just be a kid with your kids. You rely on FaceTime. And then you get on a train for 3 hours to go see the kid strum a guitar and sing the Emily King song “Teach You” like she did here in front of 500 some people on the Upper East Side, just like the two of you are back home in the living room, only that song was Crosby’s “Teach Your Children.” But I suppose this is the point too - that you grow up, they grow up, and while you may not be able stop them from leaving and stop yourself from aging, you can turn back time once in a while, and have a good laugh over pancakes.

145,000: The number of health care providers that left their jobs across 2021 through 2022 – almost half of them physicians, according to a data analysis by Definitive Healthcare. Worryingly, specialties that lost the most providers were internal medicine, family medicine, and clinical psychologists.

Any Guess? The largest healthcare union is, wait for it, in Minnesota…where providers at Allina Health recently voted to unionize, which will create the largest healthcare union in the U.S.

Union Deal: Healthcare unions have been in the spotlight recently – unions representing 85,000 Kaiser staff who recently participated in a three-day strike came to an agreement with the health provider and insurer to raise wages, as well as invest in job training programs and other initiatives to address understaffing. For example, we were at the Pipefitters Union event in Boston last month where workers got training on substance use disorder and recovery. Charlene Verga, RN, the associate director of nursing for the Massachusetts Nursing Society, said most of the education today is about fentanyl. “Addiction is like a relentless stalker,” she said, “and fentanyl was present in 93% of opioid related deaths in the state.” Verga and her team demonstrated how they deal with an overdose at her hospital. Even though Fentanyl outlasts Narcan when it wears off, it’s a 1–3-minute spray with no real side effects. She said the new long-acting Opvee used in the emergency treatment of opioid overdose takes 5 minutes to work, then lasts for 8-10 hours. “It’s a gamechanger but needs to work quicker.”

Corner Drug Stop: Rite Aid filed for bankruptcy over the weekend, citing declining sales and over a thousand opioid-related lawsuits. The pharmacy chain had already closed more than 200 stores in the past two years and will reportedly close up to 500 more as part of the bankruptcy plan.

TikTok: The social media platform is often thought of as contributing to the mental health crisis, particularly among adolescents, but healthcare professionals are trying to harness the platform’s reach for good. Both Cleveland Clinic and Harvard are among the institutions working with the social media company and some of its most popular creators to try to correct misinformation and help connect those seeking care with appropriate mental health resources.

Ending Coverage: We heard from an Aetna source related to its recent wave of coverage changes for telehealth. About 80 types of virtual care services are losing insurance coverage in December under a new Aetna policy. “We are not ending telemedicine coverage for all behavioral health therapy,” explained Alex Kepnes, Aetna’s executive director of communications for health care benefits. “We will continue to cover outpatient behavioral health therapy via telemedicine as outlined in our policy and based on the billing code.”  This will include services using real-time audio “visual” services when medically necessary for alcohol and/or drug treatment reasons, as well as intensive outpatient programs and intensive outpatient psychiatric services paid per diem. Coverage ends for some behavioral care services, ophthalmological care, services related to end-stage renal disease and more, according to a notice the insurer sent to healthcare workers. Aetna will also end audio-only coverage of nearly 60 services, including psychotherapy, counseling for alcohol use disorder, and obesity counseling. One of the services no longer covered will be intensive outpatient programs provided virtually. Kepnes said telemedicine services that remain covered for Aetna’s commercial plan employer sponsors are actually more extensive than what was provided pre-pandemic because of the access and value these services clearly bring to their members and providers.

In Other Virtual News: BCBS Massachusetts will now offer members access to Virta Health, a diabetes focused provider, and Oshi Health, which focuses on GI conditions. Another virtual GI company, Parsley Health, is launching a new GI program to self-insured employers across the country. Northeastern Blue Highmark will begin working with virtual mental health company Spring Health to expand access to behavioral care for its members. Together, they’re launching a mental well-being platform that integrates into the health plan’s existing member app. The platform will be available to fully insured, ACA and MA members in 2024. Cigna’s Evernorth also recently announced the acquisition of Bright.md, which provides asynchronous care, trials and healthcare navigation tools.

Surgery Lift: Blue Shield of California updated its bariatric surgery policy effective October 1, 2023, to no longer require failure of at least two different drugs before surgery will be approved. Members still need to meet other requirements for surgery to be considered medically necessary, but it seems that maybe the health plan found the cost of obesity medications was rising too rapidly.

Taking Risk: AdventHealth in Florida plans to transition its entire primary care network for Medicare and Medicare Advantage patients to a value-based arrangement. The health system is partnering with Wellvana to help with the transition. 10% of Advent providers will move into full risk on Day 1 while others will transition over several years.

Oncology Care: Beginning next year, a new cancer support program will be available to BCBS Michigan commercial members. The health plan will work with OncoHealth to provide supplemental services to those dealing with cancer diagnoses like 24/7 support from oncology nurses, oncology specific mental health support, nutritionists, peer mentors and care navigation.

Rate Hike: BCBC Texas will increase reimbursement for Licensed Marriage and Family Therapists, Licensed Professional Counselors, and those administering mental health Intensive Outpatient Programs starting in 2024. They will be paid at 100% of the Medicare fee schedule when seeing Medicare Advantage members, bringing these professionals’ rates in line with other midlevel providers.

Extra Point: At about 3 o’clock last Saturday my lovely wife said we were going to the Taylor Swift movie, which went from being news to me to a modern-day metamorphosis.  “We are?” I said. “I thought we were watching the Ole Miss game.” Turns out I was wrong and on the way to the show I learned that the movie was really a concert, and that I’m encouraged to stand up and sing. “I am?” I said, “I thought I was going to be sitting down watching football on my phone?” Turns out I was wrong, so I asked what songs Taylor sings in the concert. Janine rattled off about 15 songs and the only one I knew was Cruel Summer. “Oh, well that’s a good one,” I said, optimistic that maybe the show wouldn’t be so bad. “That’s the Bananarama song from Karate Kid – awesome.” Turns out I was wrong, and this was not at all the same song. So, I decided I would just turn the movie into a market research exercise. I planned to interview all the other guys there about why they had to go, did they want to go, and did they too think Cruel Summer was the Bananarama version.  But it turns out I was the only guy in the theater and instead of doing the research, I had moms asking me “why are you here?” I had 13-year-old swifties giving me a look like what are you doing here old person with the funny Italian cap, and 8-year-olds just giggling. One murmured, “I think he’s lost.” So I grabbed my box of Reeses Pieces and decided to just tolerate it, but as the movie played I started to realize there was a health benefit to the whole exercise – turns out I like Taylor Swift.

About 80: Types of virtual care losing insurance coverage in December under a new Aetna policy. Coverage ends for some behavioral care services, ophthalmological care, services related to end-stage renal disease and more, according to a notice sent to providers. The health plan will also end audio-only coverage of nearly 60 services, including psychotherapy, counseling for alcohol use disorder, and obesity counseling. We reached out for comment last week and expect a response shortly.

Watch Out: Samsung is working with several health systems, including Mass General and Tulane School of Medicine, to research how smartwatches can improve overall health and clinical care. The health systems are focusing on different types of measurements – for example, Tulane will look at a range of cardiovascular disease indicators while MIT will focus on how sleep affects health.

Diabetes Monitors? Next To The 42” Inch TVs: In a somewhat surprising move, tech retailer Best Buy will begin selling continuous glucose monitoring systems in the next few weeks. They will start with Dexcom G7 CGM and may expand to other systems in the future. Those looking to buy a CGM will be sent to Wheel, a telehealth platform, where a clinician will assess need and write a prescription if needed. Consumers can then buy the CGM through Best Buy’s website and have it delivered anywhere after HealthDyne, their pharmacy partner, receives and processes the prescription.

Bringing It Home: Uber continues to expand into the healthcare world, this time by partnering with Optum, United’s healthcare services group. Uber Health users with certain Medicare Advantage plans will be able to use their Optum benefit cards to pay for non emergency transport along with delivery of grocery and over the counter medical items.  Only thing missing, the caregiver support service.

PPO Control: Carbon Health, the primary and urgent care provider, announced they’ve signed their first at-risk value based contract with United that will start in 2024 for California PPO members. Carbon Health says the arrangement is a “very novel deal which should benefit employers and members in California who are facing unprecedented premiums.” In recent years, there have been more at-risk deals involving United and physician groups. For decades, physicians didn’t want to take risk with PPO populations given lack of controls, but improved data analytics is changing this.

Dispatch: In Louisiana, a Medicaid MCO has been requiring preauthorization for mobile mental health crisis units before it can dispatch to help patients in need, according to Randal Gomez-Simon, the vice president for Business Development at Woodlake Addiction Recovery Center. “It’s causing people to end up calling 911 and eventually end up in hospitals.” In a positive alternative in Houston, a 911 and 988 crisis center co-locate responders, which gets better results. Full story in our upcoming “The Behavioral Ecosystem” paper.

Ladies First: My mother used to say that the “ladies choice” skate at the roller rink in 1982 was ‘a necessity to survive amongst you sweaty boys.’ Women-focused communities are now commonplace, even if less circular – there are sports teams and book clubs and in healthcare a growing number of services just for women. SCAN Health Plan is launching what it calls the first women-focused Medicare Advantage plan called SCAN Inspired. Initially the plan is only open to those in two California counties and is in partnership with Cedars-Sinai. Members will have access to a women’s health advocate, along with $0 estrogen therapy, reimbursement for weight management programs and more.

TeleHealth Market: At the HLTH conference that took place in Las Vegas this week, Amazon executives said their telehealth marketplace, Amazon Clinic, could soon move into partnerships with in-person providers to help decrease gaps in care when issues cannot be solved virtually. Meanwhile, Walgreens announced the launch of direct-to-consumer telehealth service.

New Lab Order: Labs like mine are known to be good hunters, persistent in finding the problem, but in healthcare there are some questions about the efficacy or necessity of lab tests. BCBS Illinois is relaunching its laboratory management program for commercial members that was paused earlier this year. Beginning January 2024, lab services provided in an outpatient setting will be subject to a post-service medical necessity review. Some testing policies may have narrowed medical necessity guidelines to reduce over-testing. There have been questions over the years about the utility of lab testing, particularly by allied health providers and PCPs. For instance, “borderline hormonal tests (like metanephrines, cortisol levels) are more confusing than helpful,” said one medical director. Our 2018 poll found that 15-22% of lab tests are inconclusive or useless, health plan medical directors said. Practices would benefit from dissecting their lab testing protocols.

Peer Support: BCBS Minnesota will begin offering both commercial and Medicare Advantage members with a behavioral health diagnosis access to Peer Specialists at $0 cost share in 2024. Peer Specialists have prior support receiving mental health or SUD services and have to go through training and certification by the Department of Human Services to be qualified and then provide support to members. They serve as an additional resource for members along with their healthcare providers.

Extra Point: A hurricane swept through our home last weekend when the two college kids blew in leaving wrappers on the couch, socks in the fridge, piles of wet towels on the floor, and hair in the sink. They took all the shampoo and protein bars, cleared out the iphone chargers, and somehow found a way to steal both of our favorite sweatshirts. There was arguing, complaining, crying and laughing, and even a few “that’s amores” after supper. The wife and I played part therapist, part nurse like these 20 year-olds were 9 again and despite the chaos, the pseudo ER meets All in The Family felt incredibly comfortable and familiar in the way you feel when you see kids next door guzzling apple cider before jumping in a giant leaf pile. Our kids left like hurricanes tend to do, back to NYC's big apple, and even though the house is a disaster, it felt like home again for a moment. They can sweep in any time if you ask me. For some folks today, a hurricane at any speed would be welcome if they could have their family back home safe. Prayers and peace to those who are suffering from the events unfolding overseas this week. Our struggles, disruptions and chaos at home, wait times and healthcare delays - as stressful as they may be - can be managed.

1.8 Million: The number of people who received an updated COVID vaccine the week ending September 22. The number isn’t as high as many health professionals hoped, likely due to some glitches with the rollout and lessened demand. The cost for COVID vaccines has also switched from the government over to commercial insurance plans, possibly leading some to forgo the shot due to worry about potential copays, though health plans are not allowed to charge.

Let The Drug Price Tactics Begin: Medicare Advantage insurer SCAN is getting ahead of the government's planned drug price negotiations by offering seniors free or $11 monthly co-pays for 13 name brand drugs starting in 2024. SCAN selected cardiovascular and diabetes drugs with no generic alternative, which means they are often more expensive. Currently, SCAN members have copays ranging from about $30 to $50 for these drugs. Additionally, none of the medications will have prior authorization requirements.

Nursing Home Flip Flop: Louie DePalma of Taxi TV fame once said nursing homes are a great deal except that they probably spend too much on meals, arguing that the resident’s memories are so bad “they don’t know whether they had 3 meals or a cracker.”  Louie was harsh at times but nursing homes today tend to agree given the high proportion of dementia and the high amount of food waste. “Acuity going up, cognitive issues more pronounced – it’s a hard age to manage,” Paula Kane, an administrator told us. Health insurers agree and are increasing scrutiny of SNFs. Carelon—the benefit manager for Anthem and others— will begin managing post-acute care for Regence BCBS’s Medicare Advantage members in 2024. They will begin requiring preauthorization and reauthorization for home health, SNFs, LTACs, and inpatient rehabilitation. On the flip side, as of October 1, BCBS Minnesota no longer requires prior authorization for any commercial members who need skilled nursing visits, likely due to a high rate of approvals.

Transport Inside: Speaking of taxi rides, the transport industry continues to evolve. Back in July, Arkansas BCBS ended its contract with Alacura Transportation Benefit Manager, moving ambulance network operations internal and distributing commercial contracts to ground ambulance providers.  These providers are now no doubt competing with the ride-share companies. Lyft Healthcare’s Buck Poropatich said in our interview last year that its fleet of drivers lowered ER visits 40% by bringing people to doctor’s offices or OP visits. “We don’t need wheelchair-accessible vans going to pick up somebody who’s appropriate for rideshare,” he said. Franciscan Health System in Indiana at one time selected Uber as a service to transport its Medicare seniors to appointments and from hospital to home as part of its accountable care organization, according to business development director Sean Duddy. Rideshare-based non-emergency medical transportation does not require any specific healthcare-related training for their drivers, Poropatich said, but driver education on identifying mental health crises and then responding to them is likely to become more important in the future. For instance, how many drivers know the difference between a panic attack and heart attack? Panic attack symptoms include chest pain, a racing heart, and sweating, which are three of the same symptoms common in those having a heart attack.

Go Blue:  BCBS Michigan is partnering with supercenter chain Meijer to offer a co-branded Medicare Advantage plan. It will include $0 premium and $0 copay on many generic drugs along with an annual allowance of $660 that members can use at any Meijer center in Michigan to purchase health-related items or healthy foods. Medicare plan Alignment Healthcare has also developed a food-focused product that will be available in 13 California and Nevada counties with benefits like a quarterly stipend worth up to $100 that can be used for Instacart purchases.

Nutrition Boost: Horizon BCBS is updating coverage of nutritional therapy effective November 2. The health plan currently only covers nutritional support if enteral nutrition comprises 100% of an adult member’s daily caloric needs but next month coverage will be extended as long as enteral nutrition meets at least 50% of caloric needs.

Last Off The Bench: Aetna began requiring prior authorization for Eylea October 1, 2023. Many insurers have already moved in this direction and promote Avastin first with no pre-authorization and, in some cases, require patients to fail on Avastin before being allowed to try Eylea or Lucentis.

Virtual Care Hiccups:  For the second year in a row, Bicycle Health, a virtual opioid treatment provider, had to fly in providers to see patients in order to continue their access to OUD treatment. An Alabama law passed in 2022 prevents providers from writing prescriptions for controlled substances without an in-person visit so Bicycle Health coordinated the “Alabama Airdrop.” Nearly 300 patients were seen in-person over 6 days which will allow them to continue receiving treatment for another 12 months. Other virtual health providers are dealing with a decision by one of the leading US insurers to halt coverage of virtual IOP. There has been some talk inside insurers about how to address growing mental health spend, up from 1% to 6-8% of total medical in many cases, and reconsidering policies for long virtual sessions with unclear outcomes is thought to be a target. It will be interesting to see how many other insurers follow suit.

Extra Point: Ironically dad’s 9^th fall leading him to the hospital ER had nothing to do with being orthostatic, not drinking enough water or the effects of vertigo and a heart surgery, but because the darn cell phone range so loud he jumped and slipped. About 24 hours before the fall, he emailed me with a problem. “BRY!!!!  PHONE ISN’T WORKING. IT HASN’T RUNG IN 2 DAYS. YOUR MOTHER PRESSED THE PHONE BUTTON REALLY HARD BUT IT DIDN’T WORK!!  NO RINGS!!! DID YOU WATCH THE GAME? THE PATRIOTS STINK!!! CAN YOU COME BY TOMORROW TO HELP?? LOVE TO THE KIDS.” It’s ironic that for years the folks resisted the cell phone and after a few short months have come to rely on it more than bran muffins and the newspaper word jumble.  Ironically, it turns out there was nothing wrong with the phone at all – it’s just that only 4 people know their number.

$226: Women’s average out-of-pocket spend is this much more per year compared to men’s even when excluding maternity services, according to a new Deloitte report. That adds up to $15.4 billion more in out-of-pocket costs across 16 million women with employer-sponsored health insurance. Women use health care more often, with 10% more in total health expenditures relative to men, but out of pocket spend is still 18% higher. This may be due, in part, to the different type of care recommended for women such as gynecological exams and earlier annual checkups.

The VBA Effect: CommonSpirit, the nonprofit health system, is launching a physician management services organization to help more providers transition to risk-based value arrangements. The platform will provide services like population health analytics and network management. CommonSpirit already has experience in the value-based care space, currently managing 2.6 million people in VBAs, including ten ACOs.

Disrupter: Following in the footsteps of Capital Blue Cross and Blue Shield of California, Select Health becomes the third health plan to officially partner with the Mark Cuban’s Cost Plus Drug Company through its PBM, Scripius. Members will have access to over 1,000 prescription drugs, potentially with lower prices than they would find at a traditional pharmacy.

Sunny Days: Along with that jumbo pack of paper towels and free samples, members will soon be able to access medical care at Costco. The company announced that through a partnership with the healthcare platform Sesame it will begin offering its members $29 virtual primary care visits, $79 mental health visits and 10% off other medical services on Sesame’s platform.

Missing Care: Mass General is working with GE HealthCare to utilize an AI tool developed together that will hopefully predict missed care opportunities. The application will first be used in the health system’s Radiology Operations Module and is intended to predict missed visits and late arrivals. Better identifying these could help with targeted patient outreach and streamline administrative operations, while allowing more room in the schedule for walk ins. In preliminary tests, the algorithm was able to predict missed care opportunities correctly, at rates up to 96%.

TV Nurse: Multiple health systems have adopted virtual nursing, which is helping increase access to care despite staffing shortages. MUSC Health in South Carolina is expanding its program to four rural hospitals that are understaffed while other health systems report their virtual programs allow older nurses to stay in the profession longer.

Addiction Partners: Some specialized virtual providers are realizing the power of integrated care. Ophelia, an opioid use disorder treatment provider, is working with Vori, an MSK provider, to help patients manage pain without opioids. Vori will refer patients already suffering from OUD to Ophelia and Ophelia will refer patients to Vori for opioid-free pain management.

Fertile Ground: Care coordination company, Rightway, has partnered with Kindbody, a fertility clinic network and employer family-benefits provider, to increase access to fertility care benefits and streamline the care journey. A recent report highlights that 61% of employees who receive fertility benefit coverage report feeling more loyal and committed to their employer, showcasing the benefit of offering fertility coverage. On the flip side, about 1 in 4 Black adults said they or someone they know used fertility treatments compared to nearly half of white adults surveyed at the same time, according to a Pew study.

Mom Duty: BCBS Texas announced the launch of the first ‘Mom & Baby Mobile Health Center’ to increase access to maternal and infant care in rural areas of the state with limited options. 20% of birthing people in Texas received inadequate or no prenatal care in 2019-2021, higher than the 15% national rate. The mobile health center is set to launch in 2024 and will offer pre-conception, pregnancy, postpartum and newborn interventions, as well as primary, wellness and preventative care.

Delaying the Deal: Elevance’s merger with BCBS Louisiana has been put under regulatory scrutiny, delaying the deal. State regulators are worried it could reduce competition and increase healthcare costs so the insurers have chosen to withdraw the merger. They plan to refile a reorganization plan and acquisition application but that timeline is unclear.

Extra Point: So, is the quality of our nation’s mental health therapy a problem?  Mental health therapists are trying, many moonlighting, many in their 20s just out of school, some talking to kids just 5 years younger who are in the midst of a crisis complicated by what they see, what they hear and what they know. 59% of the 374 therapists in our poll this week say they more often than not feel unable to treat, their readiness to solve the storm of pressures kids and young adults are facing today “is getting complicated.” Teen therapist Kelley, 29, said she had the supervision hours but “it wasn’t what I thought it would be, my supervisor wasn’t always present – they had a full panel,” she said. “I see a lot of teenagers who identify as LGBTQIA+, bullied on Instagram, struggling to find their footing at home and school. I’m doing my best, but this is hard – I’m having a hard time,” she admits. Kathie, a 46-year-old family therapist, says she left her corporate job to help people but admits it’s hard getting to the root of the issue for the 16- to 20-year-olds she works with who are struggling with transitions and self-worth. “I think the complexity of their experience is sometimes beyond the scope of my training and my experience.” Some say the issue is we box the patient into a set of diagnoses but fail to train the therapists on figuring out how to identify and treat childhood trauma, how to adjust what we ask and what we say. Others acknowledge that there are so many patients that it's difficult to match the specialist to the patient’s diagnosis – like the therapist trained around addiction is not necessarily the right fit for the 17-year-old with compulsion. Maybe the problem isn’t really the quality or training of the therapist but the lack of consistent physical movement and exercise as we come of age and go through transitions. In some ways, this isn’t surprising given the meaningful growth in coverage of mental healthcare and the rising demand in the wake of two epidemics, COVID and the opioid crisis, and the constant struggle of youth today to manage life on social media. These issues are exacerbated when therapists and psychologists stop taking insurance as is happening in some states or leave their jobs to join better paying work for a division 1 college sports team. If we are to improve quality and outcomes, we probably need to think about all of this and not just how we pay for therapy but how we pay for quality and help therapists learn how to “measure” progress. Maybe we should take a cue from Ronnie, 34, who completed training to be an LCSW last year. None of Ronnie’s sessions are over zoom and none are in the office – "I do 45 minutes around a lake, jogging, some walking, some talking.”

56%: Cataract surgery costs this much more when performed in a hospital outpatient department compared to an ASC. This is according to data from the BCBS Association. Analysis was performed on claims data for six common outpatient procedures across 133 million BCBS members from 2017 to 2022, which showed costs are consistently higher when procedures are performed in the hospital versus a lower site of care. Differences ranged between 31% more for clinical visits in the HOPD to 58% more for diagnostic colonoscopies.

Closing The Gap: A new incentive program BCBS of NC started this year focuses on closing care gaps for D-SNP members. Providers can receive $100 for each care gap closed – things like cancer screening, eye exams, and controlling high blood pressure. Providers will also receive another $200 for completing annual planned visits. Payments will be made in spring 2024 for services provided between September 1 and December 31 this year.

Off On The Wrong One Of These: So the average US adult has about 205 bones in their body and believe it or not, about one-quarter of them are concentrated in this one spot. Any guess? It's the most important tool you have to get from your bedroom to the bathroom every morning. Your two feet have combined about 50 bones. Foot and ankle injury and chronic ankle and foot pain both before and after surgery are among the most underappreciated challenges in health care spend. "A sprain is worse than a break and a break is awful," my cousin Mark, a doctor of PT at Mass General always tells me. On Wednesday in Dorchester, Massachusetts I heard union reps at a Labor Guild meeting say that more of their 50,000 workers are suffering with addiction due to pain from foot and ankle issues. "It never subsides, no amount of massage and PT really do it," one worker dealing with opioid use said. Insurers, meanwhile, would like to find ways to manage the spend but it's difficult. It's hard for them to figure out what the true time of the episode is for bundled payment purposes.

Linking Menopause: A new survey by Delta Dental highlights that 84% of women 50 and older are unaware that menopause can lead to oral health complications. Decreases in estrogen and progesterone throughout menopause commonly lead to dry mouth, an increase in cavities and sensitivity, and tooth decay. The survey aims to raise awareness and encourage women experiencing menopausal symptoms to discuss their oral health changes with their providers.

Wait For It: Patients are spending a longer time in the ER, according to data from CMS. Data from the most recent 12-month period, ending in the third quarter of 2022, shows that the median time nationwide was 2 hours, and 40 minutes, compared to 2 hours, and 18 minutes back in 2014. Times varied quite a bit between states. Average ER wait times were the longest in DC, at 5 hours, 29 minutes, and lowest in North Dakota at 1 hour, 48 minutes. It's not just a worker shortage that's the issue. If you dive deeper, that wait time is indirectly linked to the flood of youth and young adults coming in with overdoses and vomiting from vaping. Charlene Vega, associate director of nursing for the Massachusetts Nursing Association, says at her hospital things like synthetic marijuana 30x stronger than THC are bringing 12-year-olds into the ED with seizures and kidney failure. The waits, she says, are usually the less urgent cases.

Voice Journal: AI-powered tools are now being used to help screen for mental health conditions. The tech company Kintsugi recently conducted a pilot with a large health insurer that used data from 250,000 people who made voice journals to identify those at risk of depression. The National Health System in the United Kingdom is utilizing an “e-triage” tool from Limbic to screen patients across the eight most common mental health disorders. So far, they’ve found that misdiagnosis is down, along with fewer treatment changes.  Limbic is presumably named for the brain's system that hosts our memories and our impulsive, irrational thoughts.

Lower Reimbursement: Beginning December 1, Aetna will no longer allow additional payment for E&M services when billed by a radiologist for commercial and Medicare members. Also beginning in December, the health plan will only reimburse physical therapy assistants and occupational therapy assistants at 85% of the allowed amount, a change many other payers, including Medicare, have already made.

Tailored Meal: Kroger Health is expanding into the food-as-medicine space by partnering with Performance Kitchen to offer medically tailored meals and support from their registered dieticians to people with chronic conditions.

Hospitals Align: Terre Haute, Indiana, home of Indiana State University and the greatest basketball player ever, at least from my vantage point, will soon have less hospital competition for its 60,000 citizens as Union Health has agreed to buy Terre Haute Regional Hospital from HCA Healthcare. Union would then own every hospital in the city, which could be a challenge for Indiana health insurers.  In related news, Dana-Farber Cancer Institute is partnering with Beth Israel Deaconess on a new standalone cancer hospital, which will move inpatient cancer care away from Brigham and Women’s. Dana Farber has long been partnered with Brigham and Women’s.

Extra Point: If only we all just had more Neti pot. Wait, no no - I don't mean more pot. That would be awful given how the youth of America are flooding hospitals these days, sick from too much cannabis and fentanyl in their system, and addicted to a behavior that may not make sense until you see what today's youth see and hear on social media. No, no. I'm talking about the actual neti pot - this green plastic, mini teapot contraption my wife brought home in 2012. She asked me to come over to the kitchen sink.  "We're going to try this new thing," she said with that look of 'stay with me Bry - I know you think I'm ridiculous'. "It's called the Neti Pot and it's going to help us clear out our mucus problem." So, naturally, I’m like, "I didn’t know I had a mucus problem." She holds up the pot and says "here's what we do...fill it with water, then you're supposed to tilt your head to the side and back a bit, then take the spout and put it up your nose. It's going to go up and out the other nostril. She begins to have the suppressed laughter I used to have in front of the altar on the way to communion. But I’m like, "What do you mean WE?" Then with a straight face, she says to me, "You go first." Now I’m a good sport with a lot of things and so I fill the green plastic pot with water, tilt my head back and to the side a bit, and after a deep breath and a look of fear, I take that elephant-trunk looking stem and put it up my nose. My eyes begin crying, water is flowing out of my nose and ears I think but then, just like that, I'm done. Supposedly mucus and allergy-free. Bridget is laughing the entire time and I say, "Ok. Your turn." And she says, "Oh no. I’m not doing that. No." Now mucus is a problem in society. Perhaps not on the level of fentanyl addiction and cannabis addiction, but it's an issue. If you've spent any time in an urgent care waiting room you know that at least 60% of the people are in there because they have a stuffy nose or some respiratory symptoms and potentially chronic mucus issues. My grandma would call it phlegm. "Give it a good blow - you got a lot phlegm you do," she'd say. That was the last time we used the Neti pot. It sat on the 3rd shelf of our coffee cup cabinet for a few years, probably jealous every time we opened up and grabbed a mug instead. I never could see myself getting addicted to jamming a mini teapot up my nose for a daily drowning. Then again, as addictions go, it seems quite a bit healthier and perhaps a real health system cost saver than say inhaling a rag of gasoline because you are a bit lost and unsure where you fit, and the other kids said it feels amazing.