Behavioral Health Insights

988: The new National Suicide Prevention Lifeline phone number, available nationwide by 2022. The previous number, 1-800-273-TALK, was hard to remember, so advocates have changed it to three digits to make it “similar to 911 calls for emergencies.”

High School Ups & Downs: Nearly three quarters of 394 sophomores and juniors in high school either lost significant weight or gained significant weight during the pandemic, citing lack of social interaction, according to a tracking poll of high school behavior we started in March. 9% self-acknowledged that they started “dabbling” in drugs or alcohol, though that number is far higher in urban areas, and was at a peak of 17% in late April. Depression, which at its peak in early May affected 84% polled, including 91% of boys, has mitigated since, down to 57% overall since June 15th.

Dental Care, But Make It Virtual: We’ve been reporting on the inroads that telehealth has made during the course of the pandemic, but now there is growth in an area that falls outside the traditional telehealth priorities like urgent care and behavioral health. Teledentistry is emerging, which will be a factor that could impact some clinic-based practices. DentaQuest has partnered with MouthWatch to provide their teledentistry platform to more than 70 DentaQuest managed or affiliated practices in Alabama, Massachusetts, Oregon, and Washington. Teledent offers live video conferencing and file and photo sharing capabilities to help patients receive dental care from home.

Amazon: Thanks to a new partnership with Amazon, members of Anthem’s commercial medical and dental health plans can now use Alexa-enabled devices to order prescription refills. Known as Anthem Skill, the service will also allow members to access their health and dental plan benefit information using only their voices.

Go Blue: In Michigan, Cigna and Priority Health have formed a strategic alliance that will allow Cigna members to access Priority Health’s provider network, which includes 97% of PCPs in Michigan. Priority Health members who may work or travel outside Priority Health’s service area will now have access to Cigna’s national provider network through the alliance.

Behavioral Practice Gains Half Million: Blue Cross Blue Shield of Rhode Island has awarded $422,000 to a local behavioral healthcare provider, Newport Mental Health, to allow them to better collect and analyze population health data on their patients. The grant is part of a Behavioral Health Quality Grant program, which helps behavioral healthcare providers make the leap into population health models. These models support methods, such as screenings and tracking and reporting outcomes, and can help providers and payers better focus care and improve outcomes.

Hospital System Payer Affiliation: The trend in hospital systems partnering with government-sponsored plans and primary care continues. CommonSpirit Health, one of the largest nonprofit health systems in the US, is partnering with primary care provider Paladina Health to offer direct-to-employer primary care. Participating employers will pay a flat fee per employee for access to onsite or virtual clinics and primary and preventive care will be free to employees. The first location will be in Las Vegas, with plans to eventually spread to all 21 states CommonSpirit is in. And starting in July, members covered by Health Partner Plans, a Medicaid and Medicare plan in Pennsylvania, can utilize Children’s Hospital of Philadelphia and its affiliated outpatient primary and specialty providers as an in-network provider. The hospital is recognized nationally as a top pediatric center.

Game Time for ADHD Patients: EndeavorRx is the first video game ever to be approved by the FDA that is targeted to help children with ADHD and will be marked as medication or “game-based therapy.” Its intended use is indicated by the agency to improve children’s symptoms associated with ADHD. The game is based around an alien in which the user, aged 8-12, navigates through a course and responds to on-screen prompts. Akili, the creator of the game, said in a statement that the game “will be available with a prescription to families soon.”

Heads Carolina: BCBS of North Carolina launched a new two-year program in June 2020 that is aiming to keep primary care offices open while moving them into value-based care arrangements. In order to participate, providers must join Blue Cross NC’s value-based program, Blue Premier. Providers have the option of joining an existing ACO in Blue Premier’s network or they can work with Aledade to transition to a value-based model. Participating doctor's offices will receive supplemental payments to stabilize revenue for primary care services at their pre-COVID-19 levels beginning in September, through 2021, and in 2022, providers will have the option to receive capitation payments.

A New Type of Drive-Through: Humana recently announced that it will cover LabCorp’s at-home COVID-19 test, as well as tests offered at drive-through sites in Walmart parking lots; labs from the drive-through sites will be processed by Quest. Other retailers, such as CVS and Walgreens, have also promised to make testing sites available in their parking lots. CVS, for example, has established 1,400 test sites in 33 states. Patients are instructed to stay in their cars and go to the drive-through window to receive the test. Samples are then sent to a third-party lab to process.

Extra Point: Songs from Glee’s Santana Lopez soared from Sophie and Mukue’s bedroom this past spring, her angelic voice giving the girls a bit of freedom to get lost in during what’s been an isolating year for teens. So it was awfully sad to hear today that the Glee character Naya Rivera, just 33 years old, may have drowned on Wednesday, possibly leaving behind a 4-year-old son and, at least in my household, kids who looked up to her. Who hung on her every note for Glee’s six seasons. Santana’s version of Michael Jackson’s Smooth Criminal was actually the first time Sophie heard Jackson’s epic 1980s hit. “Wait, dad, Santana sings that right? Who’s Michael Jackson again? Wasn’t he a president?”  If you grew up in the 80s, dancing to Smooth Criminal was a rite of passage. You tried to lean over like Jackson did when the FM radio station played it, like you were in a V8 commercial. You wore a turtleneck, bellbottoms, a walk-man, and Reeboks with the air bubbles to pump up before jumping to a Van Halen song, or moonwalking like Michael from locker to locker. You couldn’t afford Air Jordans, but the Reeboks worked. This generation doesn’t really know about these 80s music stars. Glee is their music. Santana is their Madonna, their Michael. Their mental health.

Extra Point: Unexpected marriages of medical practices are continuing to emerge within the healthcare industry. The latest union, which took place in Missouri, is a merger of Bolivar OB/GYN, Citizen’s Memorial Hospital and—wait for it—Butterfield Park Pediatrics. Although it sounds like a page out of Prince Humperdinck and Buttercup’s odd coupling in The Princess Bride, the combination of pediatrics and women’s health is likely an emerging trend. It is safe to anticipate an expansion of health system service lines, and for more Medicaid and commercial insurers to redesign payment to favor these double-specialty practices. The amount of ‘episodes of care’ and clinical efficiencies alone could be significant—just think about an encounter involving a child potentially on the autism spectrum, or a new mom who no longer needs to shuffle between OB and pediatrics postpartum. A dental practice out West is taking note of the potential effectiveness of double-specialty practices and is in communication with an allergy and asthma clinic about a merger, which could help the Medicaid population. The healthcare marriage bug is likely to make its way into home health, too. Will an Instacart join with a home care agency? Will a physical therapy clinic merge with an outpatient therapy group and a telehealth business? If past is prologue, then yes. My own marriage is proof that unions, even in the healthcare industry, thrive on differences. At first, a short Italian marrying a taller Irish Catholic, and a Yankee fan marrying a Red Sox fan appeared absurd. However, after 20 years tomorrow, July 3^rd—in sickness and in health—it’s the best thing I’ve got. My dad used to say you ought to be able to re-contract every five years, so I guess I could ask for a fee-for-service allowance every time I bring my wife Bridget water, or a greater share of the apple pie, and for risking my life on the wobbly ladder, but there are a zillion more things she does, or puts up with. This is all to say that some partnerships may seem odd at first, but that’s just the surface. Here is my essay to Bridget back in 2012 on winning and losing in marriage. Perhaps a good lesson in here for those of us seeking new partners in healthcare: Click here.

816,000: The number of “healthy days” seen by Humana’s Medicare Advantage members in 2019, representing the first increase in this metric since the insurer began tracking it in 2015. “Healthy days” is a health metric developed by the CDC that measures physical and behavioral health. The metric is tracked as part of Humana’s Bold Goal initiative, a population health strategy aiming to improve the health of the communities Humana serves.

Uber At It, For Seniors: InComm, a technology company, announced a partnership with American Logistics and Uber Health to launch a transportation benefit program. The program will allow Medicare Advantage members to request non-emergency medical transportation using plan-provided benefits.

Patient Is ‘Community’: BCBS of North Carolina has provided a $1 million grant to Durham Technical Community College for a new mobile health lab for elementary-age children in underserved neighborhoods, where transportation is a common barrier to accessing health services. The mobile lab will provide free glasses, offer free dental pre-screenings and education, and participate in health fairs at public elementary schools, offering basic vital sign checks, cholesterol and glucose checks, and health and nutrition education to combat childhood obesity.

Left Holding the White Bag: A flurry of changes are on the horizon this summer as more commercial HMOs require physicians to order specialty medications through the insurer’s preferred specialty pharmacy, a process often called “white bagging.” As a result, buy and bill erodes as a reliable model, at least in some cases, and it will be interesting to watch, given many physicians are already pushing back. This comes at a time when more hospitals are looking to maneuver back into the specialty pharmacy arena, particularly 340B entities, establishing in-house pharmacies and trying to partner with insurers.

‘So Epic’: My son Tommy says this for pretty much everything - about ma’s meatloaf or the latest B- he got on his social studies paper, or the way he combed his hair. In healthcare, Epic is underway on a predictable initiative with insurers. HCSC Blues plans will be some of the first insurers to launch a new health information sharing platform for providers who use the EHR. The platform will be able to establish a secure, interconnected health system and information exchange between payers, providers, and patients. One aim of the platform is to identify gaps in care, helping patients make choices that will help reduce personal health care costs. Expected to launch later in 2020 for select BCBS-contracted providers and health systems who already use Epic.

Merge: Managing care in the western New York to Delaware corridor increasingly flows through Highmark, which will have about 6 million members after merging with HealthNow New York, a non-profit which includes BCBS of Western New York and BlueShield of Northeastern New York. Highmark is the 4th largest BCBS-affiliated organization nationally.

30: The number of estimated HealthHubs Aetna has planned to put in place by year's end in metro Atlanta, and 500-600 nationally.

Playing House: UnitedHealth Group announced a $100M investment in the Health & Housing Fund, which will allow for more than 1,000 new homes to be built for those struggling with housing insecurity. The first three housing developments will be built in DC, Texas, and Oklahoma. UnitedHealth will continue to focus on social determinants of health, such as food, transportation, and social isolation.

At Home CHF & Cancer Care: Intermountain Healthcare is beginning a new service to provide hospital-level care to patients at home. The service, in partnership with Intermountain’s value-based care spinoff, Castell, will focus on those with conditions like congestive heart failure, infection, and some cancers. Eligible patients will go through an orientation at the health system first, then will receive in-person and virtual checks.

Model T: How do value-based care management delivery models differentiate? Taking capitation or risk are increasingly popular, but how do these models interact with, or compete with, the traditional healthcare system? It’s a fair question to ask if thinking about these new innovative models that have popped up in the last five years targeting chronically ill patients. Most that we’ve seen lack a true physician-led service and most provide care and support virtually. One I saw had an org chart with 125 some “care coordinators” but no physician and no relationships with the insurer’s provider network. Another was focused on COPD, but its primary partner was the hospital, which raises questions given one in five with this condition end up readmitted. Yet another focused on worker injury but lacked any behavioral health services. This is not to say that there isn’t a need for these care management models. They are usually offering a way to more cost-effectively manage sick patients who, until now, have been treated primarily by a depleted primary care workforce. Question is do these new models add costs and confuse patients, or do they save the system money, and should they align with providers or payers? Short answer is, it depends largely on the patient population, the cost trend, and the services being offered.

MedTech Partners With IDN: Geisinger Health System has signed a 10-year partnership with medtech company Siemens Health. The partnership is described as a value based one, which is interesting as most value models concentrate on primary care.

Vaccination: Blue Cross Blue Shield of Illinois has asked healthcare practitioners to make sure that children are getting needed vaccinations during this crisis. In their June 2020 provider newsletter, chief medical officer Derek Robinson noted, “the reality is that we must consider the possibility of having to confront other epidemics…join us in outreach efforts to parents of children aged 0 to 2 years and adolescents aged 9 to 13 years regarding the importance of getting all scheduled childhood immunizations.”

Women Win: Billy Jean beat Bobby and Madonna beat out Michael Jackson and, increasingly, women’s healthcare beats out men’s health as priority for health systems, insurers, and primary care practices. Even internist Mitchell Baruch, MD, who mainly treats adult and senior males, says, “I’ve started to think that my patients would be better at complying and outcomes if they were women”. Last week’s women’s health sector developments can be found by clicking here.

Prime Time: Football player Deion Sanders used to have this distinction back in the early ‘90s with America’s Team, the Cowboys, but these days, in healthcare anyways, America’s Store is Amazon and it is having a prime time of its own. Amazon has already partnered with health systems offering bundled product packages for populations like diabetics, and now has done so with insurers. Molina health plan members get Amazon Prime free for three months, then at a reduced price. This is the latest example of Amazon’s entry into the business of healthcare. 74%, in a poll we did of consumers, said they’d buy medicines online via Amazon; other polls have similar results.

You Grant: Blue Shield of California announced another $300,000 in grants to nonprofit organizations providing mental health support in San Diego and Alameda counties. The grants are part of Blue Shield’s ongoing BlueSky initiative, a multi-year effort to enhance awareness, advocacy and access to mental health support for middle and high school students in California. The initiative was launched last fall and provides behavioral health counseling services for students in Alameda and San Diego counties. The $300,000 will be divided into 18 different grants – nine each in Alameda and San Diego counties. These organizations were chosen because of their range of health interventions that include arts, sports, advocacy, music, leadership, multilingual/cultural, sexual and gender identity, and mental health tele-counseling.

Extra Point: There are some things you just don’t do. You don’t change the channel when Scooter calls the picket fence play in Hoosiers or when Andy Dufrane gets his fellow inmates beers on the roof of Shawshank Prison. You don’t pay with coins unless you’re Kramer buying a calzone or rolling through the Jersey Shore toll booth circa 1978. You don’t give your kids strawberry eclairs after 9 o’clock and if you’re at least 50, you don’t wear pants, you wear slacks.  You don’t discharge a senior with a heart condition, not without orders for a home health visit or let dad go to the cardiologist by himself, not when he’s got vertigo. You don’t get mad at mom for asking you what day it is for the seventh time in the last hour. You celebrate when she finally gets it right. You don’t do multiple procedures on the same day for the same patient and expect to be paid the same for each. You don’t take hospitals lightly or assume addiction can be cured in three years, much less three months. And on Father’s Day weekend, you don’t let the nursing home’s decision stand. You appeal to whomever you can to let dad out for a few hours to walk you down that aisle, even though he’s got Parkinson’s and even though he could contract the virus. It‘s your wedding after all, so you manage to find a way.

Interest in women’s health services is rising, but if you are a hospital, doctor group, or healthcare investor – or even if you are a parent or working woman - what are the trends, best opportunities, and potential risks?

In this special edition of Managed Care Friday, we offer a snapshot of recent trends and emerging considerations, including results from a hospital CEO poll and survey of over 1,500 adult women. Click to read more.

62: Percent of medical directors, out of 100, we polled who say they get pitched ‘all the time’ on value-based models or capitated payment concepts but often get rebuffed internally from the informatics or actuary team who ‘can’t figure out a way to code’ for the new model and handle all the claims. If there’s a lesson here, it’s that the medical director is important to get on board. You’ll need an ROI argument and a ‘time to ROI’, but ‘you’ll need to be prepared for pushback on how this can work administratively’.

Concierge Surgery Benefit: Employer Direct Healthcare of Texas, a healthcare services business providing solutions for self-funded employers and their members, is partnering with the small health plan Centerstone to offer its 4,300 members a concierge surgery benefit for more than 1,400 non-emergent procedures. Centerstone will waive all coinsurance and deductible obligations when the members elect to use a participating surgeon.

Rx Distribution Innovation: This week saw exciting technology advances - private company SpaceX successfully took men to space, and public company CVS Pharmacy teamed up with Nuro, a delivery robotics company, to test out medication deliveries using self-driving vehicles. The pilot will be limited to three different ZIP codes in Houston, and customers will be able to order their prescriptions, and other items, and have them delivered within three hours, for free. Earlier this year, CVS partnered with UPS Flight Forward in a pilot to deliver medications via drones to a retirement community in Florida.

Insurer Backs Multi Specialty Clinic: Most of the insurers who have opened their own centers, like BCBS of Texas, United, and Humana, have focused on primary care only or single specialties, like oncology. CDPHP, a health insurer based in New York, is working alongside four specialty medical practices, covering ENT/allergy, gastroenterology, cardiology, and renal to open a new multi-specialty medical center in upstate New York. The center will feature an on-site lab and pharmacy, along with a telemedicine hub. While each practice will remain independent, the goal is to create a unified patient experience that will utilize the latest technology when opened in spring 2021.

Senior Center Expands: Humana’s Partners in Primary Care unit is planning to open 20 new senior-focused primary care centers over the next year in Las Vegas and Louisiana, as well as expanding their current operations in Houston. Partners in Primary Care already operates 48 care centers across six states mostly in the southeast that treat about 35,000 MA members. The clinics’ goals are to make sure seniors are getting quality, low-cost preventive care in an outpatient setting.

Permanent Telehealth: Rhode Island is looking to make their COVID-19 telehealth policy changes permanent, with a bill headed to its Senate for a vote this past week. It would require payers to cover telehealth services, including audio-only phone calls, beyond the crisis. If signed into law, the bill will mandate that telehealth services by in-network providers “be reimbursed at rates not lower than the same services would have been had they been delivered in-person,” and it would require those services to “be subject to the same health insurer policies as in-person services, including medical necessity determinations and appeal rights.” Colorado lawmakers are also proposing a similar bill. Insurers are already taking steps to respond. Anthem of Virginia, for example, launched a virtual dental care program in partnership with The TeleDentists to offer consumers an alternative to ER or urgent care center visits, which can often cost between $400 and $1,000.

Flexibility During Virus: Aetna and Cigna have both decided to lengthen the period for which they will waive out-of-pocket costs related to the coronavirus, past the initial June 1 end date. Several regional plans, including Florida Blue, BCBSIL, and Regence are extending benefits around telehealth and prior authorizations. Cigna has a new pre-loaded debit card to help members pay for medical expenses, groceries, and child care.

Joint & Spine Site: For Regence Blue Cross members in the upper northwest, eviCore will begin reviewing spinal and joint surgery requests, starting this September, to determine if the proposed site-of-service is the right one. Some requests will likely be denied based on eviCore’s objective to shift procedures to outpatient settings. At this time, there are no plans to direct surgeries to a specific provider, but based on precedence, this is likely in the future.

Extra Point: One of my kids graduated high school on Wednesday night. This was a big moment for a kid who grew up in a war-torn refugee camp, who had a soldier once raid the bamboo hut she lived in. She and her sisters had to work hard to get here, to learn a new culture, a new healthcare system. She was due to play on the Thailand National Woman’s Soccer Team this summer but with the tournament cancelled, has turned to making money for college. On Wednesday, during a televised virtual graduation on the football field, a toddler streaked across the goal-line behind the podium. It was a light moment in what was a bit of a deflating ceremony. But the principal acknowledged the moment we are in. He talked about inclusion, racism, isolation. He also talked about hope, and just as he was reading our kid’s name at about 7:15 from the 20-yard line at the school’s grassy football field, she was starting the night shift at an Amazon warehouse.

42: Percent of people delaying healthcare appointments due to the pandemic, while just 16% delaying mental health appointments, a BCBS spokesman said, thanks largely to a system of virtual sessions that was already changing before the virus. A local solo therapist for teens in southern New England had hired 5 school psychologists in January for tele sessions, turning her caseload from 50 established to 200. On a national scale, Magellan saw a staggering 1,500% increase nationally in behavioral health telemedicine claims from February to early April this year while Talkspace volume is up 65%. The point: psych works virtually and patients like and trust the model.

Marriage Is What Brings Us Together...Today: Omada Health acquired the musculoskeletal and physical therapy company Physera last week, the latest in unusual but true healthcare unions. Unusual because this isn’t the traditional hospital or doctor’s group acquisition. Omada is a digital health company, offering a variety of services that range from diabetes prevention and management to mental health tools, and with the purchase of Physera, the company adds virtual PT services to its line-up. This collection is interesting in that it blends compatible services and providers who, in theory, should be coordinating care. Ask insurers what they think of virtual PT and you’ll get a tepid response at best. It’s one of the core outpatient services that we would expect to see limited impact on from telehealth.

Getting Attention: For those of you thinking about how to get managed care’s attention on value-based care in a way that makes sense for your business and doesn’t become just another cost of operations with limited upside, here’s a way to think about it: In 2005, a cancer care provider I interviewed in Michigan wasn’t getting reimbursed for daily phone calls it was making to patients to help keep them out of the hospital. It used the daily log and data from it to get a bump in its contracted rate and an annual bonus based on ER reduction. This was early telehealth in its truest form and was among the first value-based payment models. There was no consensus on measures beforehand, it was entrepreneurial and didn’t disrupt the insurer’s systems. In 2010, as opioid prescriptions were rising, a PT clinic in Connecticut trained its assistants and PTs to flag depression, addiction, and eating disorders as part of initial assessments, as well as a part of each of the first three visits. In about 10-20% of cases of chronic pain, the group was able to flag the root pain issue, contact the employer or PCP or both, and help create a new plan of care to treat the problem. That practice used its data to get a higher fee, not an incentive or a share of savings, but more for each visit because they showed they were doing more in an hour to save the system more later. But it can be difficult to get managed care’s attention these days, not just due to COVID-19, but with virtually every specialty and service trying to compete for value dollars. One concept to consider, and it’s by no means an easy one, is to think about your value on broader scale - not just ER savings or medication reduction, as most of the earlier models have focused on, but savings for the community that surrounds the patient. How is your service helping reduce costs for the patient and the caregiver or community? This study we started last year was the beginning of what we thought showed the next great epidemic - caregiver health decline. And while it reveals the cost of caring for sick patients, it is also partly a recipe for how to get managed care’s attention. Link here.

Remote Monitoring: In what is likely an escalating trend of integrated delivery networks adding nursing and remote monitoring to care for chronically ill and prevent admissions, Geisinger, in coordination with its health plan, launched a new mobile app to help those recovering from COVID-19 at home. Through Epic’s MyChart Care Companion, patients remain in contact with clinicians and report their symptoms, temperature, and oxygen levels. If there are any alarming findings, nurses can reach out immediately to patients and video calls with clinicians can be scheduled to determine if the patient needs to be moved to the hospital.

Tracing Virus: Employees at Medica, a non-profit health plan, will call patients with confirmed coronavirus as part of an effort to help the Minnesota Department of Health conduct contact tracing for the state. Over 200,000 Minnesotans have been tested, resulting in more than 20,000 positive cases and 881 deaths, as of May 25. Calls will run 45 minutes, with hopes of distinguishing any acquaintances or family members who may have been exposed to coronavirus through the patient. Blue Cross Blue Shield of Minnesota is also assisting.

Breaking Glass Ceiling: UnitedHealthcare has signed an agreement to bring online-only vision retailer GlassesUSA.com into its network, according to John Ryan, UHC’s vision manager. Members with employer-sponsored or individual vision plan coverage will have at most a $25 copay.

Re-Open for Business: For the latest on behavioral health re-openings, click here.

Extra Point: Ironically on the same day the space flight got delayed due to unpredictable weather, my 82-year-old mother in law went for a drive to Boston’s Logan Airport to pick up her 83-year-old brother who was flying in from the west coast. She left her condo before the pancakes were bubbling up in kitchens across America and by 6:30am, her brother was off the red-eye and in Ma’s car. They did what most 80-something siblings do during a global pandemic: they went to Kelly’s for a to-go order of fish ‘n chips, popped a squat on Revere Beach to feed the seagulls, then attended Father Dan’s 8 o’clock mass, where they prayed for doctors, nurses and, of course, the Red Sox. They returned home a tad after 3 o’clock and when we finally got through on the phone, Ma convinced us her brother was resting in the bedroom. She gave us the play-by-play of his cross-country voyage from Spokane to Boston, and hers from the North Shore to Terminal B. Now, if you know Uncle Mike, you might say that it’s not entirely strange that he’d fly across the country in the middle of a global pandemic. But of course, he did not do that. None of this actually happened, but Ma thought it had. This is dementia. And when coupled with anxiety and loneliness, it means eroding senses and disabling decision-making. In the days before, Ma visited grocery stores, had her tires rotated for $900, and bought an ice cream cone from the ice cream truck. So here I am on a Friday morning, on the way to bring Mom to us. My second attempt in as many weeks. She will invariably resist but has little choice. Like that weather pattern that forced NASA’s mission to delay, Ma can be a bit unpredictable and needs a safer, consistent environment. These caregiver challenges are happening nationwide, not just in my family, but in many of yours, and they will only become more pronounced as the virus continues, or if and when there is another wave in the winter. I would suspect that the demand for home healthcare workers during this next wave will rise, and businesses able to marry remote monitoring, symptom checks, and dementia management could thrive.

90: Percent of home health agencies reporting that their clients are canceling one or more visits because they are fearful of contracting COVID-19 or potentially bringing the virus into their homes, according to a Home Care Association of America survey. Many are delaying necessary medical care and even avoiding the ER for a day or two after a stroke or heart attack due to virus fear, which could lead to clinical deterioration and complications. One large home health and hospice company that usually provides care to 35,000 patients experienced 8,000 visit cancellations in the span of one week.

Ortho At Home: Anthem launched Ortho@Home on May 14th, a teledentistry and at-home orthodontia program. The service integrates with orthodontic network provider options and includes possible discounts of up to $200 off retail prices. Consumers with orthodontic benefits will have access to at-home clear aligner therapy, remote oversight of care, teeth whitening, and retainers at completion of treatment, with an average cost up to 60% less than traditional orthodontia. A spokesperson for Empire BCBS, an Anthem plan in New York, said the model makes access “more convenient while meeting demand for remote services.” A question to think through is around the longer-term implications on some aspects of clinic-based dentistry.

10,000 Maniacs: Over 10,000 specialists in BCBS of Michigan’s Physician Group Incentive Program started receiving at least one type of value-based payment this spring, in a program that will run through February 2021. Three forms of value-based reimbursement options are available for specialists, one focused on serving specific populations, one designed more around collaborative quality and a third, in pilot form, based on team model. Two more models will be added next year. Regence Blue in the Pacific Northwest, a pioneer of these designs, says at least 40% of its health plan member claims flow through 120 value-based arrangements with provider partners. Dr. Cheryl Pegus, Regence’s president of consumer health solutions and chief medical officer, remarks they are “continuing to prioritize collaborative arrangements with providers who embrace data-driven approaches to improving the quality, safety, and affordability of patient care.”

Part B Shakeup: Doctor on Demand is the first telehealth vendor to expand services to Medicare Part B beneficiaries, which total around 33M. Before the pandemic, telehealth use in Part B was heavily restricted to specific locations and circumstances, curtailing adoption of virtual care. This changed in March, when CMS declared Medicare would reimburse telehealth visits at parity and expanded telehealth availability to beneficiaries. Though it's the first big telemedicine player to move into Part B, it's unlikely to be the last, with provider MDLIVE also expressing interest in the space.

Raising Arizona: Blue Cross Blue Shield of Arizona announced they are acquiring Stealth Health Choice Arizona in an effort to provide health coverage and related services to Arizonans eligible for Medicaid and those who are dual-eligible for Medicare and Medicaid, which will include the Arizona Health Care Cost Containment System (AHCCCS) and the Generations Medicare Health Plan.

Center for COVID-19: Mounting evidence shows that the COVID-19 virus extends beyond respiratory symptoms to include multiple systemic complications that impact the brain, heart, kidneys, and other regions of the body. Mount Sinai Health System is launching a Center for Post COVID Care to offer additional support for patients who have been diagnosed with the disease, as well as to gather data from those patients as they transition from hospital to home. The center will provide comprehensive multispecialty care and systematic evaluation of the long-term impact of COVID-19.

On a Fortnite: Kaiser Permanente is partnering with professional e-sports organization Cloud9 to launch Presence of Mind, an educational initiative for the online gaming community. Content will be on Twitch, a global video gaming platform known for the Fortnite phenomenon. Cloud9 players and staff will get mental health training with the idea of encouraging teens and young adults to prioritize their well-being.

Extra Point: My kids complain a lot about how I go down the ‘when I grew up’ road way too often. It’s just so easy sometimes. Helps me make a point, like my latest rant: When I grew up, we ate supper together on Sundays. At 2 o’clock. Not because we were hungry, or it was raining, but because grandma said so. Afterwards, we played kickball ‘til dark. We didn’t have hover boards or Fortnite or Twittergrams or Snapbook. When we fell on the driveway during a game of ‘Red Rover’, mom didn’t rush us to urgent care. There was no urgent care. She layered on three Band Aides and gave you a slice of warmed up apple pie. We didn’t have depression—at least not in the way it’s understood today. Yes, we were sad when the Yankees and Sox were in a rain delay, but dad cheered us up by putting the Polka on the record player and throwing us on his shoulders. We danced. We had a simple life with at most three principles, and I’m pretty sure two of them had something to do with mashed potatoes. We didn’t text or Jabber or FaceTime, we stood by an answering machine hooked up to the rotary dial, replaying Sam’s message because you couldn’t hear the phone number the first dozen times. ‘Download’ was not a word. To hear Survivor’s You Can’t Hold Back, we had to rewind Side B for six seconds, then flip the cassette at least a half dozen times to get to Side A to just the right time. When we were bored, we picked up a shovel and dug a hole, found some worms and put them under my sister’s pillow. Our friends were mostly the seven people we shared the upstairs bathroom with. The same seven we fought with for the Raisin Bran. We wrestled with grandma, played ‘setback’ with papa, and listened to Joe Castiglione call the game on the AM dial. On a good day, I would hold the bunny ears on the RCA, so we could watch the game on TV. What strikes me about then is how strikingly familiar it is to now. Last weekend, I asked Tommy to lean the phone against the wheelbarrow when we weeded the driveway. We listened to a replay of the inning Fisk hit that homerun. We ate spaghetti around two and then played Twister, until the dog peed on the green circle. What’s past is prologue. I would argue that, for some of us lucky enough to be safe and healthy, we aren’t standing still at all as it may seem. We are going back, and there’s some good to come from that...

8 is Not Enough: An 8% reduction in chronic care condition downstream costs from frequent exercise among commercially insured has health plans seeing the potential of movement and many are creating new CEOs. Blue plan executives we chatted with this week say they are appointing chief exercise officers who will head up a range of initiatives following results of the new national study. Ideas floated in our poll: exercise breaks at a set time each day led by mix of celebrity instructors like Glee’s Sue Sylvester or using supplemental benefit Star bonus dollars for Medicare enrollees to build at home and small community aerobic classes. In most cases, a capitated PMPM system would be used to bring in vendors to help run the program.

Gene Therapy Expanded: Cigna has recently widened its gene therapy program. The program covers two gene therapies at no cost to patients for the medications. Employers and unions would pay a PMPM fee to access Cigna’s network but would first have to submit pre-authorizations. Steve Miller, MD, Cigna’s Chief Medical Officer, hopes PMPM will reach $1. Originally, Express Scripts and eviCore were helping Cigna with the program and now they have also brought Accredo, their new specialty pharmacy partner, into the operations.

Denial Tracker: We chatted with a member of Cigna’s coding and coverage team recently and heard of four updates taking effect this spring: They will no longer cover the inflammatory pre-filled Stelara syringes under the medical benefit. It will only be covered through pharmacy, but the vial will continue to be covered under medical. Secondly, tests used to measure drug concentration to treat conditions like irritable bowel syndrome are getting attention. Cigna will deny serum drug level tests when billed with an IBD diagnosis. Third, starting this spring, Cigna will rebundle CPT codes used into a single panel code for individual genetic tests that compose a molecular cancer lab panel. Lastly, Cigna has found that several OON ambulance companies are billing EKGs, oxygen and drugs separately at times. Cigna will deny these if billed separately by non-participating providers.

Filled Up Psych: Baton Route Medical Center in Louisiana has opened a special unit for coronavirus patients needing psychiatric stabilization. Ten of the unit’s 32 beds filled up quickly this week.

San Francisco Treatment: The city’s health department is collaborating with licensed physicians to distribute “limited quantities” of alcohol, marijuana, and tobacco through private funding to addicts in quarantine under the city’s program for housing homeless people in hotels. The idea is to increase the number of homeless people staying in hotels and limit hospital care for life threatening alcohol withdrawal. The model is a “harm-reduction technique,” estimated to help 700 people living on the streets.

Free Ride: Cost share is waived through September at least for United Healthcare’s Medicare members when seeing primary and specialty physicians.

Advanced Pay: InnovaCare Health, a value-based healthcare service company, will fully compensate PCPs in Florida and Puerto Rico for April and May, along with specialists, dentists, hospitals, and hospitalists to help with the financial loss from reduced patient volumes. Hospitals are receiving payments based upon average monthly billings while hospitalists are receiving full payment based on their contractual agreements.

Rural State Changes Course: Wyoming is the nation’s least populated and second most sparsely populated state, which makes one think telehealth would be a great option. But Dr. Lisa Finkelstein, who heads the telehealth program at St. John’s Medical Center in Jackson, Wyoming, says “there was very little buy-in for telehealth - there wasn’t any interest in trying it.” But that’s changed since COVID-19. Wyoming’s Telehealth Network had almost 1,900 providers join the network in March, compared to a couple dozen per month previously. Wyoming’s Medicaid program, as well as BCBS, have encouraged telehealth and expanded their policies and Dr. Finkelstein said she is prepared to lobby to keep these new policies in place, long after the pandemic ends.

Virus Treatment: Pharmaceutical company Acer Therapeutics has entered into an agreement with the National Center for Advancing Translational Sciences to develop emetine hydrochloride as a potential treatment for patients with COVID-19. Clinical trials are targeted to begin this year.

Mood Monitor: A new University of Oxford study of nearly 60,000 people suggests mood improvement is highly culture specific: exercise led to the highest increase of mood in a high-income country, religion did so in low and middle-income countries.

Trained Therapist: Blue Cross Blue Shield of Michigan is launching new telehealth programs with behavioral health providers, so its members can participate in group sessions to discuss the impact of COVID-19 on their mental health and share their experiences with others under the supervision of a trained therapist. The programs are available for free to members with Blue Cross and Blue Care Network behavioral health coverage through June 30.

Extra Point: When my 47-year-old sister gave my son $20 for losing a tooth a couple years ago, Tommy did what any 10-year-old would – he found his brother, ate a bag full of skittles, tied a string to the doorknob, the other end to his back molar and had his brother slam the door shut. He suddenly had $60. I told him “that covers all your teeth for the rest of your life.” It’s a lifetime cap, a per member per year. No more $1 per tooth, kiddo. Like any kid, he didn’t think through the costs. He bizarrely developed pain from one of the pulls, let it fester, and got an infection. He had to go to the dentist and miss the neighborhood kickball game. In Tom’s defense, he took risk, but it backfired. Dentistry risk-taking has been slow to develop but the coronavirus is initiating new models that may accelerate the trend. The TeleDentists company is now partnered with Anthem to do virtual checks for patients. The impact on clinic-based dentistry is probably limited post-COVID-19 but I would not be surprised to see Anthem and other insurers using these virtual dentist companies to steer patients to their favored practices. I haven’t verified if they are taking any risk per se, but I assume there’s a per encounter payment and maybe some incentives for steering kids, like Tommy, from going to the ER—or from pulling their own teeth.

94: Percentage decline in screening appointments for breast cancer in March this year, compared to the last few years, according to data pulled by Epic. Komodo Health, which analyzed the billing records of 320 million patients across the country, found that screening for cervical cancer was down 68% from March 19 to April 20, compared to the previous 11 weeks and a comparable period last year. Tests for cholesterol, diabetes, and active and recurrent cancers were down, too, with the sharpest declines in geographic areas like New York and Massachusetts.

Hard to See Bruising is Cancer Problem: “Leukemia symptoms, like bruising, don’t always show up, so with in-person primary care visits down there have been fewer physicals, which means fewer CBCs ordered, reducing the likelihood that a physician could catch an abnormal blood count.” This is from Susan Buchanan, an adult leukemia assistant at Dana Farber Cancer Institute, but while it sounds like it could be the result of COVID-19, it’s not. I did the interview back in 2009, during the economic downturn that delayed care and drove up the number of Medicaid patients due to unemployment. At that time, Buchanan said they saw more complex cases for rare leukemia and bone marrow transplants, which was due more to commercial payer policies to encourage physicians to refer these types of cases to institutions with expertise, like Dana Farber. This trend helped offset the dip on less complex cases, but it came as cancer patient outcomes deteriorated for a time. About 40% of patients with myelodysplastic syndrome, for instance, convert to full-blown leukemia, and many of them were diagnosed too late.

Patients Love It, Doctors Don’t: If you guessed telemedicine, you’re right. Elderly patients with chronic illnesses across Pennsylvania have started seeing their doctors via telemedicine and they’re finding it easier and faster; instead of a 3-hour round trip, they just head to the living room for instant care. But doctors are worried their patients aren’t getting the full care they need. Ravi Ramani, the Director of UPMC’s heart failure program, said, “The biggest thing I rely on is the eyeball test. Just being able to see them, how they are sitting in their armchairs, how their skin color looks — those things are critical.” Patients and doctors will need to work together post-COVID-19 to decide what’s best for both of them.

Multi-Specialty Mindset Shift: At first it sounded more like a bad, albeit G-rated, joke your Uncle Joe would tell you at the Memorial Day barbeque, but it’s not that farfetched: a physical therapist, psychologist, orthopedist, social worker, and a former gym teacher-turned-exercise physiologist walk into a Zoom room. Seems inevitable, at least after we did a Zoom call with these practitioners this week. Several are linking up to create a new kind of multi-specialty service that blends in telehealth, remote monitoring, and home visits (when they can happen safely again) in a platform to serve seniors, MA plans, addiction treatment companies, employers, and schools. Diverse and ambitious, to be sure, but the offering is interesting because it hones in on one thing: pain.

Here’s the Skinny: One area of definite savings to monitor in the year after the pandemic settles, according to our own poll of payers, will be dermatology. One payer says they think they can use benefit design and network changes to shift up to 40% from office to tele and cut the cost of evaluation 25% or more. Seems ambitious, but there were signs before this year that some plans would try to move in this direction. Broadly, 52% say they will evaluate whether to keep paying telehealth at office levels while close to 20% will resort to pre-COVID-19 policies across services, usually paying less for tele; others say rates will vary based on location and provider type - as some may ‘be capitated’ if doing utilization management and evaluations.

EMR Gaps: 70% of home health and hospice organizations have experienced an increase in the number of referral sources requesting referral data to be sent electronically over the past two years, but many agencies aren’t equipped. 36% still use fax machines to obtain referrals, and another 20% rely on phone calls, according to a Brightree report. COVID-19 is only making the handoff worse, with patients coming in and out of hospitals more quickly and hospital systems overwhelmed with COVID-19 challenges every day.

Extra Point: All of you clamoring to watch or play sports with someone other than your teenager or spouse or seven-year-old, here’s some modest hope and a few healthcare warnings. 1) The NBA is considering re-starting its season with a made-for-TV game. Players would quarantine at an arena for two weeks, then play. If it happens, and I bet it won’t, don’t expect any defense. Players will probably be six feet  apart, which I suppose wasn’t all that different from before. Steph Curry should have a field day. 2) Be careful: gambling addiction specialists are expecting a wave of cases as the recently unemployed try their hand at predicting how many steals Lebron will get. One therapist tells us she’s "busier than ever” with “mostly 40-something males” betting on things like British darts. 3) Insurers will cover gambling addiction treatment but will be tough on medical necessity and the COVID-19 trend likely accelerates telepsych as the preferred model. If Kenny Rogers could read this now. 4) Playing any sort of sport with your spouse is not advisable. Better to keep it friendly as I’ve learned in my 20 years, and if you must compete, avoid playing on the same team. 5) Golf is ahead of things but a cautionary tale. “Lefty” Phil Mickelson and Tiger Woods will likely play a live match on TV this month. Many weekend hackers are already out on the links in states allowing it but worries about virus spread are overblown, in my opinion. Golfers often keep their distance unintentionally so as not to get hit by a shank. My dad usually hooks his tee shots left into the woods while my Uncle Hank slices right into the water. Many times, they just give up before getting to the green. “See you on the next tee”, they’ll say. 6) Tennis should see more play than it currently is, as long as people wear gloves. I’ve already dusted off my Stan Smiths to rally with my 12-year old in the driveway. To prepare, I made him watch Luke Wilson’s epic shutdown as tennis legend Richie Tenenbaum in the Royal Tenenbaums. The “Baum” committed 72 unforced errors on the way to losing every game to Gandhi. “Why in the world did you show me that dad?” I told him it’s a good lesson on the perils of distraction. In tennis, like life, “only the ball,” I said. Tommy could sure use some help focusing these days. Please pray for him. He has to write four sentences by next Wednesday.