Behavioral Health Insights

Overachiever: So, what happens when the healthcare system starts having unparalleled success in value-based arrangements? What, for example, do insurers think will happen to the target baseline on which a physician is measured, and will insurers share more savings or less? Thoughts here from our poll.

Revenue Short: There’s been a little reported issue between reimbursement for Medicare Advantage patients vs. fee-for-service Medicare. While traditional Medicare has allowed providers the discretion to waive cost share during this pandemic, that will come out of the provider’s books as uncollected revenue. In contrast, some, if not most, MA payers have waived copays for newly expanded telehealth visits, and MA payers are increasing their payments to providers to compensate them for the copays that are not being collected, essentially “making them whole”. We’ve found from dozens of providers we’ve talked to that MA plans are generally “making them whole” by paying the rate for the service, then providing the waived copay portion of the service through a second “remit” a few weeks later. But fee-for-service Medicare “is not making us whole,” sources say. “We basically are trying to collect the copay, but if the patient says they can’t afford, we just waive – it’s not a big deal with MA, but if it’s a fee-for-service patient, that’s been 20% less revenue,” one administrator said.

77: Percent of employers in our February poll of 219 small, midsize, and large companies who say the time to diagnosis for pain and orthopedic issues is “excruciatingly slow” and “wasteful,” and has led to issues with “presenteeism, productivity” and ultimately higher health cost spend per employee. “Not just lower back pain, but neck pain, knee pain, upper back, elbow – we have been pressing in recent years to use PT first for several weeks but sometimes an X-ray is needed right away to rule out issues,” says Dave Simmons, a medical director consultant for self-insured employers.

Oh, the Worried Well: If there’s one delivery model set to face some turbulence between now and 2025, it may just be urgent care. Click here to read why and how.

Caregiver Decline: Caregivers were already reporting mental stress and physical health declines before the pandemic and now it’s escalating, according to sources. Back in the Fall, 91% of those caring for a senior family member with a condition like dementia, Alzheimer’s, or cancer reported mental stress, 75% reported depression, and 27% said they had gained weight. Brigid Byrne, who cares for her 90-year-old mother who has cancer, along with her grandson, says there’s “lots of stress and worries, but lots of laughter.” There may be limited support from health providers or insurers but there are local and national networks online to support caregivers, like the Caregiver Action Network. Others say they have grandparents who have deteriorated when left to care for themselves, particularly when their spouses can’t help them, or they move out to assisted living or nursing facilities. “He’s absent a lot even when he’s in front of you...a lack of physical activity is a problem,” one research participant tells us about his 88-year-old grandfather. Using iPads and other technology is “nice to have” but doesn’t solve depression or mental health, and in some cases these things can exacerbate it. For the healthcare community, solutions are difficult because they require consistent attention, one-on-one services, commitment, and perhaps new payment strategies from insurers. More here.

Top 10 Innovations: New technology is emerging in every industry but healthcare, in particular, is booming these days with new apps, robots, and telehealth initiatives designed to revolutionize diagnosis and treatment. In this piece we published back in early February, several themes resonate even more now given the pandemic. Check out the Top 10 here.

Glidepath to Risk: In case you missed, just because there’s a pandemic doesn’t mean risk contracting has stopped, interestingly, as we’re hearing more payers and providers continuing to explore risk contracts. And why not? With the downtick in visit volume, it’s not a bad time to be getting capitated payments if you’re a provider. In discussions we’ve had this week, several suggested that they are finding some success with upside only arrangements, essentially an FFS payment or flat cap with a “glidepath” to risk, which is basically a way to limit exposure as the practice learns how to manage operations–and patients–in a new payment model. One idea is to set up the contract as FFS or flat primary care capitation and agree to share in the surplus or savings, typically 50%, but at 0% exposure to deficits. Then, as several noted, you move to a full global risk capitated payment the following year, like in 2021 as some have done. “This gives us time to acclimate, to code up patients who should be coded higher based on acuity, to get the premium to the appropriate level,” one payer contracting director noted. Most sophisticated MA payers are typically on board with glidepaths, as they do not want to see a provider group rack up deficits during the learning curve.  Other providers tell us they have had some success convincing the insurer to agree to an “early switch to cap or risk” before 2021, if they are finding success. “One MA plan was a little unsure but agreed to changing to full risk earlier than the 12-month glidepath if we are doing really well.” This “early flip” language allows the practice to stop giving away the 50% surplus back to the payer when they could be gaining the whole surplus, though it will have to prove it is meeting “minimum thresholds” of attributed members.

Extra Point: ER doctor Lorna Breen saved hundreds of lives recently but the tragedy around her at a New York hospital was too consuming. Last weekend, a few weeks after getting the virus, trying to return to work but devastated she couldn’t, she took her life. She is still a hero in my book. Breen’s end is not her story. It is that age-old story of striving to put others first – and sadly in this case, succumbing to an overwhelming feeling of helplessness. Erin Golden is also familiar with putting others first. She’s a cancer survivor two-times over, battled addiction, surgeries, raised a son, and has been trying to re-start, but has spent the last two months coordinating health and wellness care for her older parents. She is us. Golden’s 86-year-old dad was in the hospital for a week with presumptive coronavirus, had a fever and pneumonia, “so we expected the worst,” she told me. Test results were negative but two weeks after quarantine at home, Erin’s mom got a fever, went to urgent care and the staff there said, “we don’t know why you have a fever.” There was no test available.  Golden admits she’s lucky and has been doing what many of us are trying: setting up a healthcare support system and network at home for our folks. We bring my 82-year-old mother-in-law into our home this week. With severe dementia, she’s a flight risk, but in a silver lining the virus will give our kids time with nana they wouldn’t have.

21: Percent spike in the number of prescriptions filled per week for antidepressant, anti-anxiety, and anti-insomnia medications between February 16 and March 15, according to an Express Scripts report. Sales peaked the week ending March 15, when COVID-19 was declared a pandemic. Anti-anxiety medication use rose the most, at +34.1%.

Glidepath to Risk: Just because there’s a pandemic doesn’t mean risk contracting has stopped, interestingly, as we’re hearing more payers and providers continuing to explore risk contracts. And why not? With the downtick in visit volume, it’s not a bad time to be getting capitated payments if you’re a provider. In discussions we’ve had this week, several suggested that they are finding some success with upside only arrangements, essentially a FFS payment or flat cap with a ‘glidepath’ to risk, which is basically a way to limit exposure as the practice learns how to manage operations—and patients—in a new payment model. One idea is to set up the contract as FFS or flat primary care capitation and agree to share in the surplus or savings, typically 50%, but at 0% exposure to deficits. Then, as several noted, you move to a full global risk capitated payment the following year, like 2021 as some have done. “This gives us time to acclimate, to code up patients who should be coded higher based on acuity, to get the premium to the appropriate level,” one payer-contracting director noted. Most sophisticated MA payers are typically on board with glidepaths, as they do not want to see a provider group rack up deficits during the learning curve.  Other providers tell us they have had some success convincing the insurer to agree to an ‘early switch to cap or risk’ before 2021, if they are finding success. “One MA plan was a little unsure but agreed to change to full risk earlier than the 12-month glidepath if we are doing really well.” This ‘early flip’ language allows the practice to stop giving away the 50% surplus back to the payer when they could be gaining the whole surplus, though it will have to prove it is meeting “minimum thresholds” of attributed members.

Paneling Wall: As we noted last week, recruiting solo practitioners is getting easier due to the impact of the pandemic but enrolling them into managed care networks is getting harder. Licensing has been waived in some states but “it still takes us 3-4 months to get a clinician paneled in a specific region,” according to some behavioral health providers. One company, Inovatel, says they are finding that smaller psych professionals are now looking for a new home, given the pandemic, but they can’t bill the insurer yet.

College Blues: 41% of families, up from 28% last week, say they likely need to either transfer their students to a lower cost community college or smaller school, or forgo planned medical or nursing school, due to changes in job status or income. Our poll has reached 667 parents to date. There has been little discussion to date on the impact of COVID-19 on nursing and medical school enrollment and on the quality of education. In Oklahoma, the Governor changed regulations to allow e-learning at home, to avoid having large groups of students in hospitals, but how valuable this online education is for nurses is an open question.

Isolation Solution: The link between social isolation and loneliness among older adults and health risks has been known for some time, and concerns are growing that lengthening periods of social separation, resulting from the coronavirus pandemic, could exacerbate these risks. Vivek Murthy, MD, former US Surgeon General, who spoke at the first virtual Yale Healthcare conference on April 17, said “if we don’t shift how we see our social connections” then physical outcomes will decline. “Loneliness is strongly associated with heart disease, dementia, depression, sleep disorders, and longevity as a whole.” Health plans are working on ways to connect with their members to help address some of these potential repercussions. Cigna, for example, is piloting a program to reach out to Medicare customers over the phone to assess their general health and see if they need any help with food, housing, or transportation. Members can request to receive follow-up calls from the same Cigna representative to “help cultivate meaningful connections”. Cigna is also identifying high risk MA customers to help answer questions about COVID-19, conduct health checks, and connect them to a medical professional, if necessary. The pilot program will reach 24,000 customers, with plans for expansion.

Urgent Care’s Latest Delivery Model: Back in 2019 we wrote about a new urgent care mental health crisis center for the uninsured in Tennessee that was overrun with commercially insured in its first few weeks (story here). Other markets are opening similar models and it will be interesting to see which patient populations show up. In Bozeman, Montana, a new behavioral health urgent care center opened recently, in response to COVID-19, as a way to reduce hospital ER volume. Bozeman Health partnered with Western Montana Mental Health Center.

Tele Expansion: Mount Sinai Health System is launching a personalized telehealth platform for nurses, which will contain the latest information on COVID-19 treatment and protocols. The platform, Project Florence, was developed with Sana Labs and will be available on any web-enabled mobile device and has an AI tool that will measure nurses’ knowledge and recommend content to fill in gaps. Centene, meanwhile, is providing grants and gift cards, to be used for essential items like OTC medications, and piloting programs in Arkansas, Kansas, Georgia, and Mississippi to help accelerate the rollout of telehealth to remote areas. It is using FirstNet, a nationwide wireless broadband service.

Extra Point: Like many of you, I’m a history buff, and at about 7 o’clock last night I was somehow corralled into writing a research paper for my 16-year-old about the media’s influence during the Vietnam War. I found myself googling, paraphrasing, teaching, then structuring and rewriting. With no formal classes, Jack needed guidance. I was Johnny Rose from Schitt’s Creek trying to fine tune his daughter’s C- into an A. I immersed myself in Cronkite’s famous 1968 telecast, helping Jack create a thesis around the power of the media to investigate and tell the truth. This is what I learned in journalism school and here we were at half-past-midnight, trying to summarize history. I changed sentences just as Jack updated footnotes. “The document is moving, Jack, my cursor is missing, for cryin’ out loud what in the world is happening,” I remember saying. “It’s called Google docs, dad – we can work together at the same time…you’ll be okay….” We titled it, “The Rise of Cronkite: How the Media Icon Changed American Views of the Vietnam War.” I sat up today thinking about the paper, wondering if there will be a Cronkite moment still to come during this pandemic. I thought about influence and wondered who today’s Cronkite will be. I can’t really think of any one influencer in this moment more important during this pandemic, more influential, than nurses. They are helping families FaceTime with mom from the hospital bed or say goodbye to dad. They are taking shifts in ICUs and ERs. They are coming out of retirement. They are our humanity right now, helping people feel safer in uncertain times. And just as I wonder if Jack will help his own kid in 45 years to write about this crisis, I wonder if today’s nurses will inspire future generations, as Cronkite has. If they’ll influence my own daughter to take her voice bedside, to help people feel less alone, just like she does here with a bit of laughter and a lot of love.

28: Percent of families in a quick poll we did with parents of students in college or medical school who say they will likely need to either transfer their students to a lower-cost community college or forgo continuing medical school, due to changes in job income.

Underappreciated Pediatric Risks: Pediatric practices are having to revise their usual procedures during the pandemic but are having difficulties doing so. In California, Berkeley Pediatrics has split its office into two parts, a separate back entrance that leads upstairs for healthy patients and the downstairs area for sick patient visits. The practice sees about 40 patients daily right now, down from 100 pre-COVID-19. They are using telehealth extensively, but many of their patients need to be seen in-person in order to receive recommended vaccinations, and telehealth has led to a probable over-prescribing of antibiotics for suspected strep and ear infections, or prednisone for rashes that can’t be confirmed with lab work over a virtual visit. The group’s doctors worry about long-term health risks for their young patients who are not getting the care they normally would.

The More Things Change: Leo Distefano, MD, runs a small pediatric practice in Connecticut that has had to adjust, like so many, in recent years to urgent care competition and now a pandemic, but Dr. Leo takes a page out of Dr. Baker’s book from time to time. This past weekend, a young girl dislocated her elbow and called the practice - it was an emergency, but they did not want to go to the hospital, so Dr. Leo told them to meet at the office, where he fixed the kid’s arm.

Phase Two Payer Strategy: Insurers seem to be moving from policy to partnership as COVID-19 continues. In Oklahoma, the Blue plan has partnered with DispatchHealth to deploy medical mobile units that can deliver in-home care, while Centene has partnered with Feeding America’s network of food banks. In Arkansas, the Blue plan says it will now allow telehealth through May 15 for PT, OT, and speech therapy, but there is no waiver for cost-share. The tele PT coverage trend is interesting, as there has been historic reluctance to cover these visits and for payers to contract with tele PT companies. “Tele PT is just not the same, much harder to get the patient to comply,” according to my cousin, Mark, who heads up PT at UConn. Insurers I have talked to say the tele check-in has some value for training and follow-up but that “it would be a mistake” to expand tele PT in any meaningful way after the virus departs.

Hitting Pause on Auditing: Providers of outsourced services to health plans may see a temporary shift in need for their products as health plans pause some auditing and utilization management requirements to make it easier for providers to focus on access to care. For pharmacies, Humana will not initiate new desktop and onsite audits and will suspend any in-progress audits until at least April 30, 2020, except for those requested by CMS or initiated due to fraud, waste, and abuse concerns. For medical providers, Humana has paused pre- and post-paid claims review, as of April 1. However, claims submitted during this time period may be subject to reviews at later dates.

Cross Country Triage: On April 14, Intermountain Healthcare, a health system based in Salt Lake City, deployed a team of physicians, NPs, PAs, and respiratory therapists to fill in at New York Presbyterian and Northwell Health, hospitals with severe staffing shortages. Hospital systems across the country can now also submit data daily around ICU bed and ventilator supply and utilization, COVID-19 test results, and total number of healthy patients discharged to a platform created by HCA and Google Cloud.

In Case You Missed: Our Behavioral Health panel featured addiction medicine specialist Nzinga Harrison, MD, former YMCA Volunteer of the Year, who is now running an addiction recovery company taking risk for relapse in the Southeast. Their model and why it’s working during the pandemic, featured here.

Extra Point: Many of us have family on the frontline, serving in any way they can. My cousin, Erin, raises three kids at home but is needed overtime right now as a nurse at Women & Infants Hospital in Rhode Island. My cousin, Mark, heads up PT at UConn’s Musculoskeletal Institute, where elective surgeries are down but research and clinic visits for emergent needs continue. My dad, retired head athletic trainer and sports medicine director at the University of Hartford for three decades has offered, even at age 75, to lend a hand with PT consults over the phone. Our cousin, Chris, already served two tours but is still willing to help at a military hospital. And Jack, our 16-year-old, plays this every night around 8 o’clock, his trombone pointing out to the sky, the song his way to remember the fallen and with any luck, help heal the sick (click here).

50: The percent of alcohol sales growth across the country that addiction recovery provider, Eleanor Health, has noted since the virus started. “People are using more substances to cope,” Nzinga Harrison, MD, Chief Medical Officer, reported live on our behavioral health forum April 3rd. “We know this is a high stress time.” Harrison said that the company’s value-based structure has been helpful to stay in touch with patients and continue providing services. If you missed, reach out for a recording.

Sepsis Implications: An untreated UTI can lead to sepsis, and a family doctor running a small solo practice with three allied health colleagues in Georgia’s upper northwest corner says they’ve already had one patient from their small community be admitted to the nearby Polk Medical Center for this reason. “UTIs normally get treated, but people are staying home, running fevers, or getting aches and pains or chills, and it could be a UTI,” says Susan Sumner, MD, a family doctor at Cave Spring Medical Center. Sumner says she’s struggling to educate patients about when to come in. “We’re looking at far worse problems, due to the infections, if these UTIs aren’t treated,” Dr. Sumner says.

Advance Pay for Docs: More commercial insurers are contemplating advance payments to help their providers. Blue Cross of Michigan is accelerating payments to more than 20,000 primary care and specialist doctors across the state who are part of its Physician Group Incentive Program (PGIP). The PGIP program has a set amount of funding for each year that physician organizations can earn through performance, and this year, Blue Michigan is advancing funds that would have been spent later in 2020 to give PGIP-affiliated physician organizations the immediate financial means to purchase equipment needed to test and treat patients, and to pay physicians for the care they’re providing through telehealth. Other insurers are creating similar local programs, like Blue Idaho, who is providing payments to independent practices, and Blue Shield of California.

Two is Better Than One: Lou Costello would not be “On First” without Bud Abbott, while Patrick McEnroe was way better at doubles, and far funnier as a commentator, when his brother was beside him. Ringo, well - he wasn’t a star until The Beatles. And so, does it surprise anyone that in a broad poll we did of more than 11,000 physicians and therapists from small or solo practices, 58% said the virus has made them rethink the idea of joining a larger practice?

Autism’s New Model: Parents with children on the spectrum are finding themselves thrust into at-home applied behavioral analysis and learning “to be a therapist” on the fly, like Sam Francis, one dad we talked to last week who says he was “up all night” taking a training course to help his 9-year-old son who “used to go to the center 25 hours a week.” “Long-term, the gates have been opened for tele ABA,” according to James Craig, an LCSW and former VP of Clinical Autism Services at Beacon Health Options. Craig, who spoke on our behavioral health call April 3rd, said this means both direct-to-patient clinical services as well as parent training. Studies show that tele ABA can be just as effective as in-person care, even though use of it was limited before the crisis. This should change, and this is a good development, Craig said, especially after health plans have time to study what is, and is not, working. For clinic-based ABA, this likely further accelerates the importance of diversifying services and may accelerate discussions about the appropriate level of reimbursement and payment structure, as more care shifts to a home, community, and tele model, rather than center plus home.

Post Pandemic: In a bit of depressing but not-that-surprising validation of trends already unfolding, 68% of 13,209 readers polled last week said that increasing incidence of alcohol addiction is the most likely result of the pandemic, based on a list of eight options. Divorce or separation was the second most likely scenario, according to 15%. In fact, a marital therapist we spoke with said her caseload has doubled. Colleges waiving SAT requirements was the third most likely scenario, which may benefit all those class presidents with 2.9 GPAs. Several colleges, like the University of Oregon, have already said SATs are optional, since juniors haven’t gotten a chance to take them yet. Only 8% said we’d “go back to normal,” while 23% said PTSD likely surges, limiting participation in things like public transportation, youth sports gatherings, or Uber sharing, although 40% said the isolation now likely spurs more interaction than ever after the pandemic lifts, and “actually starts to limit use of technology” among youth and adults.

Oral Health Tele Option: BCBS of Kansas sent out an email saying that their expanded telehealth reimbursement policies include dental services, at least those that are “medically reasonable to be provided via telehealth.” There will be no cost to members for these audio-visual dental services for the foreseeable future. BCBS of Florida is reimbursing virtual dental care visits at no cost to patients through June 30, 2020.

Staffing Care Contrast: Vanderbilt University Medical Center is seeking to add temporary nurses to its clinical workforce, in order to battle COVID-19, just as Williamson Medical Center, 20 miles south in Franklin, TN, says it’s furloughing over 200 of their 1,250 employees, due to a significant reduction in volume for patient visits and procedures. Vanderbilt’s center has already had 78 employees test positive for the virus and has administered nearly half of all tests in Tennessee.

Around the Horn: Allergist Kristin Sokol in Rockville, Maryland says a lot of patients are telling her through her Doxy.me app that they think they have coronavirus, but she thinks it’s more likely an allergy symptom. Deciphering isn’t easy. Sokol’s practice looks up records from the prior year to check if the patients are having similar symptoms. ChenMed, which provides services to a large population of chronically-ill Medicare patients, has been dropping off iPads to patients who lack virtual capability to try and engage, while RWJBarnabas Health in New Jersey is doing robocalls to educate patients about both the virus and related symptoms.

Extra Point: So, hearing Dr. Sumner in this week’s edition talk about the challenges associated with deciphering between coronavirus symptoms and symptoms for other things, like allergies or UTIs, is really important. My bride wonders if “dummy” is a symptom too. I suppose she’s probably referring to the ivy-looking plant garden I wrestled last weekend because I was running out of things to hammer. Now I feel like I have more ivy on me than a Wrigley field, which prompted Janine to Google “rash, itchy, and coronavirus.” I suppose I can’t blame her, but there are only so many ways that I can get out energy these days. At least our kids are finding safer ways to manage my activities. Like here, they successfully dashed my hopes of a second career dancing on Jennifer Lopez’s next world tour.

Allergy Pop: A biologist from New Mexico has created a special lollipop to help with allergies, which is probably well-timed as we head into allergy season and a prolonged pandemic. The biologist was selling the pops out of a strip mall in Santa Fe, but in a bit of kismet, started selling them through Amazon in early February. The biologist, Cliff Han, claims they sort of help turn off the immune system that makes you sneeze or cough. The AllerPops are made with sugars and amino acids to promote good bacteria, but they have not been evaluated by the FDA nor do allergists necessarily buy-in. Two of three we reached this week are skeptical. “I’ve seen these and while I have no reason to doubt them, they aren’t proven on a wide scale,” Micela Swarthmore, MD, says.

Capitation Dehydration Risk: Primary care practices taking risk for medical costs under capitated or value-based payment arrangements for Medicare seniors and chronically ill patients are facing a likely surge in costs. One physician in Georgia said at least a dozen patients “in my panel” got so dehydrated during the coronavirus isolation they needed to be hospitalized. In four of the cases, the elderly broke a hip or shoulder while falling, while three others were so dehydrated and malnourished, they are still in the hospital after nine days due to a dangerously low heart rate. Peg O’Neill, a hospital ER nurse, told us that severe dementia or cognitive impairment is common in most of the patients.

Advance Pay for Indie Docs: Blue Idaho confirmed this week that they will provide advance payments to help independent physicians. A few other smaller Blues in states with a large rural population are “contemplating,” but say this is unlikely, at least on a wide scale. “Perhaps on a one-off basis with certain providers or smaller independents,” one source said, though he asked not to be named. BCBS of Idaho says it’s an opt-in offer and then they’ll recover the interest-free payments during the fourth quarter of 2020.

Work Comp Switch: North Dakota is extending workers' compensation benefits to healthcare providers and first responders who contract COVID-19 while on the job. These workers make up 10% of the state's population, and previously, these benefits did not cover lost income or medical bills due to viral infections.

May vs. Never-Ending: In a straw poll of insurers, we are hearing more of them saying their COVID-19 response policies, like waiving copays, will be in place for “about 90 days,” but then they’ll reassess, although some have set firm deadlines. Cigna, for instance, says it will waive costs related to ambulance transfers through May, while Humana’s policy is open-ended. It will reassess at the right time. On our conference call last week, we heard about the logic and thinking around this 90-day period.

East to West: In New Jersey, BCBS is relaxing its telemedicine rules to allow members to receive covered services by telephone, in addition to virtual visits. If provided by an in-network provider, these visits will be at no cost to members. This applies to all types of visits performed by PCPs, specialists, therapists, LCSWs, mental health professionals, and urgent care doctors. Regence Blue in the Northwest now offers a free, HIPAA-compliant, video-enabled platform called Pulsara.

Like a Page Out of Rosie the Riveter: Volunteers have been coming forward, not just to provide medical and nursing care. In Minnesota, a wave of people skilled in sewing have stepped forward to sew CDC-approved reusable face masks that health workers can use as they treat patients. The initiative is led by Allina Health and supported by BCBS of Minnesota.

A Half Dozen: Interviews with physicians on the frontlines - snippets on what’s working, what isn’t, volume impact, and the role of the good ole telephone. Click here for the results.

Local Access TV Care: A physician in the North Shore of Massachusetts sent a letter to his Medicare patients two weeks ago alerting them he’d be on the local Channel 5 local access TV station 4 times a week at 10am, doing exercises, showing patients how to take medicine, drink water, do Sudoku and stretches, and answer questions emailed to him that are relevant to the broader audience. Issues around pain, memory, mixing medicine with food, pillboxes, vision, blood pressure, and fatigue are discussed. The physician, Peter Wilmot, is in his 70s, but stays active and views this as a way to manage care in crisis.

Extra Point: I don't know about you, but the level of rationing going on in my home is staggering. We're down to 1.5 workable iPhone chargers, 7 socks - not pairs - but socks, a few drips of laundry detergent and no more staples, like popcorn, peanut butter, and cranberry juice. My bride, God love her, is petrified of me heading out to the market. The online food delivery companies won't actually deliver here, so Janine finally relented and “let me go” last night. I dressed like any normal person would in a pandemic, Luke in Empire Strikes Back with an Eskimo suit, ski gloves, wipes in one hand and a store diagram in the other. It spelled out my every move. Hit the greens first, grab a bag of potatoes, and then abort the cookies in aisle 5 if I so much as I see a human. Hang a left at the poultry fridge, grab 16 jars of Rao's sauce, sweep every Chobani Greek yogurt I can find into the cart, then Frogger my way over to the personal check-out. Don't touch the paper bags, just “let the force” open them, and bag the groceries. Sneak out the side door and toss your gloves in a garbage can like Goodfella Henry Hill would have... I was like a cardiothoracic surgeon carefully moving through organs with a steady hand and a wobbly cart.... As I write this, I realize a couple things. One, that I'm fairly inept at managing my wife's anxiety and following basic instructions, but when I just stick to the plan and don't go off-script, I'm husband of the year...and two, we're not alone in this. Even if it feels that way some days. And hopefully, with time and faith, we can help each other through. One day at a time.

15: A SNF in Connecticut has seen this much of a percentage boost in admissions due to bringing in patients with significant comorbidity who were at home and “went south.” Rather than be admitted to the hospitals without enough beds and staff, SNFs have become an alternative facility to help the sick patients, particularly those with dehydration or concerning vital sign changes requiring medical supervision and acute level care. This SNF could be an outlier, however, as we’ve heard reports of declining SNF volume, by as much as 30-40%. In some ways, the crisis puts a new spotlight on a nursing facility’s future role in healthcare.

Take a Chance on Me: Like ABBA’s hit, a Medicaid plan in the South has been researching a new applied behavioral analysis service that focuses on educating parents of kids on the autism spectrum. The service is the brainchild of Michigan’s Richard Solomon, who practices in Ann Arbor, training parents in what some payers have told me may be a less expensive way to do ABA. But since efficacy is not yet proven universally, there’s some hope that insurers will take a bigger chance.

Benefit Boost: Aetna is extending its Medicare Advantage virtual evaluation and monitoring visit benefit to all of its commercial members as a fully-covered benefit.

IBD, Crohn’s, and a New Tone: For those of you working in GI practices, or pursuing them, prevalence of IBD and Crohn’s is a big deal and there are reports here in the US of kids with Crohn’s presenting this week with fever and cough. My cousin Erin, a nurse in Rhode Island, said she had “at least a dozen kids” fitting this profile. “None were hospitalized,” and in several cases, the kids were on Humira plus a tablet chemotherapy called 6MP. She said, “we were briefed to be prepped to deal with IBD patients,” and “to make sure they were taking their therapies.” No wonder the commercial payer world has been increasingly interested in value-based models for GIs to help manage ER and other costs for these chronically ill patients.

Where Are All the Doctors?: Telehealth vendors are scooping them up, like startup 98point6, which expects to triple their number of doctors over the next month and Doctor on Demand said they are “rapidly increasing” their provider base.

Psych 101: The Coalition for Behavioral Health in New York, along with the New York Association of Psychiatric Rehabilitation Services, is launching a new program called ‘Strive for Five’ to encourage New Yorkers to find five people in their life who they will check in with during each of the next 30 days.

Testing Tracker: Oscar Health has built the first testing center locator and made it available to anyone who may be in need of COVID-19 testing, not just for its members. People are asked to first take a 1-minute risk assessment survey, and then the site will recommend mitigation measures. If one of those measures is to get tested for COVID-19, the patient will be directed to a testing center locator. Patients can find the closest center with availability for testing. At the time of its release, the tool mapped out 100 testing sites, but they are adding more sites to the resource daily. The tool also immediately links patients with Oscar Health’s telemedicine platform, ‘Doctor on Call’.

March Sadness Reversal: Taking a page from the Virginia hoop squad that won last year’s basketball tournament, UVA Health has independently developed its own COVID-19 tests thanks to an effort by a team of physicians, laboratorians, and the University of Virginia community. UVA is now one of the few institutions across the country that has developed its own test so that the diagnosis can be more readily made. Instrumental in developing the new UVA test were Dr. Amy Mathers and Laboratory Director Mendy Poulter, according to the University.

Demand for CNAs: If you’re an anesthesia practice or home health company experiencing a downtick in surgical volume or visits, maybe consider starting a certified nurse anesthetist traveling business. There’s a market. Distribution warehouses in Memphis, TN are paying top dollar for CNAs to screen employees outside their facilities. These centers require hundreds and sometimes thousands of workers onsite to operate properly, and a spread among employees could potentially shut down an entire business.

Anxious: 92% of people now say they have anxiety about coronavirus, according to a survey of 12,000 from The Mighty. 20% have gone without medical treatments, 85% of people are more worried this week than they were last week, and about 30% have gone without doctor’s appointments. 42% of people under 25 said their lives were “extremely” impacted by the anxiety surrounding the coronavirus, likely “job related or perhaps socially related,” compared to only 15% of those over 65. But there is hope. A rapid response by psychologists and neurologists nationally, some from academic centers, some working for telehealth companies, and some coming out of retirement, is unfolding. These practitioners are being tapped to help local clinics, hospitals, and schools meet demand. It will be interesting to see if the commercial payers further embrace this wave through contracts. For physician groups who are trying to build a tele service on the fly now, part of the objective will be to have a clinical, evidence-based approach to these encounters as well as an ability to evaluate and address mental health, and get paid for the work.

Extra Point: My folks are having an epic number of senior moments these days, and thank God - they keep me sane to hear them, even as their moments are a sign of the times and a sign they are getting much older. Managing their health is another job for me and my family, and my ‘point’ - featured here this week - is my own way to chronicle their behavior in what is the craziest time in our lives. To preview, my mother-in-law who rarely leaves her couch except for daily Mass and a cinnamon cruller at dunks, now wants to suddenly travel, and my dad is agitated because the elderly hour at the Stop ‘n Shop has turned into an old lady traffic jam in aisle 5. His never-diagnosed ADHD can’t handle the molasses-speed shopping. The more things change...

50: Percent increase in Teladoc patient visits in the past week alone, up to 15,000 patients a day, with more than half considered ‘first time users’.

Channel 5: A physician in the north shore of Massachusetts is starting to do a daily exercise show with his ‘fitness teacher’ bride on the local access TV channel to help Medicare seniors. He’ll run on the treadmill, show seniors at-home exercises, talk pillboxes, and discuss medication adherence issues. In one ‘scene’ from a pilot episode, the doctor shared an example of how NOT to take your medications. “Don’t eat them with peanut butter for example…” he showed, chewing crunchy Jiffy. “It may mean you won’t get your medicines.”

Psych Fill-in: inovaTel, a telepsych business, is working with clinics and physician groups to help them provide tele services, particularly since nursing and PA staff are having to stay home to care for sick loved ones.

Cologuard Rise: CVS is now offering five new digital health platforms to help with everything from blood pressure management to musculoskeletal care. An Aetna source tells us they have been trying to reshape primary care via the CVS clinics—expect to see an uptick in Cologuard test use, given recent cancelling of colonoscopies.

Precision Medicine: Henry Ford Health System just got a big paycheck for $25M to ultimately create a Precision Medicine Center focusing on cancer, behavioral health, cardiovascular and metabolic diseases.

Appetizer: Anthem is now working to provide access on its Sydney Mobile app for members at no cost to help assess their own coronavirus risk and symptoms. Based on the results, Anthem members will be able to connect directly to a board-certified doctor via text or secure two-way video via the app who can then recommend care options.

Homeless Fix: Kaiser Permanente of California has pledged $1 million toward efforts to prevent and treat coronavirus cases among the nation's homeless population. California, Seattle, and Portland account for nearly half of all coronavirus cases in the U.S. and have some of the largest homeless populations in the country.

Closing the Loop: A new artificial intelligence platform, hosted by ClosedLoop.ai, will attempt to help a managed care organization in Illinois better flag those members that may be at higher risk of coronavirus, focused on social determinants of health that will make it hard for these managed care enrollees to access essential health services, such as testing and treatment.

Coronavirus Coding: The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel has approved a new, specific CPT code to describe laboratory testing for the coronavirus (SARS-CoV-2).

Survey Snapshot: Reports of underlying anxiety, obsessive-compulsive flare ups, and panic attacks are on the rise due to the coronavirus but the overall market response in adding telehealth quickly is helping to address this. Our survey, published this week, on the health system’s response is featured here.

Extra Point: Feels like a Stephen King science fiction story unfolding right about now, doesn’t it? But the thing is, we are seeing the best of people. Of kids and moms and nurses and cashiers who have very little, doing so much. All this healthcare innovation is only one piece of a puzzle, only one part of the selfless work going on behind the scenes in the last two days. In education circles, schools are trying to create miracles every hour. My wife is now my desk mate and is running a middle school for an inner-city population of middle school kids who are underserved, all Medicaid beneficiaries, in some cases without parents, limited in meals and access to technology and a safety net. Her teachers spend 6-7 hours a day talking on Zoom with the kids, teaching them about analogies and long division, helping them create an anatomy poster, listening to them read. Kids send back videos doing jumping jacks and on how to make mashed potatoes. Is it all educational? Maybe not. But it is engagement. These teachers are mostly volunteers, but this little school is one example of educators trying to engage during a crisis. It’s a great lesson for all of us in healthcare. Find the most vulnerable - give them a voice, teach, and make tomorrow better than today.