Behavioral Health Insights

94: The number of posts on a high school’s Facebook page up here in Connecticut from parents complaining about the canceling of the ‘championship’ basketball game. “Kids are being deprived of their opportunity for all their hard work,” one parent expressed. Juxtapose that community anger with the challenge ahead for getting take-home backpacks of food to the 49 some kids on free and reduced lunch at an urban school one town over, to kids who are likely to be out of school by next week. Puts the pandemic in some perspective.

Social Experiment Continues: That health systems are starting to line up to partner with payers to prevent social determinants of health from increasing morbidity and mortality should be a sign of opportunity. Humana is starting a new value-based care model precisely for its Medicare Advantage members focusing on food insecurity, housing, social isolation and loneliness. Ochsner Health has signed up as the first health system to participate. It would not surprise us to see a wave of more MA and Medicaid plans go all-in on similar initiatives. The one mistake vendors may make if looking to capitalize is that a tech or center based solution is unlikely to work; the models that will prevail are more likely those with local feet on the street, more 1 to 1 caregiver interaction and support that taps into volunteers and social workers. The question is who has the strategic foresight to amass these resources and use data systems to deploy?

Virus a Gamechanger for Tele: The new coronavirus (COVID-19) federal spending bill includes a major expansion of Medicare coverage of services provided remotely and while the expansion is temporary, assuming it turns out to be helpful, it may turn into a large-scale real-life test of telehealth’s value, not to mention accelerate coverage and payment of these services.

Corona’s Mental Impact: One wonders how Jack Nicolson’s obsessive-compulsive character in the movie ‘As Good As It Gets’ would have even gotten to breakfast at his favorite diner had a pandemic like coronavirus hit. Truth is stranger than fiction as mental health professionals are preparing for a spike in demand due to the pandemic. “Anyone with underlying anxiety or OCD will have a flare when a new external stressor occurs,” says Paula Sandroni, MD, a neurologist at the Mayo Clinic. “The external stressor of the coronavirus definitely qualifies. So I would anticipate a flurry of panic attacks,” she said. People suffering from mental health issues such as anxiety or OCD, including cleanliness fears, could be affected through sensation expressed in the media. “Having said that, some are so self-focused that they are impermeable to even major world events. We all witnessed that after 9/11 for instance. Either response needs to be addressed.”

Amazon Payer Partnership: Priority Health, a Michigan based health plan, recently announced a new collaboration with Amazon that allows its insured members to use their Amazon accounts to order and pay for eligible healthcare items. This also includes members using their health savings account (HSA) for products such as vitamins, bandages, and more. Members can save receipts to get reimbursed by Priority Health or add their savings plan debit cards to their Amazon account.

Diagnosis Stop & Go: Blue Illinois will not allow for reimbursement when mutually exclusive diagnosis codes are submitted for Blue Cross Community Health Plans and Blue Cross Community Medicaid plan members as of March 31, 2020. An example is code E78.00 for pure hypercholesterolemia unspecified and E29.1 for testicular hypofunction. Anthem was regularly denying these codes when billed together.

Silver & Gold: Ohio University’s Chillicothe Health & Wellness Center is hosting the SilverSneakers benefit through leading Medicare Advantage plans to help older adults to take control of their health through fitness training. Some insurers, like Humana, have pulled back in offering this benefit given low uptake.

Genetics Mark the Date: Blue Shield of CA is the first health plan in the US to cover whole genome sequencing to help critically ill children who have unexplained medical conditions. Whole genome sequencing scans your entire genetic makeup and can help medical teams make more precise decisions around treatment. Blue Shield members under individual, family and employer-sponsored plans who have a critically ill child, up to 18 years of age, may be eligible.

Extra Point: My sister Laura says the insanity at Whole Foods is at an all-time high - people are fighting over toilet paper, flavored water, and gummy bears! My bride had me scurrying around after work today to buy lentils, black beans, and wipes. I suspect I’m not the only one who got that text and I’ll admit I stopped on the way home for a bottle of Chianti too. I’ll toast my Italian relatives tonight who are held up in Monte Cicerale, a mountain town near Napoli. Tommy, our often anxious 12-year-old, sees the pandemic as an early spring vacation. In a refreshing 180, he asked if he could play outside with buddies over the next couple weeks now that Connecticut, like so many states, is closing schools. I told him why not—fresh air, running, mental health— but I sort of don’t know if that’s right and four of my doctor buds I called today all gave me a different answer. My point is that I don’t know. Life is going on in some ways: Jack had his hoops banquet tonight without parents, trophies, and handshakes, though “not sure of the point of this,” he quipped as I dropped him off. Sophia’s play postponed its Brigadoon musical, which seems right on point since the only people who would go to that anyways are grandparents over the age of 70. Janine’s middle school classes will close for the month, but teachers will keep teaching through the Google classroom and staying in touch with families, particularly since all of them are from underserved areas in Hartford. Starting Saturday, I’ll be delivering food backpacks to the three-dozen families who are on the free and reduced lunch circuit. I just hope I can manage to stay healthy and not run out of gas like usual, since one can only assume that’s the next thing – long gas lines. Nurses like my cousin Erin in Rhode Island aren’t shutting anything down – they are holding up in the ER, checking temps and BP, finding beds, and running low on respiratory equipment. “We had a woman in here last night with sepsis, one today with a severe respiratory infection. That’s the healthcare I see, but now this – every sniffle and headache is showing up.” They are no doubt heroes in all this – handling so much of the brunt of the unknown and taking one for the team. Here’s to hoping they can manage to stay healthy.

19: Percent of hospitals in a poll last week considering or establishing in-house specialty pharmacies. This developing trend is interesting given a new UnitedHealthcare policy starting in April. Hospitals will be required to obtain specialty medications from UHC’s specialty pharmacies when administered in the hospital outpatient setting, unless otherwise authorized. This means the hospital can’t bill for the medication and can’t bill the patient. The pharmacy will bill United and the hospital can only bill for ‘administering’ the drug. The insurer says they may deny the full claim if the hospital uses a non-participating specialty pharmacy. It will be interesting to see how the push and pull work between these new in-house pharmacies and shifting payer policies.

Retail CleaningHouse: Walmart is beginning a new healthcare approach at two stores in Georgia. There, customers will pay a standard rate of $30 for a checkup, $25 for a dental cleaning, and $1 per minute for counseling. More advanced services will also be available, and prices will be provided clearly before services are utilized.

Value Tracker: BCBS of Western New York has entered into its value-based reimbursement contract with Value Network, a behavioral health group with over 100 providers in New York. The model will use a PMPM capitated payment along with some FFS payments, specifically around preventive care.

Oral Health Progress: BCBS of Massachusetts is expanding value-based care contracting into dental services, through an agreement with the dental provider group 42 North, in the hopes of improving access to dental plan coverage. Blue Cross says it has seen success in VBC with medical providers and is hoping to expand these positive results to dental health.

Diabetes Cost Switch: Beginning in January 2021, CareFirst BCBS will begin offering insulin and other diabetic supplies as a covered benefit to its commercially-insured members, with no costs associated. In 2019, members in commercial plans paid a total of nearly $6M in out-of-pocket costs for insulin alone. Starting in 2021, CareFirst will also allow self-insured plans to have an option where they waive the cost of insulin.

Generic Buzz: The Blue Cross Blue Shield Association (BCBSA) and 18 of its member organizations are investing $55 million in the nonprofit Abbreviated New Drug Applications, with the goal of creating cheaper versions of certain expensive generic drugs. The partnership expects to start with a focus on roughly seven to ten products and expects some of the initial products to be available in early 2022.

Juul’s Rise: There was a 10% increase in the rate of use of Juul among middle schoolers in the last year 8 years, according to Truth Initiative data. The number of teens and young adults who have used Juul doubled in one year, according to a study published Jan. 21, 2020 in JAMA Pediatrics. “Yeah, big problem,” says Mayo Clinic’s Paola Sandroni MD. PhD. “Various cannabis preps can be vaped, as can bath salts, and I am sure more. Plus, folks are creative and will try to vape anything such as crushed pills mixed with some water or oil base.” Many teens don’t have the foresight to know what they are doing; it’s potentially fatal. And, because ‘vaping’ synthetic drugs is more discreet than other forms of drug abuse, they are easy to hide in places like schools.

Bipolar Stat: Among symptomatic youths at high risk for bipolar disorder, the time between mood episodes are longer for those receiving family-focused therapy, compared with enhanced usual care, according to a study published by JAMA Psychiatry.

Payer Direction, Addiction: Healthcare-technology company WEconnect announced a partnership with Pennsylvania managed care plan, Gateway Health, for an innovative program designed to help patients stay in recovery. Patients who undergo substance use treatment will use WEconnect’s app after they leave in-patient treatment, providing them with a comprehensive network of support during their first year of recovery. Pennsylvania’s rate of drug-related overdose deaths far exceeds the national average. Every year, 23 million Americans seek treatment for drug and alcohol addiction and more than 80% of patients relapse after treatment. WEconnect’s innovative app reduces relapse rates by providing comprehensive and reliable tracking metrics to bridge the gap from treatment to recovery, taking a 28-day program and turning it into a 365-day program.

Extra Point: Andy looked frail and he couldn’t find space on offense for a jumper. He had 22 in our last contest with #1 Plainville, but that seemed impossible today. He turned the ball over twice on consecutive possessions and then Plainville’s #15 easily wrestled the ball from Andy at half-court for a third. Our best player wasn’t just coming off the flu as mom thought. He was on the verge of a heart attack, and with 2:16 left in the first quarter, no one knew it. To read more, click here.

77: Percent of employers in our 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 low 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.

Palliative Care: Anthem has entered into an agreement to acquire Aspire Health, the nation’s largest non-hospice and community-based palliative care provider. Aspire currently provides services under contracts with more than 20 health plans to consumers in 25 states. The company uses patient algorithms to identify patients with a serious illness who may benefit from an extra layer of support. Once patients are identified, Aspire assigns a comprehensive care team that includes physicians, nurse practitioners, nurses, and social workers.

Autism Testing: Researchers at the University of Virginia are conducting tests for autism when a baby is born in an effort to detect certain DNA markers. The research will especially narrow in on premature babies, as they have a higher chance of having autism. This testing is made possible because of a grant from the UVA Alumni Association.

MRI Direction: My neighbor convinced her insurer that an MRI was the only way to figure out her neck pain, that PT would do little – and she was right, having had a successful spinal stenosis procedure last week. But the cost of the MRI matters, and AIM Specialty Health has developed an imaging clinical site of care program to determine where MRI and CT scans can be done, particularly on weekends when access is limited. Through AIM’s portal, referring clinicians have access to a variety of data that identify lower cost imaging sites. Comparative imaging-facility scores highlight self-reported measures of adherence to standards established by the American College of Radiology and the Intersocietal Accreditation Commission. Anthem owns AIM.

Telehealth TakeOver: Premara BCBS in Washington has started to push doctors and nurses in primary care settings to encourage patients to use Talkspace for mental health sessions, as part of a new partnership. Meanwhile, Wellin5, an online telehealth counseling platform, has acquired Therachat, a San Francisco, CA-based mental health platform designed to help therapists, psychologists, and mental health counselors to keep their patients engaged in between therapy sessions. And as of February 1, PreferredOne, a subsidiary of Fairview Health Services, is partnering with Learn to Live, a digital platform that offers cognitive behavioral therapy tools. PreferredOne’s self-insured clients with 200+ employees are able to offer Learn to Live’s interactive digital programs to help with anxiety, depression, and substance use.

Pre-Authorization Around the Horn: United’s commercial plans in most states will start to require pre-approval this spring for 50-some arthroscopy procedures, destruction of cutaneous vascular proliferative lesions, and extracapsular cataract removal with insertion of an intraocular lens. Only commercial members in Alaska, Kentucky, Massachusetts, Texas, Utah, and Wisconsin are not impacted.

In Case You Missed It: A Northeastern nursing & rehab center is poised to turn a profit on their Medicaid business after years of losing millions, and has created a new behavioral health team of psych social workers, clinical psychologists, and full-time music therapists as a way to reduce psych-related medication use, head off potential Medicare readmission penalties, and better manage dementia and Alzheimer’s patients. Read the interview by clicking here.

Top 20: The number of emerging payer priorities, ranked from 1 to 20 by commercial, Medicare Advantage, and Medicaid managed care plan leaders include five from behavioral health and several new entrants previously unranked. A recording of the 20-minute podcast we did discussing the rankings can be accessed by clicking here.

Extra Point: My daughters take at least one of these a month, my sons maybe two, and if I’m being honest, I probably take at least four. No, not showers, though my 12-year-old is close to setting a record-low this month in bathing. I’m talking about mental health days. Some states are allowing students to just take off class, in recognition of some of the highest rates of depression, anxiety, and suicides among young adults. The Montgomery County school district of Virginia now allows students to use “mental health” as an allowable excused absence, while Oregon, Utah, California, New York, and Florida have proposals in their legislature. Florida’s would allow one mental health day per semester. Advocates say adding mental health as a reason for excused school absences puts it at the same level as physical illness and reduces stigma. 50% of mental health issues are established by the age of 14, and 75% by age 24, according to the Polaris Teen Center. New York, last year, started to require mental health education in its schools. In Colorado, the Denver Public School system has increased their number of psychologists and social workers by 96% in the last five years, and recently implemented a sports program for youth and teens, called 241 Sports, to provide more movement and exercise as a way to address physical and mental health. We all take mental health days, or at least hours in a day, but what’s noteworthy here is how this cultural norm is moving into law.

Twenty: The number of emerging payer priorities ranked from 1 to 20 by commercial, Medicare Advantage and Medicaid managed care plan leaders are featured here in the 15th edition of our Healthcare Payer Index. A conference call to discuss the list will be held today, Friday, February 14th at 1 o’clock eastern. Dial 800-874-4559 (password is Cote41810).

Nursing Rehab Center Turnaround: A northeastern nursing & rehab center is poised to turn a profit on their Medicaid business after years of losing millions, and has created a new behavioral health team of psych social workers, clinical psychologists and full-time music therapists as a way to reduce psych-related medication use, head off potential Medicare readmission penalties, and better manage dementia and Alzheimer’s patients. Read the interview by clicking here.

Incentive Pay for SUD Treatment: A new value-based payment model now encourages substance use treatment providers in New Jersey to contract with a leading payer and, if successful, may be rolled out to other behavioral categories. The model offers case rates for an episode, with different rates for different levels of care, along with value-based incentives, and payment regardless of the length of the stay or visits. There are no administrative requirements, no pre-approval. An incentive payment of about 10% of commercial claims is available to providers who meet several outcome measures, like readmission reduction, and process performance measures, like ‘engaging the patient on MAT’, stepping the patient down effectively to the next level of care, and communicating with the PCP. A higher incentive (~15%) is available to providers who can manage Medicaid patients too, although interestingly the incentive will be based on commercial claims. The insurer stops short of seeing a single payment for full-year engagement of a substance use patient in this market as it can be difficult to assign care to one provider, but there are other commercial insurers trying capitation and full-year engagement models. BCBS of North Carolina has recently contracted with Eleanor Health on a multi-year global capitation risk arrangement, while Anthem partners with Aware Recovery to provide in-home treatment under a yearlong PMPM arrangement.

Extra Point: I love my folks. They are part Frank and Estelle Costanza, part Cosmo and Rose Castorini from the classic Moonstruck. And they drove me a bit nuts this week after I bought them cell phones. On Tuesday alone, my mom called me 27 times, only half of which were on purpose, the other half were voicemails of her asking dad which button to press and how to talk into the phone. One message was an hour and 33 minutes long, and I’m 90% sure it was during her visit to the dentist. They are in their late 70s, frail and aging - dad dealing with the balance issues from vertigo after a serious fall hospitalized him 5 years ago, mom juggling heart disease and osteoarthritis and all the diet and exercise confusion those conditions bring. But now with their new found google map app toy they have a way to get to their doctor visits or to the kids games without asking me directions every 5 minutes...but I’ll say this, I’m lucky they are here, love that they make me laugh, and happy they still like to grab a table at Silvanos for spaghetti on Valentine’s Day because “they just have the best sauce Bry.” Here’s to managing your parents’ health, one cell phone call at a time.

42: The percent of physicians who just retired or changed jobs after an insurer acquired their business, according to our small poll of 103 who say their practice was bought by a health plan in the last few years. Age and quality of life and the ‘components’ of the deal were the leading factors. The 58% who stayed on were, for the most part, under 50.

Lab Testing Utility: Physicians sometimes order lab tests as cover, sometimes because it’s protocol and sometimes because they have a hunch. The science behind their lab ordering behavior is increasingly interesting given a range of healthcare developments like addiction, pain and payment reform. Here in this poll we did of 150 endocrinologists, cardiologists and health plan medical directors a couple years ago, we found out the so-called ‘utility’ of the test - when it helps and when it flops. Some interesting perspectives to consider if you are a practicing physician or run a physician office or hospital and are moving toward value-based payment. Click here for a 1-page poll. Note: if interested in additional research on this topic, reach out anytime.

Alzheimer’s Option: Science continues to make strides at slowing disease progression. Eagle Pharmaceuticals and the University of Pennsylvania have agreed to a licensing agreement for the development of dantrolene sodium for the potential treatment of people living with Alzheimer’s disease, including an agreement to fund additional research in January of 2020. Essentially, the study will be looking at dantrolene’s role in changing intracellular calcium levels or calcium signaling, which involves complex cellular pathways and may lead to neurodegeneration and neuron death. I lived with my grandmother for a few years back in the earlier 90s in the latter stages of the disease that took her brain, but not her humor. For my grandmother’s story, and that of a good friend of mine who developed Alzheimer’s in his 40s, click here.

First Rx Value Contract: Just as specialty pharmacies continue to be important to regional payers to help with distribution and care management, driving down acquisition cost and helping with pipeline management, there is a new dynamic in play to consider: insurers partnering directly with manufacturers. UPMC Health Plan will receive discounts for two multiple sclerosis drugs manufactured by Biogen in a first-of-its-kind, value-based contract. Patient-reported measures of disability progression will be used to determine effectiveness of the drugs instead of outcomes gathered by claims and EHR data. Value contracts have been slow to develop for medications. Some payers have tried to institute tumor shrinkage as a measure of success in value contracts with cancer treatment companies and NICE, the UK’s National Institute of Health & Clinical Excellence, has made strides in this area, but establishing the terms and shared savings is complex, which has kept development of these contracts at slower pace.

Social Determinant Buzz: Molina Healthcare is opening the National Molina Healthcare Social Determinants of Health Innovation Center in Columbus, OH. The Center plans to partner with local and national community-based organizations and providers. It intends to collect and analyze patient data and create a database to help develop best practices for supporting those who are addressing these issues. For this trend to take hold, it requires local collaboration and investment. I see that in my community where the Medicaid population of refugees has been able to address asthma, addiction and prenatal care costs through simple volunteer advocacy help. All local. Scaling social determinant focused businesses has challenges although models that can help local providers collect and disseminate data and provide support to local caregivers and volunteers are likely in demand.

Pilot Helps NY Medicaid: The benefits of care coordination were on display as part of a value-based care pilot that encompassed New York Medicaid patients with high mental health needs. Healthfirst, Mt. Sinai, and the Institute for Community Living have worked together to better integrate mental and physical healthcare as well as social service needs like housing and transportation for 400 patients with mental health or substance use disorders and chronic medical conditions, achieving $1.3 million in savings in Medicaid costs in 2018.

Addiction Model Innovation: With national focus on the opioid crisis, Workit Health is expanding their digital addiction care program to include medication for alcohol use disorder. Workit Health members in CA, MI, and NJ can now use telemedicine to meet with clinicians and then receive naltrexone. Alcohol use disorder is the third leading preventable cause of death in the US and Workit Health is hoping to use their successful platform to tackle this issue alongside opioid use disorder.

The SNF Conundrum: “Reduction of antipsychotics in SNFs is a big initiative with CMS and while we are not getting penalized for using antipsychotics right now, it does affect our quality rating because some people may not come to our facility and if we don’t reduce it, CMS might penalize us directly financially.” This from Ellen Casey, administrator at Wilton Meadows Nursing and Rehabilitation in Connecticut where Casey has implemented a new behavioral team and helped the facility break even on Medicaid after losing $1.5 million a year. Her story next week.

Extra Point: You want to show value, take your daughter who’s struggling out to supper and blast Ben Platt’s new album on the way. Sing an uncomfortably ambitious falsetto at the traffic light, with the windows down. Not because it sounds good, but because it makes her laugh. Use your gifts, for good. Nurse Jared Axen sings to patients at Los Angeles’s Valencia Hospital. His nursing director tells me his patients actually give the hospital a better satisfaction score even though they are often sicker or deal with more complications, and that they are “3x less likely to be readmitted.” Nurse Brenda Buurstra once sang ‘You Light Up My Life’ to Robert Olsen during the older man’s weeklong stay for breathing issues at Bronson Hospital in Michigan. Despite initial expectations that Robert’s lungs wouldn’t hold up, he was discharged home in a week and hasn’t been admitted back. Brenda sang to patients before things like readmission penalties and ACOs and social determinants were a thing. She has a gift. “I’ve been singing to patients for 14 years,” she told a CBS TV reporter. “It’s just the first time I got caught.” I showed Sophie these video clips last night after supper and after my own embarrassing stoplight song. She heard Brenda singing on key, and Jared moving his patient to tears. So, she didn’t get that part in Sound of Music this week. Like a lot of teens and young adults facing defeat, failure, the unknown—she was thinking of quitting the music club. She has a voice and a dream and loves to perform, but maybe she’s missing the point. We are trying to measure value in so many ways these days—in our healthcare businesses, in how we deal with patients, in how we parent, in ourselves, and for Sophie, well maybe she’ll be a Bernadette Peters or star as Belle on Broadway, but if not, something tells me there’s another leading role waiting for her bedside.

20 Million: The amount Blue Shield of California has pledged for behavioral health services, largely to support California’s large homeless population. The money will go to the California Access to Housing and Services Fund, a new initiative proposed by the governor in the most recent budget. Blue Shield of CA also recently launched a 10 year, $10M plan, Blue Sky, focused on supporting mental health for students.

Gateway to Value: If you ever doubted insurer investment in value care models, look to Blue KC, which has partnered with Cedar Gate Technologies to use analytics to help the insurer to focus its value-based care initiatives and move away from fee-for-service. Cedar Gate will provide a single platform that Blue KC can use to serve up offerings like wellness programs and transparency tools for their members.

Fertility is In: Payer focus on fertility continues in Part II of our ongoing coverage of the sector. UnitedHealthcare and Optum RX have changed their designated specialty pharmacy for infertility medications from Freedom Fertility Pharmacy to Avella Specialty Pharmacy. The change, which took effect Jan. 1, 2020, is an effort to create an enhanced patient experience for those going through fertility treatment. Other changes were made to preferred medications and clinical review.

Go Cardinals: The University of Louisville’s Division of Infectious Diseases will play a significant role in epidemiologic research related to vaccines as part of a Pfizer supported Center of Excellence. The collaboration will be long-term to determine the human health burden of infectious diseases and effectiveness of vaccines. Studies will take place in nearby hospitals, long-term care facilities and within the community. Pfizer selected University of Louisville because of its ability to conduct population-based surveillance and clinical research that engages health care facilities, health care personnel and industries. The data that will be collected is intended for government and health care policymakers to help reduce the burden of infectious disease.

Surgical Merger: Regent Surgical Health announced a collaboration with physicians from the Center for Specialized Surgery and Lee Health, a nationally recognized, award-winning health system in Southwest Florida with over 100 locations. The Center has specialties including foot and ankle, sports medicine and pain management and more in orthopedics. Regent Surgical Health now owns or operates 28 U.S. facilities, 21 hospital joint ventures, 14 total joint replacement centers and three bundled payment entities.

PTSD BuildUp: BetterHelp is an online platform of 5,000 therapists that helps treat PTSD with therapy. The Berkeley Well-Being Institute found that BetterHelp is as effective as face-to-face counseling where 70% of users reduced their depression symptoms. PTSD is not just for veterans. It affects millions of people who have experienced trauma from sexual assault, a natural disaster, abusive family members or anything that could have prompted someone to have a distressing reaction. According to the National Alliance on Mental Illness. 37% of people diagnosed with PTSD show serious symptoms, like night sweats, flashbacks, panic attacks, and retreating from family and friends. The U.S National Library of Medicine says that traumatic stress affects the brain in a way that changes it. Traumatic stress is associated with increased cortisol and norepinephrine responses to subsequent stressors. This change in the brain combined with the stigma against mental health can lead to many individuals not feeling comfortable to seek treatment.

Profile: Our conversation with BCBS of North Carolina’s chief of behavioral health is featured here.

Extra Point: Rosie usually bounces the ball off her nose and has a penchant for passing to the other team, but boy does she hustle. She lives with her aunt on the 4th floor of a partially boarded up apartment building in the north section of Hartford. Her dad is in jail and her mom left years ago. She doesn’t have much…. outside of the school my wife works at and her favorite Adidas sweatshirt and striped sweats she wears every day. The school is her ticket out. On Monday, I was planning to cancel the kids’ basketball game with the boys’ team across town, but Rosie wouldn’t have it. “Hey Mista Coach! We have to play. You can’t cancel. You know Kobe’s daughter played basketball. Did you know that? She could beat boys. We have to play.” Funny how this 7th grader may not be able to dribble with her left or understand ball-you-man, but she understood the moment. She may never play basketball in high school, but I can’t tell her that. She, like Kobe, wants to take advantage of every moment. She wants to be better tomorrow than today. She wants to challenge the system. Healthcare is sort of in this struggle now: trying to capitalize on an insurgence of demand for data and payment innovation but sometimes butting up against a stingy system too inflexible to change. There’s progress, but it will require more Rosies. For what it’s worth, we played the game. Lost 36-15. By my count, Rosie had at least a dozen turnovers but made a backdoor cut and 2 free throws Kobe and his kid would be proud of.

13: Number of newly awarded contracts that BCBS is going to give out this year alone to physical education vendors focused on movement, exercise and fitness solutions to address both physical and mental health, a spokesman confirmed. Companies will focus on chronic adult patients, seniors, new moms and youth as part of tailored programs designed to limit prescriptions and reduce stress and downstream medical complications of events such as stroke. One of the leading ‘companies’ in the mix, PLAY, previously had a grant with BCBS of Rhode Island, while others are more data and fitness focused, like Orange Theory. Read my essay on this here.

Gene Therapy Innovation: A new crop of expensive but potentially revolutionary therapies is getting attention from insurers who are unusually ahead of the curve in establishing policies, perhaps better versed in how to address expensive treatments after a decade plus dealing with novel treatments for cancer and hepatitis C. Policies seem to be focusing on providing wider coverage, fewer barriers, cost sharing and centers of excellence, but also outcomes refunds and more accountability on manufacturers. Novel indeed. Reach out anytime for a primer on developments.

Women’s Health Monitoring: The University of Pittsburgh Medical Center has created a remote monitoring program to measure blood pressure for new moms after leaving the hospital that is increasing the number of women who are keeping their postpartum appointments, 90% compared to the national average of 60%. Women were discharged from the hospital with an automatic blood pressure pump and then a computerized system within the participants’ electronic health records prompted them to take their own blood pressure and heart rate readings. In 2020, UPMC plans to expand the program to all 15 of its hospitals.

Fertile Ground: Insurer focus on fertility is going up. Starting this year, BCBS of Illinois started requiring some members with group coverage to obtain fertility benefit pre-authorization through WINFertility, a company which helps insurers manage fertility benefits and costs. Think of them much like you would OrthoNet for physical therapy or eviCore for surgery. WINFertility handles both the medical and pharmacy benefit, as well as genetic testing, egg freezing, and surrogacy services. This comes at a time of increasing interest in fertility benefits from employers and investors. In October last year, another fertility benefit manager, Progyny, joined Nasdaq as it went public with its IPO.

Glass Half Full for OP Psych: In a positive development for psych therapy providers, Kaiser Permanente has lifted its previous 20 visit limit on outpatient psychotherapy and says it will only require re-authorization annually through an abbreviated form. The code for the service is 90834. Other insurers, like BCBS of Illinois, have leaned somewhat the other way by requiring re-authorization after 7 visits, much like they had done in prior years for physical therapy when use of those benefits began to increase. In the aggregate, the attention to psych should put any outpatient provider on notice that it will need to capture and demonstrate visits are needed even if there is a swing in momentum to allow more access. In our 15th edition of the Healthcare Payer Index, several behavioral services made the Top 20, including previously unranked ‘telepsych’ cracking the Top 10.

Latest Payer Investment: Optum, the health services platform of United, is partnering with Allina Health Systems in Minneapolis to open as many as a dozen new ASCs over the next five years. Optum has grown in the ASC space after it acquired Surgical Care Associates (SCA) in 2017. SCA already managed several ASCs in Minnesota prior to this deal.

Predicting Health: If you had to guess, what are the top two factors most associated with risk of an inpatient admission or ER visit? Well, a study published in the American Journal of Managed Care showed that a machine learning algorithm was able to accurately predict inpatient and emergency department utilization using only publicly available social determinants of health data, and the top two factors most associated with risk were air quality and income. The team who conducted the study hopes that health systems can use this information to inform future initiatives and reach out to those most at risk.

Profile: Check out our recent profile with BCBS of North Carolina’s chief of behavioral health Kate Hobbs Knutson. Click here.

Extra Point: So, I’m getting older. My kids now leave the room when I start to say, “You know when I was your age,” we didn’t have PayPal and lunch accounts, we brought a rusted Star Wars metal box with Chewbacca stickers into the cafeteria and hoped-to-God Lenny wouldn’t corner you for the SuzieQ dad snuck inside. Even with a diet of Twinkies and Pop Tarts, if you passed your physical the nurse would give you a lollipop. No cavities, and you got a plastic ring. We didn’t have special boots for sprains and breaks, we wore hard casts that smelled like old pillows. There were no electronic records. Our doctors didn’t talk. They asked us the same questions each time. Urgent care was dad telling you to take a hot shower and throw back a few Halls lozenges. We didn’t have ‘Play’ programs before school or weekend travel teams with shorts donning our last name. Our contact sports had names like 'Red Rover'. We wore blue t-shirts with a faded REO Speedwagon on the front because the coach said, “wear dark,” so you did. I’m getting older. I consider it a good day when I look at my to-do-list and check off items like ‘take kids to school, reply to that email you deleted, reorganize to-do list’. My bride says I’m just stretched thin. She’ll say, “You’re stretched thin,” which only makes me think I either need to eat more carbs after 8 or stop yoga. At least I’m not the only thing getting older. Doctors. Hospitals. Fee-For-Service. Nursing Homes. Antidepressants. Opioids. All getting older or at least entering a new era that tests their behavior, patience, value. I suppose I’m not much different. Here’s to embracing age, appreciating your roots but being open to pivoting, carefully.

Four: Autism is 4x more common in boys and ADHD prescribing is far more common too, spurring a new wave of sports-focused programs led by counselors, coaches and educators that take the principles of applied behavioral analysis and put them into practice. Literally. Several models have popped up as alternative offerings for parents whose idea of a win is not measured in points or playing time or whether Robby will make the elite team, but in exercise, focus, social development. One of the earlier models we covered is discussed here. Expect continued interest in these alternative models as the cost of autism rises and more kids get diagnosed sooner. Also expect more insurers to take a closer look at the diagnosis and treatment plan given what about a third we’ve polled say can be a misdiagnosis, given that kids labeled with autism spectrum often have ADHD symptoms.

Women’s Health First Click: WebMD is launching a new platform that will allow users to search its database for physicians based on specialty, openings and insurance. Back in 2016, we polled moms in our health accountability study about where they turn first for healthcare insights and 38% said WebMD. Incidentally, Dr. Oz was third at 15% and ‘my mom’s group or book club’ was second at 24%, up from just 6% in the first poll of the same 375 moms back in 2010. Building off its physician database, the WebMD Care platform will also include chiropractors, dentists and health care professionals specializing in acupuncture and holistic modalities. It will also boast a free prescription savings service where visitors can compare prices at local pharmacies.

Now Hear This: Starting in May, hearing screening with or without the use of audiometers or other electronic devices and vision screening will be separately reimbursable from preventive medicine evaluation and management visits under a new Anthem Indiana policy.

Cardiology Innovation: In our healthcare payer index publishing this month, cardiology moves into the Top 20, the first time on the list in the 15 years of the index. Medical directors, particularly those board certified in cardiology, say there are few big trends to keep an eye on including the shortage of adult congenital trained cardiologists and a new pulmonic valve from Medtronic that should help treat patients with congenital heart abnormalities, as about two thirds of those with this condition have an anatomy too big to be able to have a percutaneous value, so they end up having a more risky open heart surgery.

Triple Threat: Cigna and Oscar Health are partnering up to provide more health plans for small businesses. Fully insured plans will be sold under the Cigna + Oscar brand and will focus on integrating medical, behavioral and pharmacy services in a kind of triple threat. Technology will also be a focus with 24/7 no-charge telemedicine.

Free Food For Thought: Starting in 2021, Optum will begin offering pre-paid debit cards to its members...for the full story, click here.

Habit Change: Constanza once famously started doing the exact opposite of his usual behavior in a last-ditch effort to lift himself from being a self-prescribed loser. George was ahead of his time as healthcare companies like Newtopia are working now on habit changes to help employers prevent disease. They tout savings of 70% or more under an Aetna study. The program includes genetic testing and 1-on-1 coaching with a focus on keeping people healthy and changing behaviors in those who have signs of potential disease. These employer programs aren’t new, per se, but they are evolving, with more focus on mindfulness and yoga and use of test results to guide habits and avoid disease onset. But they have the same challenge - they get a PMPM for a period with a goal of bending the cost curve and ultimately need to show ROI quickly up.

Rx In and Off: In 2020, insurers are adjusting drug formularies more than my daughter sings Frozen. Several trends: Gonal becomes the preferred drug for in vitro fertilization while Follistim AQ moves to non-preferred. Xolair wins as the preferred treatment on a number of formularies for asthma, while cancer therapies Tarceva and Xytiga are now off formulary given generic alternatives. ADHD medications are now increasingly requiring pre-approval, as well as tighter evaluation after 6 months, as insurers see value in non-medication approaches. Forteo and Tymlos, two osteoporosis drugs, will now have quantity limits and require pre-approval. For GI practitioners, Xifaxan will require quantity limits but Trulance will become a preferred agent for irritable bowel disease.

Extra Point: My cousin Matt could sketch a lion or tiger leaping through a meadow in just minutes. He would captivate my kids after Sunday supper more than any iPad could. ‘Matty can you show me how to do that like you?’ He then had the patience and imagination to show my youngest Tommy how to draw a dolphin riding a bicycle. He had a gift but passed away a week ago today from a 20-year battle with addiction. The Heroin ultimately got him. His parents found him. He just could never get enough. It seems so many more of us know someone with addiction. Perry Meadows, a medical director I’ve done panels with, always chokes up talking about his son’s addiction and what might have been. His son’s story has very much framed Dr. Meadows' work in trying to address addiction at Geisinger. There are signs that the opioid crisis has turned and that there are new ways to address addiction, new treatments, new delivery models. Matt never had any success in treatment and never did medication assisted therapy. I wonder what if. I wonder if he could have one day worked for one of the companies some of you lead - those changing the outcome of addiction. Could he have done art therapy? There are tons of regrets when you outlive your kids as my aunt and uncle did or when you are giving a eulogy at your cousin’s funeral. There are no words. For those who have gone through this they know that managing the disease is nearly impossible, that it cannot be solved in a day, or with words or treatment alone. It takes something more. I would argue the unique models popping up like Aware’s at-home addiction treatment or Eleanor Health’s global risk-taking featuring MAT and social support are great successes that show what’s possible. Question is whether stigma lifts and whether more creative models can be developed.

50,000: The number of Medicaid enrollees Molina gains in Illinois’ Cook County now that it has just agreed to acquire the Medicaid managed care organization NextLevel Health Partners, which is a community-based health plan focused on social determinants.

Home Rx: Beginning January 1, 2020, members of Oscar’s insurance plan in New York can select Capsule’s same-day pharmacy service through the Oscar app to start receiving meds straight to their homes at no cost.

Yelp The Doctor: Cigna is now giving 5 specialists access to patient reviews and will likely add 7 others this year to help both providers and patients figure out who’s nice and who’s effective. If you think the insurer won’t use this in benefit, contracting and reimbursement decisions, think again. Doctors get an initial look at the results and can challenge them but, much like those too-close-to-call NFL catches, few are likely to be reversed. By April, patients should be able to access comments and recommendations through the provider directory. Podiatrists, ophthalmologists, dermatologists, telehealth practitioners and chiropractors will join primary care providers in getting the inside scoop in the first quarter. Likely next up later 2020 or 2021: ENTs, cardiologists, OBGYNs, gynecologists doing routine care, not cancer care, orthopedists and PTs.

PostPartum Extension: Comedian Robin Williams once tried to convince Hugh Grant and Julianne Moore of his baby-delivering credentials in a classic scene in the flick 9 Months that has relevance today. ‘I was chief of obstruction in Russia….so I know that post pardon deception is very common.’ ‘I beg your pardon,’ Moore winced. Of course, being chief of obstetrics increasingly means you have to understand and help parents prepare for postpartum depression. More insurers are seeing the importance of helping cover services to address it including Empire BCBS of New York, which has lengthened the time for postpartum care from 45 to 90 days under its 2020 maternity services reimbursement policy. Billing is done with CPT code 59430. Other insurers are considering creating 12-month episodes of care featuring 3 months of postpartum services.

Dual Dx No Longer Different: 6 in 10 substance abuse treatment companies are already providing or trying to provide treatment of the whole person and by 2025 it will be rare for these companies to be solely focused on addiction. More of them will also be in some version of risk arrangements with insurers, especially self-insured employers who are already looking for assurances on treatment outcomes. One company, Brandon Electric, told us they are going to do an RFP with 3 regional companies for 1 exclusive slot as the mental health and addiction treatment provider for their 600 employees and their families. The CEO, Brandon Nicols, says they used Shatterproof to help them narrow the list. A recent wave of substance use issues involving both employees and some of their teenage kids prompted the move. Pennsylvania’s Retreat Behavioral Health is one example of the shifting focus. In 2020, they have just added Synergy Health, a treatment division dedicated to mental health. Aetna recognized the company recently for its quality.

Diagnoser Misnomer: While Cigna is urging physicians and other practitioners in its network to start using behavioral health screening and assessment codes, there’s little overall trust and comfort in talking to doctors about depression, our poll found. The 10 codes include a series of G-codes and other codes with recommendations on the type of condition and time you should be taking to diagnose, but screening and evaluating often takes more than just 15 minutes – heck, it can take 3 months in the case of my dad who finally figured out an eating disorder in a young athlete coming in for PT appointments - and it often requires careful nuance in how to get the patient to talk and how to get them to consider the right solution. Physicians, for all their value, aren’t necessarily the right diagnoser-in-chief according to parents. 90%, of 516 polled, said their teens would much rather open up to a teacher or coach than the pediatrician, and they would much rather talk to a friend or even stranger, than their doctor. As for seniors? 56% in our poll say mom or dad most open up to strangers - the person they sit next to at Sunday mass, the home health aide who they’ve never met, or the cleaning staff who come to their home on Tuesdays. Cigna agrees that more of the health system needs to improve how it screens and reacts to these situations.

Radiologists Beware: Artificial intelligence is making its mark on cancer. A study published in Nature earlier this month shows that AI performed better than radiologists when locating certain breast cancers on mammograms. Back in May, Google also collaborated with researchers to show that computers were equal or better than doctors at finding small lung cancers on CT scans. And most recently, brain surgeons started using AI in the OR to help diagnose potential brain tumors during surgery.

Hospice PowerHouse: Humana, which represents the second largest provider of Medicare Advantage plans in the country, acquired Enclara Pharmacia, which provides pharmacy services only to the hospice industry. The deal is expected to close in the first half of 2020 and seems to be another step in Humana’s quest to better control the continuum of care and end of life costs. Humana also acquired Kindred Healthcare (home health) and Curo Health Services (hospice) in the last few years.

Extra Point: So I play Sunday hoops with several Cigna, Aetna and other health plan insurance ballers. It’s old man hoops with a classic Princeton-like flare. Backdoor cuts and pick n’ rolls, fighting through screens and using the glass on a 10-footer, rather than 3-pointer. They won’t let me talk about their missed layups or mysterious muscle cramps, but they are willing to chat about health policy in between games. Not exactly locker room banter, but c’est la vie. This issue features a host of changes from Cigna. Most seem up the fairway but one caught my attention. Former NBA player Chris Herren’s drug addiction is chronicled in the documentary ‘The First Day,’ a film Cigna is promoting as part of an educational program with schools and communities. Horizon BCBS created its own school musical focused on addiction, and others are looking to film as a way to prevent the disease. These are refreshing trends for insurers to support these stories. In my time before writing 24-7 about healthcare, I used to review films and I watched one of the 10 best with my son Tommy last weekend. Coach Carter, which features Samuel Jackson as a coach trying to change the lives of a high school basketball team living in a community where drug dealing and abuse was commonplace. It’s one of the 10 best films ever about losing in sports, partly because it ended with a loss, but also because it showed me that changing behavior – be it in healthcare and physician decisions, or in our kids and parents - requires less emphasis on what is and more on what can be. Here’s that losing sports top 10 review: (https://thebehavioralhealthhour.com/the-lost-column/). Stay tuned, maybe a healthcare top 10 is next…

39: Percent of insurers, up from 14% last year, who will focus on adjusting or trying to ‘rework’ value/shared savings contracts given first wave of contracts are ‘too easy’ to hit targets for. Results published in the upcoming Managed Care Investment Index.

ENT's Balloon: A number of insurers are updating policies for balloon procedures done by ENTs to address chronic rhinosinusitis. Starting this year, several Blues will require a full course of treatment for all of the following before considering balloon dilation: nasal lavage, intranasal corticosteroids, and antibiotic therapy if the physician suspects a bacterial infection. The earlier criteria was more lax, allowing physicians to either skip some of these or not carry out a full course. If symptoms persist after full courses of all of these, then insurers are more likely to approve.

Have You Met Formin? Diabetes is an interesting new priority for Medicaid plans given there are several changes taking place in the treatment of the condition, and in early 2020 new treatment guidelines are expected. Medicaid managed care drug utilization review boards are planning to debate. Both Utah and Mississippi’s board are running analytics and found at recent meetings that a lot of their Medicaid beneficiaries with diabetes have no history of a documented trial of metformin before initiating another diabetes drug, and many who have been prescribed the drug without any diagnosis. These review boards want to explore opportunities for pharmacies to be able to intervene at the point of sale to change metformin from immediate to extended release and likely make other changes as more data gets reviewed.

Dry Needling: If you work at a practice that does dry needling, perhaps a PT group, there are some new billing rules coming out. Blue Louisiana, for example, now requires you to bill this under manual therapy code 97140 and use modifier CG. You can longer use codes 20560-61 for dry needling.

Surgical Appropriateness: If you do spine surgery, radiation therapy or advanced imaging of the abdomen and pelvis, new coverage criteria will be published in February by AIM Specialty. The guidelines will sharpen the rules on what’s clinically appropriate, and what isn’t. AIM is increasingly a key managed care decisionmaker for Anthem and BCBS health plans.

Oh Baby: 11% of United members in Mississippi deliver babies before term if enrolled in the plan’s healthy first steps program that offers individual care plans including getting followed by a care coordinator until 2 months after delivery. This compares favorably to the Mississippi average of 17%, according to United Healthcare community plan pharmacy director Heather Odem. Other insurers have similar care coordination initiatives. Molina’s pharmacy manager Trina Stewart says they have a process for identifying good candidates for their motherhood pregnancy monitoring program, then they give coordinators the patient’s information.

Quality Behavioral Health: Illinois BCBS has created new tip sheets (click here) to help providers satisfy HEDIS measures for behavioral health.

In Network: Houston’s Kelsey-Seybold multi-specialty group is in network with BCBS in a new value-based contract kicking off this month for PPO and HMO members. The group, founded just after WWII, has 400+ physicians.

Extra Point: That knee pain I felt after a few games of basketball over the holiday persisted last night so much so that I’m now self-diagnosing arthritis, though whether I do anything about it is another question. My bride says I should just talk to a doctor and not my buddy Jay in between hoop games. ‘Don’t be a dummy,’ she says. In my defense, I’m not all that different than most guys on the cusp of 50 – just 19% go to the doctor regularly according to one poll I saw. It’s probably why so many health systems are looking to expand woman’s health as a service line, because they see value in the household’s health CEO. My dad will take a look at my knee later today and, knowing him as I do, tell me to ‘just go see Dave.’ Dave is Dr. Burstein, an orthopedist who did my ACL repair when I was 19 and has helped my kids over the years with their litany of injuries. I’m sort of nervous about the visit because I don’t want to have to rely on medication, injections or God forbid miss hoop games. The only chronic condition I’ve ever had is losing. I started writing about it 8 years ago here in this column (click here). I guess the one difference is that losing isn’t bad for your health. I would argue it’s the best medicine. But pain in my knee? That’s a horse of a different color.