Behavioral Health Insights

1.      New #1: Primary care moves up 9 spots to become the top priority in our 2020 Managed Care Investment Index, results to be released in January. Telehealth, for all its critics, jumps 15 spots to #3 as part of a move to use it as a triple threat: interceptor of care, diverter and treatment. ‘We had been missing the point of tele for a lot of years. It’s a better way to do network steering,’ says Charles Bright, network relations for BCBS. Infusion, a staple in the top 20 recently, moves into the top 5, while PT, which had slipped, moves into the top 10. The changes are generally good for PCPs and subsectors serving them, but mean pressure for others around site of service and payment.

2.      Year In Review: Here are the 10 most viewed stories from 2019 in case you missed:

1. Losing beats winning

2. Indiana health system taking risk, changing behaviors

3. Avoiding autism’s cliff

4. Caregiver health decline becoming epidemic

5. 560,000 referrals to social services

6. Moms vs Dads

7. Inside the mind of young physicians

8. Brainstorms

9. New mental health ER already at capacity

10. Zero splat points is not the point

3.      The Replacements: A new study shows how older patients with joint replacements are recovering at home rather than a rehabilitation center or skilled nursing facility. The JAMA Internal Medicine study looked at 17 million Medicare hospitalizations from 2010-2016 who went home or to a skilled nursing facility after their procedure. The patients who were sent home with home health care services showed the same level of functional improvement, such as ability to walk and go up and down stairs, as those who were sent to a skilled nursing facility. Medicare costs were lower for patients who went home. New York University researchers reported in JAMA that from 2009 to 2012 and 2013-14, discharges to rehabilitation facilities fell from 68% to 34% for patients undergoing hip and knee replacements.

4.      Home Alone No More: Utah’s Intermountain Healthcare, a health system that operates 23 hospitals and nearly 170 medical clinics, is bringing an array of services — palliative care, dialysis, primary care and hospital care — into the home through its new Intermountain at Home program. Recovering at home after a hospital procedure is also a focus, and Intermountain has created standardized procedures for hip and knee replacements over the past few years, according to Rajesh Shrestha, the system’s chief operating officer of community-based care. Every joint-replacement patient going home after surgery now gets a thorough assessment to determine the resources that are needed. A care plan is created and a case manager, usually a registered nurse, makes sure that physical therapy, durable medical equipment and home health care are supplied. The case manager also coordinates postoperative care with orthopedic surgeons and makes sure that patients reconnect post-surgery with their primary care physicians. A team of providers is available 24/7.

5.      OON Claims: Starting in January, BCBS of Illinois implements a new process for specialty drug claims filled at an out of network specialty pharmacy. If members continue to use an OON specialty pharmacy they may be responsible for the full cost of the medicine. Based on their plan, members may be able to submit a claim to have their OON benefits applied.

6.      MA Plan University Partnership: Beginning in 2020, Bright Health will offer Medicare Advantage plans for the first time to Cleveland-Akron, Ohio-area residents through a new partnership with University Hospitals. In an expansion of its existing collaboration with Mercy Health, Bright Health's Medicare Advantage plans will now also be available in the Lima area. Bright Health plans have some of the lowest maximum out-of-pocket limits of Medicare Advantage plans available in these markets. Bright Health's model features a so-called proprietary Care Partner Network developed specifically for Ohio residents based on several criteria, including comprehensive care across specialties, geographic reach, quality of care and operational efficiency.

7.      Saliva: George’s fiancée, Susan, has made us all think twice about licking the envelope this time of year, victimized by her own saliva and a toxic adhesive in the classic Seinfeld scene. Saliva tests for drug addiction are much safer than Costanza’s envelopes, but are they accurate? Several insurers say there are a high number of false positive results with these tests, particularly in smokers. These tests are likely to be scrutinized more in the coming years by insurers as they attempt to help in drug detection, but do so affordably. Saliva tests can help with detecting very recent abuse but they only detect abuse for a few days.

8.      Extra Point: My 16-year-old played Judd Nelson’s John Bender character from Breakfast Club fame this week, called in for an out of school comment that landed him in the Principal’s office. It’s a twist for a kid whose teachers consider him a leader and for my bride and I who think of Jackie more as Anthony Michael Hall. He slipped up using a phrase in a kind of truth or dare question game with a group of kids who didn’t like it. Said in the huddle during hoop practice and nothing happens. But that’s adolescence: hear social media say one thing, our President say another, your parents push you to be respectful, classy, kind, but bold. Mental health took a bit of a dive for Jack following the Breakfast Club consequences. He was mixed in for a full day with kid repeat offenders - smoking on campus, selling vape, cheating on another test. Our kid’s mistake is a growing pain, character building and while disappointing, doesn’t change what we think of him. Question is, does Santa give him candy or coal?

600,000: Number of people who are weekly users of the drug methamphetamine in the United States. The State of South Dakota launched a media and billboard campaign -- ‘Meth: We’re on it’ -- to bring awareness to the epidemic and destigmatize substance abuse disorder. The campaign went viral on social media with many people questioning the ad’s message. The campaign uses a website to help educate people in the U.S. on the signs of meth addiction and provides the resources available to combat addiction.

Volunteers Back: First Tennessee’s college football team, which heads to the Gator Bowl in 3 weeks, and now a study showing that volunteering reduces depression and improves overall health, including lower blood pressure. A survey for Charity Community Service Volunteers found that half of those who had volunteered for more than two years said it made them feel less depressed. The poll of more than 600 volunteers also found that 63% of 25-34 year olds and 62% over 65 said volunteering reduced their stress levels.

Gene Therapy Outcomes Pay:  Cigna has developed a coverage program, the Embarc Benefit Protection, for two gene therapies that don’t require any out-of-pocket payments related to the cost of the medicine. The insurer will pay a per-member per-month (PMPM) fee, starting in 2020, to access Embarc’s gene therapy network and physicians are required to submit prior authorization requests for patient eligibility. Novartis subsidiary AveXis developed the gene therapy Zolgensma and is partnering with Cigna’s coalition members offering payers pay-over-time options up to five years and outcomes-based agreements up to five years for the drug.

The Caymans In Network: 70% of risk-taking PCPs across 11 predominantly southern states polled (about 200 doctors in all) say they are interested in a story we posted a couple weeks back about a business called Price MDs that helps groups avoid super high cost drug expenditures or treatment costs, like 80% below typical levels. In a common example, there are some rheumatology drugs that are in the millions each year so "this network helps us send the patient basically to a 1-day vacation to an outpatient center that’s fully licensed and meets all the requirements, for ‘mere pennies’ " – it’s a good model for risk takers, and an indicator for any risk taking practice – where are you sending patients and are you sure you know the cost of that decision?

Integration Rx: In the latest move by the big insurers to integrate medical and pharmacy, UnitedHealth is acquiring the specialty pharmacy and infusion services provider, Diplomat, which manages medications for patients with complex diseases, such as cancer, hepatitis, HIV and multiple sclerosis. The company will be part of the Optum organization.

Falling Down: I mentioned last week at our conference’s managed care panel in DC that my mother-in-law fell 3 times over a 2-year period because she was orthostatic and dehydrated and, ultimately, wasn’t being monitored enough. Humana will soon be able to deliver a more integrated, meaningful care experience for its high-risk Medicare Advantage members, like my mother-in-law, through a partnership with Royal Philips. Humana will identify at-risk MA members and offer them a Philips Lifeline medical alert service, including a fall detection device that is supported by predictive analytics technology. The partnership will also aim to help those members with CHF, allowing these patients to proactively manage their own care from their homes with remote monitoring.

Avoidable Admit: Several hospital systems are combining efforts to provide in-home care to patients who would otherwise have to be admitted. Ascension, CommonSpirit and Highmark Health are among those in the collaboration. A Highmark executive says they were initially surprised at how many patients were flagged as potential candidates for at-home care, according to a spokesperson. Messina Health noticed that at least 40% of the system’s admissions were for medical complications that did not require 24/7 monitoring.

MacEnroe The Boat Ashore: The tennis legend never believed the baseline official had it right and his iconic, if not incredulous, stance depicted here in this story serves as a metaphor for healthcare leaders today trying to figure out the right baseline target for total cost of care. Click here.

Extra Point: In 2020, United will start to pay oncologists for following evidence-based pathways. The program will reward physicians for following the pathways at least 75-80% of the time. This is not novel - Aetna started this back around 2010 and Highmark BCBS before that. Ira Klein, MD, a medical director for Aetna at that time, told me when I was reporting on these issues that the idea would be to share savings by encouraging the right choice of drug protocol and post-treatment at home, but that there are always circumstances when the patient or tumor type requires a unique approach. If I tried this model with my kids, it would fail miserably. Of my 5 kids, 2 of them will eat the chicken and rice and veggies, the rest say they need some combo of mac ‘n cheese, Oreos and Honey Nut Cheerios. 1 will clean her room, the rest will have too much homework. 3 will practice their instruments, 2 wing it on concert night. And as I’ve instructed, 3 don’t use semicolons in their essays, as they are the lazy man’s comma, but 2 still do. Well, you can’t always change behavior and here’s hoping United has more success than I have...

10,000: The number of psychiatrists across the country we’re missing, and 40% of the ones we do have do not take commercial health insurance, according to a panel of Medicaid behavioral health professionals who debated the issues at BRG’s healthcare leadership conference Thursday in Washington DC. Other takeaways: payers are asking providers to ‘please accept Medicaid and please make telehealth work’, and they see a growing need for transitional housing for patients swept up in the opioid crisis.

Worried Well: As Archie once said, ‘why do they always give me a shot where the pain ain’t…?’ It was classic Bunker, worried, agitated and usually offensive. I wonder what he’d make of all the changes in healthcare – urgent care clinics, for one, are more often than not staffed by allied health providers. Bunker only wanted ‘regular doctors’ as he called them and, even though he didn’t know it, he had a bit of managed care in him. ‘Do I really need this um needle?’ he would argue. If there’s one delivery model set to face some turbulence between now and 2025 it may just be urgent care. Even though it has found an important niche in the health system, the advent of more front-line tele models and nurse hotlines and apps will likely continue to be a volume diverter that hurts these retail clinic models at least those in competitive, saturated markets. ‘They absolutely have a place but when we start seeing the ambulance show up every hour to take patients to the hospital, that’s a big flag for me,’ says Valerie Andrews, a network manager who just moved into the Connecticut market. ‘My sense is 20-40% of cases would self-resolve.’ The ones able to use data and use their clinic to do urgent and follow-up care or ‘have a PCP traffic cop mentality,’ they have sustainability.

East Meets West: 517 parents who have children on the spectrum are not shy – about 75% in our poll say the best place to get their kids services quickly and cost effectively has no doubt been the northeast and mid-Atlantic, including Pennsylvania, but by the time their kids roll through their teens and hit adulthood, the geography changes. 81% say there’s limited access to any sort of programs to help their kids, now adults, transition to vocational schools or jobs, but if there’s a region better suited to help foster a good transition, it’s the west. Think Seattle, San Francisco, Portland. Cities with companies focused on populations needing help transitioning into adulthood. These companies should become more necessary and visible over the next 5 years. Question will invariably be funding. Anthem’s moves recently to reduce payment rates are a signal that they anticipate increasing volume for autism treatment.

63: Percent of commercial plans who say telepsych is now one of their top priorities for 2020 – how to pay for it, contract, and fit it into benefit design. Driving this? ‘Dissatisfaction’ with existing ‘behavioral vendors’ who lack the savings and integration with primary care. The number of ‘vendors’ now pitching the plans is going up, though – from smaller start-ups like iHope to the pioneers like Insight and now the traditional telehealth companies entering the space. Their role in helping get appointments for patients right away will be a key to success for risk-taking primary care practices, hospitals and schools.

Rx Patterns: A physician group in the Midwest used to just grade its own doctors at a therapeutic level by compensating them based on their generic dispensing rates, but now they’re getting creative – convincing its Blue plan to share data about the prescribing patterns of all the doctors in the area where its PCPs refer. The idea, practice administrator Melanie Figlante says, is to get visibility into doctors outside the group and help show the PCPs that their ‘referral decisions’ may be either too costly or simply clinically inappropriate.

The Ambulance Won’t Leave. Ambulances of all things will be incentivized through new forms of contracting to go directly into people’s home to diagnose and treat and avoid the transport to the ER, according to interviews we have been doing with commercial and Medicare plans. It’s like what I thought Peapod ought to do back in 2013 by adding nutritionists or therapists when they drop-off food. Bring more value to that home visit. For ambulance companies, it could be tricky: Doesn’t mean the 70-year-old with chest pain won’t be transported to the hospital, but it does give the ambulance clinical flexibility to make a decision based on data it may have on their device based on a patient’s history. To check blood pressure and ask questions. Yes, it means the ambulance’s clinical team need the ability to diagnose and ‘make a call’ and it may create challenges around all the gray area, but it’s a step in the right direction for healthcare. Suggests that the healthcare company of the future isn’t just a doctor or a service, nor is it a technology company or a logistics company. It’s really just a health delivery company that blends everything.

Pressure: Not A1C control for diabetes or regular dental check-ups or, heck, exercise. No, the number one way that the health system can have its biggest impact is with hypertension.  61% of 310 practitioners say so from a cast of private practice doctors and payer medical directors. If missed and not managed, the so-called silent killer leads to stroke, hospitalizations, dialysis, wheelchairs. Expensive wheelchairs. If you’re in the primary care space in some capacity, or even if you’re a therapy provider dealing with pain and injury, how you are looking for and addressing hypertension will be increasingly important, particularly if your payment increasingly shifts to cost avoidance.

Specialty Pickle. So value based models are encouraging less testing, more primary care oversight and management of patients, and more flexibility to frontline providers to manage patients themselves. But value models are where the payment is headed, particularly in Medicare. How the capitated payment from the insurer is shared, how savings or payments are attributed or divvied up is going to get more complicated particularly in markets where the insurers hang their hat on a PCP led value based strategy. How will savings and payments be attributed for example particularly in situations when the PCP has the risk contract and uses outside specialists who have contracts with the insurer. Several specialists have an opportunity to make a play to be the primary care provider for their chronic patients and essentially avoid these attribution challenges. Think Crohn’s or irritable bowel disease managed by the GI doctor, or OBGYNs, behavioral specialists focused on addiction or cardiologists for heart disease. Some primary care groups are building multi-specialty practices to avoid the disjointed system, to make the handoff more effective – to share data right away so the specialist – or subspecialist – has all the information to do the right thing to solve the problem and stop it from happening again.

Intelligence: Worried machines are going to take over managing patient care? Don’t fret! A panel at our conference said AI needs human curation, particularly in healthcare. Data is so massively complex that a human eye needs to help determine that the output is correct and safe, but we can’t enter data with a bias. The machine will pick that up. So just as we’ve created programs in real life to guard against bias, like affirmative action, we need to think about creating these in AI. Start small in your practice: design an intelligent solution with 3 things: historical data, labels, and a well thought out business problem that can be stated in a couple sentences.

1 v 1: Health insurers are turning to technology platforms to reach teens and young adults for their mental health needs. Blue Shield of California has collaborated with the California Department of Education to make mental health resources available online for middle and high school students. Its program, BlueSky, will have one-on-one therapy for students and a mental health first aid training for public school teachers and staff. BlueSky will include organizations such as Wellness Together, National Alliance on Mental Illness California and DoSomething.org, and will be evaluated by a research team from the University of California following its pilot to determine the impact on student- and school-level outcomes.

Extra Point: So true to form, I ran over the recycling bin again today enroute to say goodbye sadly to an old friend.  Happens every year when the 14 feet of snow pile up and turn our 2-lane driveway into a skinny, icy bowling lane mailman lawsuit waiting to happen. And today is one of those where my conscientious kids decided to put the week old rice and beans and pasta leftovers into the bin. So here I am, 5:30 am, bleary-eyed from a late flight home, on my way to drive 2 hours to Massachusetts and on my hands and knees pulling food scraps off the road, my blue suit muddied, my hands cold. Zaggy, our labradoodle, who I’d describe as part stuffed animal part monster, thumped his 67 pounds down our icy driveway. My problem was about to be solved, only thing is the $1,500 electric fence – Zag wouldn’t break the barrier this time. My neighbor Allen simply shook his head. He knows my pain. Allen gets locked out of his house every other week and can only enter through the back window, made much more difficult in 2 feet of snow. This is life for unprepared and easily distracted dads in the northeast. But I’ll say this for New Englanders – the winter bonds us. There is real community here. The shoveling and ice melt. The D&D runs and igloos. First story I ever wrote for the Herald back in my late 20s was about a group of kids and their igloo. Photo made its way into the Swampscott Reporter in December 1999 and a young teacher from Peabody, Cara Murtagh, had me come in to talk to her students about it. About how to engage readers and write a ‘how to story’ in less than 100 words. It's been 20 years since I was in that class. That friend I'm saying goodbye to today is Cara. Just 44, but boy did she make an impact. Her story here

1. 5: The amount of copay for a Physical or Speech therapy visit starting in 2020 for Cigna HMO members in Arizona, a change from the $20 this year.

2. Concierge Is Back, With A Twist: A company called Accolade will act as the “front door” concierge practice for life science manufacturer EMD Millipore’s 18,000 some employees. BCBS of Massachusetts will administer the benefits but Accolade will be the contact - handling care management, triage, steering members to care, and managing costs. Think of it as a new version of a benefit manager.

3. 2021 National Network: If you’re a physician group or outpatient therapy provider and you’re not in the soon-to-be-coming national Blue exclusive provider networks, or EPOs, you’re probably missing out. Blue plans, according to 37 of the 40 we polled, will start offering these plans in 2021 to members of self-insured and national employers. These so-called ‘high performance networks’ will be based on a soon-to-be revealed quality and cost metrics score.

4. University Free: Showing just how severe the psych shortage is, health plans are starting to pay the full-ride for PCPs to train them on mental healthcare. Where and how it works, and how it may complement the growing trend around telepsych - Click here

5. Downside Risk: Non-solicitation and right of first refusal terminology are new and potentially risky requirements that primary care practices and other healthcare providers will have to manage if entering into contracts with Medicare Advantage insurers. It’s a new world and this piece, based on interviews we did with about 30 MA risk contracting veterans, lays out the trends. Read the story here.

6. Blue & Buckeye Huddle Up: Even though Ohio and Michigan battle next weekend in football, they have partnered to study healthcare utilization. OhioHealth and UM found decreases in ER and specialist appointments, as well as PCP visits, and the Icahn School of Medicine at Mount Sinai echoed this trend, finding a 20% per person drop in PCP visits from 2008 to 2015. Icahn studied a sample of 3.2 billion visits, according to a description of their work in the Annals of Family Medicine. The declines are likely geographic and population dependent. We assume urgent care has taken part of the share particularly in more urban areas, and of course there will be differences by age - less for healthier young adults, less for males 20-35 (based on our polling), and higher for chronics. Authors also suggested longer appointment times for more complex patients and increasing reliance on nurse practitioners and physician assistants as likely factors.

7. Transporting Medicaid Patients: Handoffs have been the core issue limiting progress in preventing overdoses but L.A. Care, a Medi-Cal plan serving LA county, is piloting a 12-month program that provides transportation for its members hospitalized for substance abuse to residential or community-based treatment. This initiative is interesting given that substance use disorder and specialty mental health services are not under the responsibility of Medicaid managed care plans here in California (they are what’s called ‘carved out,’ covered through a mostly county administered system).

8. College Kid Initiative Could Impact Personal Care: A kid at my wife’s school was being evaluated yesterday for potential spectrum issues and during the 25-minute Q&A, the 11-year-old said she is ‘always’ lonely and that ‘no one ever calls her house.’ The problem is addressable because the young girl is in a school setting from 7 to 5 each day, but for seniors the challenge is exacerbated without caregivers. Aetna is launching a new partnership to help combat loneliness among their Medicare Advantage members. Starting in 2020, Papa Inc. will link college-aged caregivers called “Papa Pals” with seniors who need help with companionship, house chores and technology lessons. The program will be available to MA members living in Florida with one or more chronic conditions but likely roll out more widely if effective. This initiative further validates demand for personal care but it also shows that insurers are trying to think about being creative in how they pay for and deliver these services.

9. Pharmacy DownHill: Express Scripts, starting this coming year, will take over home delivery of pharmacy for Cigna.

10. Prior Authorization Stats: Surgery and Imaging were the two most denied services according to several insurers who track prior authorization trends. Denied PA requests for imaging were around 31%, surgery around 47%, according to one insurer who will release the full results to us as part of a 2020 study. Additionally, insurers continue to add CPT codes to prior authorization lists, but remove others. Starting this month, Cigna added prior authorization requirements for 67 of these codes but dropped 40. Regence BCBS added tougher criteria to get hyperbaric oxygen therapy approved for skin grafts while easing criteria for sacroiliac joint infusions. HCPCS drug codes also get attention, like the new requirements for gene therapies like Luxturna. The PA trends are unavoidable and manageable; outpatient providers should track and retain data to help them avoid PAs. There’s precedent with payers like Regence of reducing requirements for consistently high quality providers who try to do the right thing.

11. Extra Point: In less than a week, Janine will ask all 19 and counting at our stained, or as mom would say ‘lived in’, dining table to tell us one thing we’re thankful for, at which time Tommy will spill his water, Jackie will already be onto seconds, my mom will be in the kitchen, and Aunt Edna will be asking where the ravioli is. Yes, in an Italian household, there’s turkey and ravioli. I’m usually the last to go and have little to say other than Salute, but this year I’d like to offer something more impactful. Maybe I can say I’m thankful my kids remember my passwords, or that I’m thankful my gym membership allows us to enter without the key card I keep losing. Or maybe I ought to be thankful Mukue’s acceptance to Springfield College only comes with a $9,500 bill because the next 4 kids won’t be so cheap. Maybe I could say I’m thankful for teenagers, but I’d be lying. I am thankful for my bride and I am no doubt thankful that sometimes I make predictions in the work we do that are at least somewhat more accurate than the New England weather people. I’ll come up with something hopefully but in the meantime, I would say for those who read this point every week and others we’ve come to know over the years, we are thankful to you and hope you all have a restful, happy Thanksgiving. Mangiamo!

We sat down recently with our managed care contracting veterans from more than 30 MA plans and provider groups, and they clued us in to several new and eye-opening changes finding their way into Medicare Advantage risk contracts these days, including increasingly shocking terms designed to protect the plan. In this special Managed Care Friday, we lay out some of the terms and lessons. Click to read more.

1.   174 of 221: Middle schools in our poll this week who said they hoped to add psych and mental health programming and staff into their 2020 offering, including experimentations with telepsych in some districts and partnerships with local mental health groups, but have ‘struggled to staff and recruit’ due to a shortage. Only 86 of the 174 say they filled their slots and started programming.

2.   Extenders Win: In an effort to increase access to healthcare, Anthem Virginia now contracts directly with NPs and PAs for its Medicaid beneficiaries under new state regulations that took effect last month. These allied health practitioners, if credentialed with Anthem, must bill the company’s HealthKeepers system directly using their own ID; billing incident-to is longer applicable. Nurse midwives are contracted separately.

3.   Second Opinion Out: While pre-authorization is still required, the city of Chicago will no longer require employees to get second opinions for hip, knee, shoulder, neck, gallbladder and gastric bypass surgeries. The city used to require its BCBS of Illinois insured members to go through a service called Best Doctors to get second opinions; the service reportedly reduced the number of surgeries needed by 10-15%. The new policy takes effect in January 2020.

4.   Medication Drop Ship: UPS is expanding into healthcare, or at least the delivery of health care products. It has partnered with CVS to test delivery of prescriptions and retail products to the homes of CVS customers, not by the brown trucks we are all familiar with, but by drone. UPS Flight Forward, a subsidiary of UPS, already uses drones to ferry lab samples between locations of WakeMed hospital in North Carolina.

5.   Uber Meet Cerner: Uber Health is partnering with Cerner to allow hospitals to schedule non-emergency medical transportation pick up and drop off through Cerner’s hospital EHR platform. Patients do not need to be Uber customers or have either the app or a smartphone because health care providers will set up the service.

6.   Uninsured Target: In 2018, 5 million Texans had no health insurance but efforts to address this are here as BCBS of Texas will open 10 Sanitas-branded clinics in the coming weeks in areas where the highest number of uninsured people live like Irving, Mesquite, and Houston. These PCP-retail clinics will compete with Walmart’s health clinics and CVS Health’s 1,500 new health clinics opening by the end of 2021.

7.   Behavioral Switch: In a continuing trend, insurers are moving management of behavioral in-house – the latest being BCBS of Illinois, which is set to take over behavioral benefit decisions for AT&T employees starting in January. It will replace Beacon Options, the current benefit manager.

8.   Radically Different: Even as insurers begin to lay groundwork to require episodic payment for radiation treatment, they are adjusting the criteria for coverage, and sometimes in positive ways. Anthem, starting in February, tells us they will broaden the description of adjacent normal issues which may be a concern and allow for IMRT or SBRT and add new guidelines for fractionation with EBRT or IMRT in treating prostate cancer. AIM Specialty is making the changes and overseeing decisions. Contact me for full details.

9.   United Changes to Site of Service, Technical Payments: In October, United Healthcare started doing site of service reviews for sleep studies for its Medicaid plan in Missouri and starting in February, United will start doing site of service medical necessity reviews on MRI and CT for its Oxford commercial plans. Additionally, UHC will no longer allow separate pay for the technical part of neurophysiological studies (billed with codes 92585 and 92587) and audiological function tests (billed with code 92588), when these are reported at a facility place of service. Currently, you can bypass the denial under certain exceptions. The new policy mirrors CMS rules.

10.   Tech Boom: 46% percent of young people would prefer to have a broken bone than a broken phone, according to Margaret Laws, CEO of Hopelabs, which has developed technologies to improve the emotional health of teens and young adults, including mobile apps, wearable devices and virtual reality enabled diagnostic tools. These tools come at a time when depression is up 52% on college campuses and college counseling has increased 5 times due to anxiety, depression and stress. In high school, the numbers are equally staggering, with a 22% rise in the latest poll of freshman experimenting with eating disorder behavior, according to one of our latest polls of 812 parents. Using technology to help the Gen Z population access support more quickly is one solution. Laws, who we met at the Connected Health Conference in Boston in October, says teens are asking questions like “why can’t I text with my doctor?”

11.   In case you missed it:  Check out stats on where medical residents are looking to hang a shingle in our new poll-- click here.

12.   Extra Point: I lived with my grandmother Carmella when she was about 10 years into the Alzheimer’s, so I was struck this week by a documentary about a boy and his dad and a disease that may be hard to understand and impossible to manage, but doesn’t need to be the end. Read more about it here.

110: The number of nurses Blue Carolina is using through its new Health Blue Line to help members facing a serious medical event or chronic condition. Initial calls can last between 30 to 60 minutes, with follow-up calls lasting around 15 minutes. Through an integrated care management program officially launching in January 2020, nurses will refer patients to outpatient services, community resources, and PCPs as needed, including for behavioral health help.

Telehealth Momentum: Despite last week’s study revealing senior dislike for tele-encounters, Intermountain Health System has launched a Kidney Care Center with doctors, nurses, and dietitians providing at-home dialysis and access to treatment through a telehealth platform; while Amazon just created a virtual care clinic for Seattle area employees, their dependents, and some aging relatives meeting criteria.

Walmart University: Perhaps not ready for Big 10 football, but nearly free college courses are available to its workers who want to become pharmacy technicians or opticians, as well as behavioral health for a total out-of-pocket cost of $1 per day. Walmart covers tuition, books, fees, and counseling support and will plug in the new trainees in its own Walmart and Sam’s Club stores. The University of Florida, Southern New Hampshire University, and Purdue University Global will help in training.

Video Game Addiction: My youngest suffers, and my usual approach is to toss the phone in the garbage. The UK has a softer approach: it has opened its first clinic to treat video game disorder, which the World Health Organization will put into its disease catalogue in 2022.

Angama Health: A cloud-based tool leveraging artificial intelligence in helping physicians and their patients get access to medications as a part of Georgia Tech’s Advance Technology Development Center incubator accelerate program. The startup intends to utilize AI expertise and resources to minimize physician and patient access friction to specialty and branded medications in an effort to provide more effective therapy. 92% of physicians reported the prior-authorization process required by health plans is having a negative impact on patients’ clinical outcomes, according to an American Medical Association survey.

Painfully Ineffective: A new report says a common therapy for joint pain may not be as helpful as once believed. Corticosteroid injections are given to reduce inflammation from osteoarthritis, but a recent report found that shots in the hips and knees may accelerate the progression of osteoarthritis, the Arthritis Foundation reports.

Welcome to LA, We Hope You Stay: LA Care Health Plan, a publicly operated Medicaid managed care plan in California, is spending $500,000 to help train 50 Community Health Workers who will, among other things, help implement a state Medicaid program that serves members with certain chronic health and mental health conditions access enhanced care coordination services, including referrals to community and social services like food and housing. Some of the trainees will work for LA Cares, while others will work for community-based care management entities, such as the member’s assigned primary care providers. Training will be offered through Loma Linda University.

Extra Point: 26-year-olds coming out of residency are getting less predictable. Interest in traveling positions that plug in the doctor for 1- to 3-month stints in interesting and oft times ‘vacation-like’ destinations are increasingly popular, despite prior-year demand for security and limited hours in a hospital or academic environment. The initial results, available at the link here, are part of a multiyear study on physicians we started about a decade ago, and they are a window into how to recruit doctors and how to use them.