Behavioral Health Insights

68: Percent of older adults who say the quality of care would not be as good as a face-to-face visit, according to a University of Michigan National Poll on Health Aging, with half saying they did not feel personally connected to the health care professional and 4 in 10 reporting difficultly seeing or hearing. The poll asked a national sample of 2,200 adults, ages 50 to 80, about their ‘tele’ experience.

Prostate Story Twist: Nebraska Internist Marvin Bittner ended up buying one of those imaging vouchers through MDSave to cover an MRI his doctor thought was necessary to identify suspicious areas for targeting during a prostate biopsy. And who said doctors weren’t cost conscious? The night before his scheduled MRI, Aetna called to deny the scan, arguing his results didn’t meet coverage criteria. Bittner says his doctor was ‘using judgment’ after a series of suspicious PSA results. For what it’s worth, clinicians we talked to in the UK say they routinely do prostate MRIs before these biopsies. But rather than leave Dr. Bittner fledgling in the wind, the hospital where his doctor works told Bittner to buy an MDSave voucher to cover the MRI at a cost of about $150 less than he would have paid for the deductible had he submitted the claim to Aetna. The story ended well. No cancer. But it illustrates some oddities: (1) A US insurance company not covering something that the UK National Health Service does cover, despite its reputation and (2) The MDSave Groupon-like voucher for the entire MRI coming in at a lower cost than a deductible.

Air Conditioning Only Scratches Surfaces: So the latest move by insurers is yet another signal that healthcare is moving rapidly into the social sector. Anthem is creating a benefit for Medicare members enrolled in its plans specifically offering pest control vouchers, likely to help mitigate the causes of Asthma, while Cigna beneficiaries with COPD can get an allowance to buy an air conditioner. Several insurers are also looking to help avoid falls – Anthem offering 124 hours of an in-home personal care aide for assistance with activities of daily living (ADLs), 64 meals delivered and up to $50 in allowances for the installation of home safety devices.

Watch This: Medicare Advantage start-up Devoted Health says it is the first Medicare Advantage insurer to offer the Apple Watch as a benefit to its members. Devoted will subsidize $150 of the wearable’s cost. The move is an early example of offering wearables benefits for older consumers.

AI Boom: For Philly hoops fans, this already happened when point guard Allen Iverson led the 76ers to the playoffs, but for healthcare organizations the promise of a different AI, Artificial Intelligence, has been slow to develop, until now. 9 out of 10 healthcare executives are confident they’ll see an ROI sooner than previously expected, according to a survey from UnitedHealth Group’s health services arm Optum. AI’s potential is greatest, the healthcare leaders report, in automating prior authorization, providing patients with relevant health information using personalized communications, managing EHRs, detecting fraud or waste in reimbursement, and selecting appropriate care settings. AI has clinical benefits, but there are still many questions about its value vs. physicians. Authors of The Lancet Digital Health published study scanned more than 20,500 articles published since 2012, yet only 14 directly compared clinician and AI diagnostic abilities side by side. In sum, AI was able to detect diseases when looking at medical images with similar accuracy as medical professionals.

Burning Mississippi No More: Mississippians have a new choice of health coverage in 2020 – Molina healthcare is entering the marketplace for families looking for insurance. Molina will include telemedicine services that provide 24/7 access to doctors at the same price as a primary care visit.

Extra Point: Phil Collins’ people were on the rotary phone 38 years ago to call my dad, of all people, to help the Genesis pop legend tape the ankle he rolled in time for his show one cold October night at the Hartford Civic Center Mall. Dad, who was athletic trainer and tennis coach at the University of Hartford for nearly four decades, treated Phil like any student-athlete. My sister came along for the quasi emergency, backstage ankle taping – Collins offering dad a pair of front row seats to hear him belt out his “Can you feel it in the air tonight” number, his #1 hit back in 1981. I wanted to go desperately, but Dad picked my sister and, while I was bummed at the time (okay, I was mad), I get it now. Flash forward to two Sunday’s ago at Madison Square Garden in New York – Collins, now almost 70, hobbled on stage with a wobbly cane and a broken foot and admitted to the sold out crowd he probably wasn’t going to be skipping around stage or beating the drums, that his ‘messed up’ foot, bad back and a number of other health issues would keep him stationary, but, against all odds, he was going to sing a few songs…His teenage son played drums and my bride and I, neither having ever seen Phil in concert, sang “Follow You Follow Me” like we were still 10 years old next to the scratchy record player in our parents’ living rooms. It is remarkable how pain, injury and surgery don’t have to mean you stop. You just have to adjust. I think back to that night when the phone rang and how my mom dropped the receiver on dad’s foot and nearly choked my sister with the phone coil as she frantically, if not excitedly, stretched the phone over to dad’s ear…. I think back to how dad showed me the next morning how he taped Phil’s ankle like an artist in his own right, and I wonder if the pop star would remember that moment. If he’d remember dad.

1.   90: Percent of US population who live within 10 miles of a Walmart where finding home goods and supplies probably just got easier now that the retailer has partnered with home health company Amedisys. How the partnership will play out remains to be seen. The objective of ‘Walmart Health’ is to provide clinic-based primary care, counseling, home care, and dentistry, at reduced costs. If our straw poll is any indication, the medical director community isn’t buying yet – just 11% said they anticipate high-quality care at Walmart, with several ‘wondering if the partnership’ could potentially ‘disrupt our efforts to narrow home-care networks.’ Alternatively, these retail-healthcare partnerships seem to be increasing. Best Buy, if you might recall, bought an emergency call service called GreatCall to add to its home-based motion sensor and monitoring technology to help aging seniors. You could see risk-taking super groups promoting such a service and technology, perhaps MA plans too. Perhaps offering discounts on flat screens or DVDs if they even exist in 5 years. Can’t you just see it – while Best Buy installs the sensor in your mom’s condo, you ask the technician if he has Geek Squad credentials to help reboot your laptop. Then the Amedisys nurse arrives in a Walmart van to take your vitals.

2.   Path to the Lab Side: Contracting changes over at Anthem are probably going to lead to some challenges for pathology companies. We’ve heard that the team that used to be responsible for contracting with pathologists is no longer involved, that the job has moved over to what’s called the ‘ancillary’ contracting department, which is the same group responsible usually for DME and clinical lab. And in their first move, commercial reimbursement will change to be in the range of 60-80% of 2018 Medicare rates. Now in some markets that’s only a bit lower than the usual, but in others it’s potentially a much bigger drop.

3.  Contracting’s Next Life: This whole idea of changing who is responsible for contracts isn’t all that surprising if you consider how much insurers now have to change arrangements from fee-for-service over to value-based risk. It’s a new world so they’re trying to create specialized contracting experts. Sean Duddy, whom I’ve known for years in his role overseeing managed care contracting at the health system Franciscan Alliance in the midwest, says that ‘nowadays the number of personal contact relationships with each payer is growing exponentially,’ depending on the track you (the hospital or the physician practice) are discussing with the payer. ‘There’s a rep,’ Duddy says, ‘for the FFS contract and a different one for the ACO contract, and there are other reps involved with other lines of business.’ To listen to my conversation with Sean, click here.

4.  The Groupon Phenomenon: Patients are using Groupon and other pricing tools to get deals on bundled medical treatments and services. MDsave, a site that contracts with providers to offer these discounts, offers deals at more than 250 hospitals in the U.S. and sells discount-priced vouchers for ultrasounds, MRI’s, back surgery, and more. My wife says she wonders how good these providers are if they’re partnering with online pricing tools. Fair question, but the market is asking for these more transparent healthcare options for the uninsured or underinsured, like those with high-deductible plans. These ‘coupons’ aren’t new per se. There are deals for dental work, eye care, mammograms, and medication.

5.  UnderCare: Hospital visitation is down, membership in the public option MetroPlus declined, and post-acute care patient satisfaction is at the lowest point in 5 years here in NYC, according to a City report by Mayor de Blasio. At the same time, spending, staffing amounts, and overtime are rising. Approximately 1,081,000 people visited the 11 hospitals in the 2019 fiscal year compared to approximately 1,112,000 last year. MetroPlus, the city’s affordable health plan on Medicare and Medicaid, lost about 3,000 members. Pediatric care wait times rose approximately 1.5 days longer for care, blamed on a new EMS system, while fewer women received mammograms and prenatal care. Details here.

6.  Cardio Screening Grows: After childbirth, Cigna is now recommending providers screen for cardiomyopathy, or weakened heart muscle, because each year 700 women die from complications of pregnancy and 60% of these deaths are preventable. It will be interesting to see whether the emerging episodic payment models for maternity that include the 3 months post-delivery will include screening like this, and how that will factor into the payment to OB-GYNs.

7.  Social Screening Lags: Despite the hype surrounding the importance of social determinants of health, including new codes to report work in this area, just less than a quarter of hospitals and approximately 16% of physician practices screen patients for social needs that affect health outcomes, according to a report published on JAMA Network Open. It does appear that practices serving more economically disadvantaged populations screen more than others. Kaiser Permanente, United Healthcare, and the American Medical Association are working to address food insecurity, housing instability, and transportation, among other social barriers to good health. We reported on those new codes in the spring; click here for details.

8.   Extra Point: So I was at my checkup a couple weeks ago and my internist had the audacity to give me homework! ‘I want you to keep a log and then record your BP.’ So here I am sitting on the couch last week, filling out my log, wearing my cuff, complying. It’s quiet and my bride heads out with a friend and I tell her, ‘no worries, I’ve got this.’ My daughter Sophie quickly says she needs help studying for her ancient civ test even though she has no notes, and no textbook. We start frantically googling things about the Ottoman Empire just as my middle schooler Tommy comes to ask me if I can help him simplify some improper fractions and solve for ‘X’ which—let’s be honest—I cannot do. I shuffle him off to Mukue, who gets As in math in high school, but I leave the kitchen unguarded, so the dog starts licking the rest of the chicken out of the frying pan while my oldest, Jackie, yells from his room as though he’s the only one in the universe, to ask me if I’ve seen his stretch cord for those at-home PT exercises he keeps avoiding. Orthonet, for what it’s worth, has stopped paying for his PT visits and frankly I agree with them. And now I’m not only doing my homework, I’m doing theirs! Flash forward about 3 hours and 2 of them are crying and none are in bed….and my bride, God love her, gets home and says ’what in the world did you do?’ So I respond like I thought I should, which is to say I stood up, tapped her on the shoulder, and said ‘you’re right honey, this is hard.’ Now I don’t know about all of you, but there are times managing the care of these kids can wear you down…but I will say these moments, like helping kids with homework, do connect us. It’s this sort of shared experience many of us have not just as working in healthcare, but as parents of teenagers. I know I’m trying not to wish this away, if for no other reason than because eventually these kids will be taking care of me!

1.   Lyft In & Off:  The ROI on getting patients to appointments is so good that a network contracting team decided to hire rideshare company Lyft, even though industry commenters say Lyft does not have the same type of credentialing standards for drivers as traditional medical transport businesses (such as medical vans), according to a poll of our network operations managers. Some figured the ROI was good enough just to keep patients from using hospital ERs that they could worry about consequences later, like a lawsuit because the driver isn’t vetted and gets in an accident. Other insurers are more risk averse – one was willing to give Lyft the business for its Medicaid patients to take them to doctor’s visits, but only if they agreed to a more advanced credentialing process featuring 27 points of verification, rather than just DUI and felony records. Some managed care plans and large risk-taking primary care practices think about transportation somewhat differently – they are less convinced about the ROI. ‘I almost see the reverse trend with our population of seniors … we’re trying to bring services to people’s communities and homes, so they don’t need the taxi or Uber, but just need to walk down the hall or down the path–I’m not sure there’s ROI across the board,’ Mark Cavanaugh, MD, said of the new interest by insurers in outsourcing transportation. ‘Depends on your membership.’

2.   Oncology Strategies Vary, but Who Owns the Data? Attention to oncology is rising again but the decisions raise some new questions for providers and patients. First, a number of smaller Medicaid MCOs are requesting help from third-party oncology companies to add a layer of medical and drug treatment review and home in on things like off-label prescribing. These plans have seen a rise in incorrect diagnoses and improper treatment plans and ‘related downstream costs like hospitalizations,’ so they will pay a per member per month fee to an oncology vendor to manage the initial decisions. Commercial plans, meanwhile, are taking a different tack, trying value-based models. Regence BlueShield has partnered with Northwest Medical Specialties to implement an oncology initiative, a move that John Partin, Vice President of Network Management, says is an example of the continued move away from payment models ‘reliant on volume of care.’ The initiative is based on Medicare guidelines from the Merit Based Incentive Program. The question for oncology practices is not just how their decisions are being managed, but how their decisions and patient care data are being used, and more importantly who owns the data. Here’s a poll I did back in my days writing for Oncology Business Review that gives a window into the oncologist’s mindset: Click here to read.

3.   Farming out Behavioral: In California, in our straw poll of a couple dozen network contracting directors, there’s the sense that Medicaid managed care plans will be responsible for behavioral health by 2021. One plan is doing a retreat this month to discuss its strategy, like whether to use Magellan or do it themselves, or partner with the counties who have behavioral networks now and manage these services. Delegating is somewhat easier ‘because we can just farm it out and audit the delegated entity’ but there’s a cost to that and disjointed decisions in a time when there’s a push to integrate behavioral and primary care. BCBS of North Carolina, for example, takes behavioral in-house across commercial, Medicare, and FEP members in January. For California’s MCOs, ‘broad networks’ are likely initially given the ‘unique nature of patients,’ from SMI, SUD, and general depression to autism.

4.   McEnroe the Boat Ashore: Halleluiah, I finally get John McEnroe’s point. In case you missed last week’s Labor Day edition, we debated how the tennis legend’s iconic, if not incredulous baseline arguments serve as a metaphor for healthcare leaders today trying to figure out the right baseline target for total cost of care, particularly as providers start having success in the so-called first set of value-based contracts. Figuring out the initial baseline is one thing but then how does the insurer adjust if the doctors miss it or beat it, or if the baseline moves? How should the contract change? Our poll sheds some light: Click here

5.   Repricing: My neighbor used to run a Rhode Island hospital and recently sold his repricing software to Oscar Health, and he’s now helping an insurer build out a hospital network in the northeast but it’s not easy. The market here has been averse to reference pricing, he says. ‘They have lived in a world where the rates are 250-350 percent of Medicare, but those days are eroding.’ With reference pricing, the rates are more reasonable (like 150-180% of Medicare).

6.   Extra Point: My 9^th grader came home Wednesday saying that several girls asked her to vape in the bathroom, that ‘because you only made the freshman field hockey team…you might as well give up on sports and be cool ….’ The epidemic is quietly finding its way into middle schools too and the healthcare system is having to adjust with new clinical protocols for vaping-related emergencies, and business protocols. For instance, vaping is not typically an option doctors can select when needing to note a patient’s possible substance use. The options for smoking or drinking alcohol are there but with the current vaping epidemic, it’s becoming an issue. Paola Sandroni, PhD, a Mayo Clinic neurologist, says they recently added vaping to their queries. ‘I am afraid vaping should be considered at the same level of risk as illegal substances that oftentimes kill due to the mixing of ingredients, rather than the drug itself,’ Sandroni says. ‘Who knows what is used in the mix?!’ Michigan became the first state to ban flavored e-cigarettes and New York state wants to ban shops from opening. Vaping has been used as a sensation tool effective to quit smoking, yet the marketing towards young kids has been extremely harmful, according to 91% of 372 middle school and high school counselors in our poll last month who say ‘it’s showing up in bathrooms and locker-rooms’ and ‘it’s now an epidemic.’ They are marketed towards kids with flavors and unknown chemicals causing a mysterious disease in the lungs. “Regulated products, bad as they may be, at least must have a known list of ingredients, so you can always trace back to them if there is a bad batch,’ Sandroni notes. ‘But here we are all in the dark.” Our recent vaping story was chronicled here: Click here

A HIP or a Knee? Several of us will be onsite covering the annual AHIP meeting for health insurance plans in DC on Wednesday September 25^th. If interested in meeting, send me or my colleague Ashley Chilton a note (bcote@thinkbrg.com or achilton@thinkbrg.com) and we can try to coordinate a time.

1.   No House of Cards: Health plans are continuing to act on the link between stable housing and better health. Illinois’ Blue plan recently invested in housing to improve the health of homeless Chicagoans by partnering with private and public funders, investing as much as $1M in the project in Chicago’s Flexible Housing Pool. The two-year grant will fund housing, paired with intensive case management services, for people who are homeless and have been frequent visitors to hospital emergency rooms. The city of Chicago aims to host 750 units of supportive housing in the future. United Healthcare so far has invested in 80 communities across 18 states, resulting in 4,500 new homes in communities that also offer a host of health care services and social services such as job training and adult education. United, which began investing in housing in 2011, had Medicaid data that showed ER use dropping 60% and cost of care 50% lower for people with access to a housing initiative.

2.   Houston, We Don’t Have A Problem: In May, Humana subsidiary Partners in Primary Care announced it would collaborate with the University of Houston to open 5 senior-focused, primary care centers in and around Houston. Three of these centers are already open, with two more scheduled to open this fall. They host a mixture of staff, which could include on-site pharmacists, clinical advocates, and behavioral health professionals, in addition to physicians and nurses. The centers also function as community centers to offer free health and fitness programming, and partnerships with local food banks and community organizations. Noticeably, they accept not only Humana Medicare/ Advantage insurance, but also Aetna, Cigna, WellCare of Texas and TexanPlus. Others here (namely Aetna, Wellcare, Walgreens and BCBS of TX) are making their own primary care investment. We will explore implications during a Friday Forum call in September. Stay tuned.

3.   Vascular Diagnostics: United HealthCare will have a new preauthorization process for lower extremity vascular angiograms for commercial, Medicare Advantage and Community Plan patients starting in October. Some claims data showed that providers were using lower extremity vascular angiograms before less-invasive diagnostic approaches.

4.   McEnroe The Boat Ashore: Halleluiah, I finally get John McEnroe’s point. The tennis great rarely believed the baseline official had it right and his iconic, if not incredulous stance serves as a metaphor for healthcare leaders today trying to figure out the right baseline target for total cost of care, particularly as providers start having success in the so-called first set of value-based contracts. Figuring out the initial baseline is one thing, but then how does the insurer adjust if the doctors miss it or beat it, if our shot is too close to call, or if the baseline moves? How should the contract change? Our poll sheds some light: click here

5.   Extra Point: My daughter’s shin splints may keep her from making the freshman field hockey team this weekend, sending her potentially into a not-so-uncommon struggle to balance life without activity and the social benefits of team sports. Parenting teens through these seemingly end-of-the-world moments makes diaper changing seem as easy as toasting waffles. If I’ve learned anything with Sophie, it’s to talk about anything other than the problem or the pain….to get her to laugh about when she would poop her pants as we walked up to communion and Father Mesler would strangely run out of hosts just as I came to the front of the line. But I’m no expert and 9 times out of 10 I can’t break through. She’s 14, sometimes going on 21, sometimes still 7. But I can tell you I’m beginning to understand what my dad has taught me all these years about pain and sports and the importance of strength and conditioning. It’s why the recent efforts here by some PT groups to start athletic training programs coupled with sports psychology counselors and adolescent mental health therapists is innovative and certainly needed. Parents are usually unequipped to talk to kids after injury, not to mention help them prevent it. I know I am.

1.   Younger but Not Better: Millennials are a less healthy generation compared to Generation X at the same age. One in three millennials do not have a primary care physician and are less likely to seek preventative care on a regular basis, based on a new study of medical claims by the BCBS Health Index. The report found that millennials had substantially higher diagnoses for eight of the top 10 health conditions than Generation X, and based on their current health status, millennials are more likely to be less healthy when they’re older, compared to Gen Xers. These findings are based off a study of millennials who were between the ages of 34 and 36 in 2017, and Gen Xers who were 34 to 36 in 2014, according to BCBS. The biggest health difference between the two generations was a higher impact of physical conditions driven by increased cardiovascular and endocrine conditions including diabetes.

2.   The Next Big Bird: Oscar Health, a New York based health insurer, has announced it’s expanding the company’s reach to 12 new markets and six new states, including Philadelphia, in 2020. Oscar will compete against Independence Blue Cross, Aetna, United HealthCare, and Cigna. Oscar currently provides health care coverage in 9 states among New York and New Jersey.

3.   To The Pain: Insurer efforts to manage the pain category continue. Starting in January 2020, Horizon BCBSNJ plans to collaborate with American Specialty Health (ASH) to implement and administer a Chiropractic & Physical Medicine Services Program, which will include pre-approval Acupuncture, Chiropractic, Occupational Therapy, and Physical Therapy.

4.   Magellan Out:  To consolidate their behavioral health networks, Blue Carolina will no longer contract with Magellan on their utilization and case management, quality management, and customer service support for almost all commercial, Medicare, and FEP patients, effective January 2020. BCBSNC says bringing the services in-house will lead to improved member health outcomes, and provider and member satisfaction. Von Nguyen, MD, told me he thinks of behavioral in 3 buckets: 1) substance abuse being the number one focus; 2) the lower volume but hard to manage and potentially high-cost severely mentally ill patients, like bipolar and schizophrenia; and 3) the broader lower acute depression universe, likely important to identify early enough so they don’t elevate into substance users. Interesting that autism spectrum wasn’t its own category per se. Dr. Nguyen, who will be a panelist at BRG’s Healthcare Leadership Conference in December, focuses on helping providers have success taking risk. On addiction, Blue Carolina will be partnering with Eleanor Health soon in what Eleanor’s chief medical officer told me will be a 2-way risk arrangement paying a PMPM based on either a 3 or 5-year window to get the patient to goal. Focus will be on alcoholism and drugs, using counseling, MAT, and home and community visits to address social issues. Full interview next week.

5.   Extra Point: Middle-aged men need therapy sometimes to juggle all the ridiculous but unavoidable. There’s a new company trying to help us. I say “us” because I’m very often a case study in mental health. My longtime neighbor, Allan, asked me why I was putting peas in a Styrofoam cooler yesterday. “Haven’t had a workable freezer for over a month, so we are living off soggy waffles” I quipped.  But Allan has me beat. With 3 kids in college starting next week, repairing things is a luxury.  “Our dishwasher’s been broken all summer so we only eat off paper plates.” This is usual and customary for the family who hasn’t had a front door they could open since their oldest first went to college. Allan once had to Winnie Pooh himself through a second floor window. Not a pretty sight. I should know. I was holding the ladder. If you ask me, we all need an Allan in our life. Someone who doesn’t have it all together but isn’t afraid to show it and occasionally asks an outsider for help.... To talk us off the ledge sometimes, or in Allan’s case keep us from falling off one. We came across this new business that focuses on guys and their oft times wobbly mental state. Take a look at our interview by clicking here.

1.   406: The number of responses to our recent caregiver story about the health impact of being a caregiver and what was most shocking was that about half came from those in healthcare, and the other half from educators or business owners, almost all of whom are struggling themselves to take care of their parents. The response is by far the biggest reaction to any one story in the 20 some years of this managed care column. Our full study will be published by 2020 and we will make every effort to incorporate everyone’s ideas. A teacher from Oregon said she wishes her dad trusted others. She doesn’t have any support from other family members and has had to leave her job while she sees her own health declining. A construction worker from Illinois lost his job because ‘I needed to travel back home to help my parents deal with their cancer’, and with all the travel his own lack of exercise and mental stress caused him to have a heart attack earlier this year. A health plan contracting manager is weighing whether to put her mom in a home or leave her job – an impossible choice, she says. See last week’s preliminary study results by clicking here.

2.   Copay Out, PT In...But What Does It Mean?: In a bit of an outlier but predictable move, United Healthcare has started waiving copays and deductibles for up to 3 physical therapy visits for patients presenting with low back pain. We think the decision has more to do with curtailing addiction than expanding access to therapy. PTs in five states will be part of the rollout (Connecticut, Florida, Georgia and North Carolina), with other states likely added in 2020 and 2021. The decision is a plus for PTs for now, but if you look more closely it almost pushes PT into a hybrid model as more so a diagnostic service than treatment provider. United, like other large insurers, has found that more patients use PT almost as their primary care provider, presumably to deal with pain and hard to fix musculoskeletal issues. But patients using PT have other conditions – possibly early onset of substance abuse, ongoing psych and mental illness, or as my own dad found in his years as a PT and athletic trainer, eating disorders masked as knee pain. The traditional 7 approved visits is likely still the norm but the 3-visit, no-copay allowance is no accident in our opinion. The insurer likely wants to motivate enrollees to use their PT to get the right diagnosis earlier, and motivate PTs to better manage care. This means PTs need to improve their ability to identify symptoms. Our study, now about 5 years old, illustrates that most groups have not been focused on finding out about addiction (click here for the study). This also means that primary care providers, orthopedic practices and probably even educators and sports coaches need to make sure they have good relationships with a PT group. Cigna and Evicore are two other entities who are likely to explore similar initiatives as United given their focus on musculoskeletal costs, and it’s possible BCBS and Anthem do as well. BCBS of Louisiana has started to offer an enhanced payment to PTs for sharing patient outcomes related data. At a minimum, the pilot program diverts somewhat from the trend of higher cost share for using specialists and often times requiring PCP referrals. UHC will email enrollees quarterly ‘as they gain access to the benefit’ but there are some rules: patients have to use in-network PTs and will need to have PT benefits remaining in their plan for that year to use this benefit.

3.   Extra Point: There’s a misconception that value-based care is only for primary care when, in fact, there are a lot of specialists who become the defacto PCP for patients, like cardiologists, oncologists, or psychologists. Several insurers say they are trying to create tools to help physician groups take on more risk and have more success. ‘We were tired of having too many conversations with groups who were failing at this….so we created an entire dedicated team.’ By our poll’s count, 79 of 103 insurer executives say they have formed ‘payment innovation teams’ designed to provide tools to support doctors take risk. I’m noticing a similar issue with sports coaches in our area, too many of whom are struggling to juggle the growing number of kids on the autism spectrum playing sports. This is a good trend, but not without challenges. I once had Max with Tourette’s and Ollie with Asperger’s. The health system had labeled them on the spectrum. I had them as fast defenders. Coaches today, particularly those who like to hold 3 to 5 practices a week, are in many ways becoming a kind of specialty parent. They see youngsters a lot. They see little Bobby roll around the midfield swallowing dirt while Lucy dribbles past. They see Andy put the orange cones on her feet and Donnie put the ball under his shirt. They are teaching and disciplining, but many are failing as they try to dictate plays and structure to a diverse roster. Like their healthcare counterparts who are trying to find their footing in value-based payment design, these coaches could use their own tools to help them learn how to work with kids on the spectrum, teach kids how to behave, hustle, keep stats, make decisions by knowing the odds, and to ultimately take risks on the field without second guessing every decision. Seems like a similar lesson those of us in healthcare need as well.

1. 72: The percent of caregivers reporting mental stress and physical health declines. In our initial study on caregiver health we found that 91% of those caring for a senior family member with a condition like dementia, Alzheimer’s or cancer report mental stress, 75% report depression, 27% say they have gained weight, 19% say they have lost it, and 25% say they have been to the hospital or urgent care at least once for their own health event. 72% say their overall physical and mental health has declined since becoming more responsible for their mom or dad or relative, partly impacted by things like reduced wages, having to change jobs or lose their position at work. There are some positives, says Brigid Byrne, who cares for her 90-year-old mother who has cancer and her grandson, a toddler. ‘Lots of stress and worries, yes, but lots of laughter,’ Byrne says, noting that while there is essentially no support from health providers or insurers there are local and national networks online to support caregivers, like the Caregiver Action Network. Insurers like Humana, Anthem, and United who continue to see an increase in there Medicare Advantage enrollment will likely to need to think about how their networks and benefits can help address this growing issue.

2. Alzheimer’s Awakening: First Billy Jean’s win over Bobby Riggs, now this. New research has arisen on why women are more likely than men to develop Alzheimer’s, and it’s not just because women live longer than men. Scientists offered new evidence that the disease may spread differently in women’s brains than in men because of several newly identified genes that seem related to the disease called APOE-4. Vanderbilt University researchers found that women do better than men on verbal tests for Alzheimer’s leaving them undiagnosed. A protein called ‘tau’ that destroys nerve cells is spread more in women’s brains than in men’s. The female advantage masks early signs of Alzheimer’s and delays diagnosis because of better brain metabolism. Researchers have received a grant from the National Institute on Aging to complete an international study on 100,000 people to try to validate and extend the results, NBC reports.

3. Taking From Peter to Feed Paul & Mary: In a poll of 17 network contracting directors this month, we have learned that there is a renewed effort amongst nearly all of them to find ways to ‘chip away’ at specialist reimbursement to help support the growing need to increase payments and incentives and bonuses for high quality primary care related providers.

4. Vaping’s Impact on Respiratory: 3.62 million middle and high school students have reportedly used e-cigarettes in 2018, a 78% increase among the high school group. In Wisconsin this week, vaping is suspected to be the cause of serious lung damage in 8 teens according to hospital officials there who alerted the state’s health department. The hospital announced that some of the teens even needed to be put on breathing assistance. An exact cause is unknown but with the increase of teen e-cigarette and vaping use, parents and teens need to be aware of the potential danger. Our poll earlier this month found that a majority of teens in one high school had tried or been asked to vape. The FDA says 3.62 million middle school and high school students were reported using e-cigarettes in 2018 and a 78% increase among high school students.

5. Reimbursement Stop: Starting in November, Anthem will no longer reimburse two codes that have been used traditionally by healthcare providers to report the 5+ minutes of time they spend calling other doctors or nurses, writing a report to a peer with an opinion about a patient, or analyzing a chart as part of this interprofessional communication. According to Anthem, the new Interprofessional CPT codes 99451 and 99452 are not eligible for reimbursement when they are reported with another service or reported as a standalone service.

6. Site of Service Musculoskeletal Review: Arthroscopic and foot surgery procedures will require a site of service review for UnitedHealthcare patients starting in November. This basically means that UHC will evaluate not just medical necessity but whether the procedures should be done, or could be done, outside of a hospital outpatient setting. This change will impact commercial and exchange patients.

7. Medicaid PT Targeted in Tennessee and Louisiana: PT, OT and speech services for United Healthcare Medicaid patients will require both a medical necessity review and a site of service review to make sure they’re not happening in the hospital outpatient setting, starting in October.

8. Spectrum Indicator: Recent research shows women who are exposed to solvents on the job may be more likely to have children on the spectrum, according to the National Institute for Occupational Safety and Health in Morgantown, WV. This research was completed before and during pregnancy on 750 mothers and 891 fathers that had occupational exposure and have been linked to neurological or congenital abnormalities in children. The agents can include medicines, metals, pesticides, anesthetics, asphalt, brake fluid, plastics and polymers, radiation, cleaners/disinfectants and paint chemicals and degreasers. Exposed mothers were 50% more likely to have a child on the spectrum and the solvent exposure was linked to an 85% higher autism risk. The study was not completed in a controlled environment so other factors could be involved.

9. Airport ASD: Pittsburgh international airport unveiled one of the world’s largest, most comprehensive airport sensory spaces designed for travelers on the autism spectrum. The space includes a first-of-its-kind jet cabin and jetway replica to help those on the spectrum get comfortable with the space constraints of an airplane. Sensory rooms can make all the difference for a person on the spectrum because they are sound-proof and can have calming lights, and private areas for families to decompress before flights. Airports in Atlanta and Birmingham have also recently constructed sensory rooms.

10. Correction, Falling Down: Last week I reported how falls were named as the number one risk of injury and hospitalization for seniors and unexpected medical costs that can impact a risk-taking, senior-focused primary care group. I noted that the root cause of falls is not poor balance or drinking or slippery conditions, but dehydration or malnutrition stemming from often untreated anxiety, grief and loss, PTSD. But as one reader, Bruce Gordon, pointed out, there are counter forces that can definitely help mitigate fall risk and have benefits for osteoporosis, such as exercise and weights. Gordon, an older endurance distance runner, says this type of exercise doesn’t guarantee you won’t fall, particularly if you’re running in nature, but the benefits outweigh the risks. As risk taking groups try to understand their patient’s home environment and what drives behaviors – learn not just about their medical history, says Nancy Feller, MSW, who does home visits for physicians taking risk, but learn about their ‘social’ history too.

11. Extra Point: Somehow I finished the 100-mile Pan Mass Challenge bike ride for Dana Farber Cancer Institute last week in record time – 6 hours, better than my usual Eeyore-style clip. I hadn’t trained, so my neck, back and thighs didn’t feel so good but the muscle rub at the 20 and 50 mile marks helped. And what I saw along the way was nothing short of amazing. Carole, an 81-year-old retired nurse from Tewksberry Massachusetts, was riding a tandem bike with 9-year-old Desean from Dorchester who has been in out of treatment for AML, one of the most common types of leukemia in kids, since he was about 6. Desean was standing near a sign cheering on riders at about the 75-mile marker. He had a Red Sox bike helmet but was not in the ride. Carole was riding by herself but borrowed the tandem and took Desean with her. They rode for about 3 miles to the next stop to rising, if not chilling, cheers along a crowded stretch near the harbor of Onset. Carole managed to get Desean safely to the next stop. I unclicked my shoes to watch as Carole broke into tears. I was maybe 10 feet from them at this point. Desean, frail and shy for a kid his age, reached out and grabbed Carole’s arm and said ‘are you okay?’ Carole hugged the boy, then began to ride off toward the finish line. I caught up with Carole after the finish. She said she was an oncology nurse for 22 years so moments like that were more common than not, but ‘I’ve never had a kid ask me if I was okay…’