Behavioral Health Insights

1.  59: Percent of school teachers and administrators in our poll of 1,306 last month who say 2 of their top 3 challenges they need help addressing in the next school year are health related—autism and mental health.

2.  Jet Blues: The airline operator now will give its employees access to psychologists and psychiatrists 7 days a week at $20 a session.

3.  Pre Approval Coming: BCBS of Texas will require pre approval starting at the end of August for genetic testing and sleep studies. Evicore will handle the decisions.

4.  Lung Outcomes: Kramer took dog pills to treat his chronic respiratory condition during a classic Seinfeld but much has changed since the 90s – now, drug companies take risk if their treatments don’t work, so people like Kramer don’t need to experiment….for instance, commercially insured with Highmark BCBS in mid Atlantic states Delaware, West Virginia, and Pennsylvania can benefit from an outcomes-based contract between the insurer and drug company Astrazeneca’s Symbicort, which helps decrease lung inflammation in patients with asthma and COPD. Essentially, Astrazeneca gives a rebate back to the insurer if patient’s Symbicort falls short of its marketed goals.

5.  Rx Review: At a recent drug utilization review board meeting we attended, the committee said it will look back for several ICD-10 diagnosis codes for those with depressive disorder, and then look back as far as possible for prior diagnosis. Other topics to be investigated: patients on long acting injectable drugs may not need oral antipsychotic drugs, and those diagnosed with epileptic seizures or muscle disorders should be flagged for chronic use of benzodiazepines because these aren’t first-line treatments for seizure treatment.

6.  Falling Down: Falls in seniors was named as the number one risk to injury and hospitalization and unexpected medical costs that can impact a risk-taking primary care group….and I would argue that the root cause of falls is not poor balance or drinking or slippery conditions – yes, these are all factors particularly in gloomy, icy New England in about 6 months – but moreso dehydration or malnutrition stemming from often untreated grief and loss, or PTSD. As risk taking groups, it’s important to understand your patient’s home environment and what drives their 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.

7.  Teach Your Children: As Crosby Stills & Nash would say, teach ‘em well and let them lead the way…74% of academic centers in our poll say they are concerned about the future of their model as care shifts out of hospitals, but a majority of them say they are creating a strategy to partner with community-based practices and expanding their teaching programs to incorporate other sites of care, including value-based models where the academic centers will acquire or partner with pediatric specialists and care management providers who can ‘get into the home’ as patients are discharged.

8.  Tiered HMO: Starting in October, BCBS of Rhode Island will offer a so-called tiered HMO network. Only high performing providers are included and, interestingly, there is at least one provider for each of the 6 New England states, including for surgical treatment. As a lifelong New Englander, it is nice to see a network that gives us Yankees access to specialists we may not have in our area, and it’s particularly beneficial for the large number of New Hampshire and Rhode Island residents who work in Boston and can sit up to 3-4 hours in traffic to get home or work.

9.  Extra Point: I’m writing today from Babson College, site of the opening of the Pan Mass Challenge charitable bike ride for cancer research. It’s so humid here the air is sticking to me like cellophane. I’m wearing humidity like a hoodie and I’m not looking forward to pedaling for 7+ hours. But that’s New England in August – generally miserable. My Aunt Jane and Uncle Bobby from the south part of Boston used to have me over the night before my first few rides in their 197 degree  apartment. ‘Turn on the fan Bry, don’t be shy, crank it on, but not too high because it’ll blow all my papers…’ Jane would say, holding her ashtray like a catcher’s mitt and dangling a cigarette over the Schitzu. Jane’s papers were mostly old Funnies and crosswords, and a stack of bulletins from Church with the ‘megabucks’ numbers scribbled on them in red pen. ‘No, I’m good Aunt Jane…I tend to really enjoy suffocating…’ ‘Well that’s nice,’ she would say, her mostly deafness preventing any of us from having an actual conversation….This is my 9^th  ride and this time is particularly tough as I’m, one, out of shape, and two, riding for the guy who, even in his 50s, still shoots hoops and back cuts like his days playing for Pete Carril at Princeton. Burke and I are often matched up on Sunday hoops as the two short guys who never stop moving.  Burke’s family has been hit from both ends – his wife a tough but beatable breast cancer, and now his teenage son with a surprising but all-too-real testicular cancer. John is 17 and himself is a good ballplayer. I am hopeful for John and Carol’s recovery and for the good doctors taking care of them, and I’m hopeful for Burke who takes on the role so many of us have had to as caretakers. In fact, I was talking to several insurer medical directors last week about the idea of studying the impact of diseases like cancer on caregiver health. Like most of you impacted by cancer, I’m hopeful that all of the good things we see lately in cancer treatment and payment innovation will have a real impact. In my days as a correspondent covering oncology, I remember how Highmark took a chance on sharing savings with UPMC for keeping cancer patients out of hospitals. Now, even drug companies are taking chances that their treatments can shrink the size of tumors faster than plan, willing to risk sales if the tumor wins. These are bold times and I could use a bit of boldness this weekend myself….to read more on my ride, click here. I’ll be interviewing physicians, patients, and families along the way and will report back next week.

1. New MA Plan 2020: Montifiore Health System and Oscar Health will create a joint Medicare Advantage plan in NYC starting in 2020 featuring individual and small groups plans for New Yorkers. It will be interesting to see two things – adoption of the plan as well as how well these models fare on a total cost of care basis vs. purely independent providers.

2. NW Blue Inks Deal With TalkSpace: Premara, the Blue plan in the upper northwest, wins in early votes as among the most favorable insurers for behavioral health. Case in point, it just signed a contract with the virtual counseling service Talkspace, which promises initial sessions within 3 days and counseling within a week. A spokesman said ‘we are encouraging’ physicians and others to refer to Talkspace.

3. Cliff For Autism, Psych: In a surprise move, our managed care index of priorities continues to look increasingly like a list of social services. Coming in at #16 for the first time in the now 15-year study, commercial and Medicaid insurers say they are beginning to discuss how to create a better system for older teens and young adults with significant psychiatric conditions as well as severe autism. This includes benefits, care coordinators and in-home counseling, as well vocational and housing support. In 2018, we covered this issue in a feature story.

4. Sloan Enters Value: Cigna and Memorial Sloan Kettering dipped their toe in the value-based contract arena this week. Patients get one RN to coordinate their treatment and one Cigna contact to help navigate benefit issues The cancer center gets a share of savings if reducing total cost of cancer care.

5. Chief Complaint: TennCare Kids screening guidelines now allow reimbursement for both sick and well visits on the same day so physicians don’t need to schedule other appointments. Managed Medicaid plans are encouraging this in other markets and in some cases primary care groups and even oral health groups are using this as an opportunity to hire specialists to address the common complaints they typically have to refer (respiratory, bladder, pain, psych).

6. Air Intercept: Patriots fans remember the greatest surprise interception in Super Bowl history vs. Seattle in 2015. Well, hospitals and skilled nursing facilities have been dealing with their own surprise interception too as payers use the prior authorization process to change the next level of care order for patients needing air transport out of state. 82% of non-emergent air ambulance transports, up from 67% last year, will require pre-approval starting in 2020, based on our tracking poll of 62 different health plans. Besides the obvious issue that many of these inter-facility transports run through OON operators costing 3-5x in-network transports, there’s a hidden benefit: payers using the authorization process to intercept the next level of care (i.e., hospital or SNF) and diverting to a different option, if lower cost and better quality.

7. In-Home Assessments: In 2020, a company called Matrix Medical will handle in-home assessments for a handful of Midwestern and southeastern Medicare Advantage plans, including FIT testing for colorectal cancer, A1C diabetic measurements and diabetic retinal eye exams. All results are supposed to be sent to each patient’s PCP.

8. Midwife Win, Loss & Tie: A Wisconsin state law changed in 2018 to allow licensed midwives to enroll as ‘providers’ for the state’s Medicaid programs but Anthem decided at the time not to contract with these type of providers, so they won’t cover services midwives perform. The plan covers nurse practitioner services if the NP is certified with the nurse midwife specialty, but a source said Anthem is re-evaluating.

9. Retail Health: A string of multi-cultural health and retail facilities continue to open through partnerships between managed care and providers, like Sanitas and Horizon BCBS’s retail, grocery and healthcare set-up in northern Jersey. Sanitas, which opened in 2018, has a presence in 6 other countries and most notably in Florida – it primarily helps Horizon manage health for the large Hispanic population here. Other models exist such as Community Health Services in Hartford that include adolescent, pediatric, women’s health, lab, behavioral and physical therapy, among other services for Husky Medicaid patients. The center is located next to a newly revamped YMCA center. The center’s number one health issue it sees – asthma, due to smoking but also very poor housing conditions in the area. An educational effort is underway to help families understand how to use inhalers and the different types of asthma ‘but things won’t get better until the housing improves’. Physicians often prescribe exercise to moms, dads and kids and are working on a training program for students interested in careers as PAs and NPs. The innovation in care delivery has been in the shadows here. In early 2018, there was a Homicide one block away during a community event.

10. Psych Up and Down: Primary care providers who collaborate with psychiatric professionals on a patient’s care can get paid for this collaboration but the rules for billing have changed and recently Anthem started using a new audit vendor, Alliant, to ensure appropriate services and billing. Licensed clinical social workers or psychiatrists were mentioned as the likely collaborators for PCPs. Billing a series of CPT codes like 99492 to 99494 is allowed, as of 2018. Anthem hopes this encourages information sharing. Alliant, meanwhile, examines Anthem’s outpatient behavioral health claims data and conduct provider audits.

11. Extra Point: So 83-year-old Uncle Mike, the tenured political science professor at Gonzaga and the Jesuit priest who married Janine and me, is in town this week – bringing all his peccadillos with him. This morning he managed to put three or four shakes of sugar on his cinnamon LIFE cereal. ‘A little heavy handed there?' my wife said with a smile….'you do know it’s ‘cinnamon flavored’ 'Well, um, it just needs a little something,' he said coughing a bit while using the bowl as a cup to drink up the last bits of sugary milk. 'It’s a wonder you don’t have diabetes' my mother-in-law quipped. 'Well, I do take this pill every day to control my blood sugar….my regular endocrinologist gave it to me…but I’m not diabetic.' I’m pretty sure you are but say this for Uncle Mike, he has his idiosyncrasies but he can eat what he wants as far as I’m concerned because, nearest I can tell, he’s blessing all the food and he’s the one who may be a key vote for me when it’s my time. I quip, but having the old guy here with my mother-in-law reminds me how challenging the healthcare system is. Neither of them can walk up or down any stairs without help and a lap around the block is like digging a hole to China. Both them have fallen asleep at least a dozen times mid-sentence since arriving. 'What’s wrong with Uncle Mike?' my daughter Sophie asked yesterday, scared for the answer. 'I think he’s dead' Janine said, 'go check him Bry.' My mother-in-law was in the corner laughing for some reason. Uncle Mike simply fell asleep and when he awoke to the dog barking, he repeated the same story about how his parents used to take them to the 5 and 10 for Christmas but one year didn’t because they all got Bs in grammar class. God bless them. Both Michael and Ellen live independently most of the year battling an encyclopedia of conditions: dementia, vertigo, osteoarthritis, prostate cancer, skin cancer, and anxiety. One wears compression socks, the other wears pain cream. They are the face of aging in America and highlight so much of the challenge ahead….but when they are here, thank God, they sure do bring a bit of levity.

1. 319: The number of high school students in our poll of 500 who said they have a friend who vapes.

2. In-Home Behavioral Coverage Kick Off: Starting this month, Blue Massachusetts now covers in-home behavioral health monitoring and therapy for those under 19, as well as intensive care coordination, community based treatment, mobile crisis intervention.

3. Transgender Boost: Transgender employees with the University of Michigan will now have new medical services covered starting this fall under a new BCBS policy here – procedures now covered include face and neck hair removal, facial feminization surgery and Adam’s apple reduction. The benefit has up to a $30,000 lifetime limit.

4. You Grant: There’s a major trend unfolding among insurers in the number of grants and the dollar amount of them dedicated to wellness, physical activity, social determinants and other ‘preventive’ or lifestyle related programs. BCBS of Oklahoma has 14 such programs it is supporting this year including the OK City Community College Foundation focused on food insecurity, Palomar, an OK program to help kids exposed to domestic violence, The Center for Individuals With Physical Challenges that offers a sports camp, ReMerge for families who have faced addiction, and Tulsa’s Children’s Museum to expand playground and other physical activity programs. These are really the new network for insurers, not simply a check the box. The impact of these programs and insurer support will vary--primary care practices are unlikely impacted over a 10-year-period whereas hospitals and surgeons who rely on volume from unhealthy patient populations are likely impacted to some degree. The programs are more so a signal to medical groups and therapy groups interested in getting insurer attention – that designing pilots with a preventive element to them for high risk populations will get attention.

5. August, And Everything After: First the album title for Counting Crows hit 1990s record that included the anthem Mister Jones….and now it’s a new policy from Anthem of Georgia who is moving ahead with a new policy affecting therapy providers. Pre-authorization will now be required for PT, OT and speech therapy as of August 1st. The insurer originally was going to require this in April but had to delay the change due to trends in group membership, provider status and other ‘system’ issues.

6. Urgent Care Maybe Not: There were 47 ambulance trips from an urgent care clinic in my home town last week, according to several sources – suggesting at first that the clinic is being mis-used to some extent, but when probing further the hospitals in the area who get these cases say that ‘more often than not’ it’s a case of the urgent care PA or NP just not being clinically educated enough to diagnose and treat, so they ‘refer to the hospital for liability reasons….’ An example of one such case is chronicled here that we wrote about a few years ago: click here for story on urgent care Observation Case

7. The New Diagnostics: The rise in policies and coverage around remote monitoring and telehealth and social determinant services are fascinating to watch as more insurers agree to pay for these at similar or in some cases higher levels than face-to-face care, simply to address shortages and access to care problems. Still, when I sat down with 3 medical directors earlier this month about how they view these services, two of the three put them in the ‘diagnostics’ category. ‘That’s really how I think of telehealth and even social determinants – yes it’s a way to evaluate and manage and counsel, particularly if mental health, but I would view these services as more so an extension of diagnostics,’ said Andy Kellogg, a former health plan medical director now retired. To that end, if you are investigating adding these services or thinking about owning them, consider how insurers may manage them and use them in benefits. ‘If I were still in charge I would still be thinking of these as the diagnostic and then establish the payment and benefit similar to how we might do it for lab or even imaging….outside of a risk model, in fee for service you would want to manage these or use them to understand what’s happening, not to replace the treating provider’

8. 50: The percent of all lifetime cases of mental illness that begin by age 14. And 75% develop by age 24, according to the National Alliance on Mental Illness. Talkspace, an online therapy company, now has a service for teens rather than just adults. With parental consent, teens can be connected with a licensed therapist in their state. By 2022, we think that the national telehealth community will get behind a change in policy to allow credentialed/licensed therapists to treat a patient outside their region. Full story: click here

9. Shattering Policy: The non-profit Shatterproof is now teaming up with insurers nationally in most states to help provide guidelines and recommendations for addiction centers of excellence. Our prior reports on this non-profit suggest that there is demand in several markets to help families stung by addiction – namely to help guide them about where to go for treatment. For behavioral health providers, it’s clear that being on Shatterproof’s short list of recommended providers will ultimately be important if looking to be considered as centers of excellence and looking to get increasing volume from the major referral sources of these cases.

10. Extra Point: I will have to pay full freight, or close to it, for a tartar debridement procedure that Guardian Dental just won’t pay for….and who could blame them? My usual dentist retired 3 years ago and I’ve failed to find a new one, so I’ve gone all that time without a check-up even while traipsing my own kids from appointment to appointment….My lapse landed me in the dental chair Wednesday facing a terrifying tartar battle – my hygienist, 20-something Rachel, scraped my teeth and gums with fearless vigor, while making jokes ala Tim Whatley of Seinfeld fame…. I suffered, gripping the chair, sweating, choking, hanging on for dear life….Rachel asked if the front desk gave me the skinny on the cost of the procedure. ‘I just won’t be able to do the cleaning today, too much tartar – that’s next month…you’ll need debridement….’ Now for someone who works in healthcare, at least in the research world, it’s a tad bit embarrassing that I talk about the importance of oral health but then don’t go to the dentist. Sort of like those primary care doctors who have heart disease and smoke….'So we can submit this to Guardian for reimbursement but they don’t cover it….,’ according to Cindy, the care coordinator. Personally, I don’t want to go through the procedure ever again (like ever, Taylor Swift might say), so if paying full price (around $300) is another deterrent then I’m happy to pay. In fact, I called Guardian who said they usually evaluate the patient’s factors and, if they haven’t been to the dentist for several years, coverage is usually denied.

1. 50: The percent of all lifetime cases of mental illness that begin by age 14. And 75% develop by age 24, according to the National Alliance on Mental Illness. Talkspace, an online therapy company, now has a service for teens rather than just adults. With parental consent, teens can be connected with a licensed therapist in their state. By 2022 we think that the national telehealth community will get behind a change in policy to allow credentialed/licensed therapists to treat a patient outside their region. Full story here.

2. Surprising Episodes: There are some episodes that catch you by surprise, some you see coming. Like I always knew we were moments from a commercial break when Mr. Roper stared with those glassy eyes into the TV on Three’s Company, but I was floored when Colonel Blake died in that MASH helicopter or when Tom Hanks purposely swallowed a bottle of Vanilla Extract because the Keaton’s were out of Miller High Life on Family Ties. In health care circles today, you hear a lot about episodes of care and payment innovation – some are sort of predictable, and I suppose that’s the point. Think Maternity, Hip and Knee. Some may surprise you going forward, and some seem to perhaps miss the mark on who ought to be accountable. A 12-month episode for dealing with drug addiction has promise, particularly Anthem’s through a home-based provider out of New England, Aware Recovery. There’s a new one emerging that addresses predominantly Medicaid populations in poor housing areas who regularly present with asthma and co-occurring depression in ERs. The idea one PCP has is to use a simple home visit by a social worker, treatment led by an allergist and PCP, and a re-housing plan to either fix the environmental causes or find the patient a new home. United Healthcare is touting these kinds of community focused models. Problem is, when you look at the traditional episodes of care (link here to Arkansas BCBS’s core list) most seem to put the ‘hospital’ as the principal accountable provider in these. For asthma, while there may be a triggering event bringing you to the hospital, the so-called accountable provider probably ought to be a PCP, a specialist, or perhaps the MSW given the social factors involved. As you build your episodes, try to see what’s coming by finding the right mix of providers and the right person to lead.

3. The Cayman’s In Network: 64% 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?

4. Social Stat: One unhealthy day equates to 10 hospital admits per 1,000 people or $15.64 per member per month in additional costs. I asked my kid Tommy to read this for his quasi 20-minutes of reading time he’s supposed to do every day and he fired back, ‘….um, but dad, I thought you wanted me to read…this is math.’ He has a point and this is the latest statistic that insurers are starting to lean on to shape programs to address social determinants of health. In what they’re calling Bold Gold, Humana says 5 of 7 communities reduced unhealthy days last year. Loneliness, for example, causes Medicare seniors to have an average of 24.4 unhealthy days a month; food insecurity averages 26.6. But there are community programs that are beginning to address these stats – and for provider groups like medical groups taking risk, these are indicators of a rapidly shifting trend in where the MA value dollar is headed. In New Orleans, those with CHF had a 9% improvement in unhealthy days due largely to a food bank program and San Antonio reports a nearly 10% decrease in unhealthy days. In contrast, some cities where Humana members have struggled – including Broward County Florida where unhealthy days increased by 4% as did depression prevalence among members. By the end of the year, the insurer hopes to ‘screen’ 1 million for social related determinants of health.

5. PTSD Returns: 53% of parents who have senior moms and dads, up from 44% in our poll 3 years ago, say at least one of their parents has had a post-traumatic stress condition due to a childhood incident, time serving in the war, or most commonly due to the loss of a spouse. Of the 429 polled, about 220 said the PTSD ultimately led to alcohol abuse, dehydration or malnutrition, and eventually to a hospitalization due typically to a fall in the home. PTSD is likely top of mind for many veteran’s families during this July 4th weekend. Question is whether your businesses are equipped to train practitioners to identify this condition early enough in care.

6. Extra Point: Ever think about who is diagnosing you and if they are getting it right, if they are undertreating, missing something, or perhaps overthinking it? The cancer doctor who hits you with one more round of that yellow syrupy stuff that they tell you is just Methotrexate but really feels like chemotherapy. The internist who takes a sore throat to mean you may have a Thyroid issue and sends you to a specialist because your cousin had Thyroid cancer. Your scalp is itchy because you haven’t showered in weeks, but you’re 47 and the primary care doctor you play pickup hoops with says it could be a sign of stroke if you’re not careful. It’s a bit like school, or camp – who’s teaching your kids, right? Three of my kids were in fact teachers themselves this week at what my bride calls Vacation Religion School – or since this doesn’t exactly roll off the tongue, what I call it: Bible camp. What’s confusing isn’t the 3-hour format where kids sing songs and do arts and crafts but that my youngest, Tommy, is a lead counselor. He’s 4 foot nothing and is still carryable on my shoulders. His on-pitch singing is flat. He barely knows the Our Father, and despite all that time in the Pew at church still sets his hands the wrong way for Communion. And he admittedly lacks some basic training in dealing with a wide variety of kids on the spectrum here who are using art supplies as paper airplanes. ‘Dad, I’m just surviving’ he said at dinner last night. The bar was obviously fairly low here for counselors if you ask me. Janine tells me ‘it’s good for the kids’ but it sounds more like McDonalds where if you spot a hamburger you’re suddenly a manager. Locate an apple pie and heck you’re a district manager. In healthcare, the consequences of under-prepared staff are more important obviously. There continues to be an effort to address gaps in care and access and one solution is taking less experienced staff into healthcare settings, and training them. Deploying social workers to the home to deal with seniors after a hospital inpatient stay, sending younger aides out of college to schools to work with autistic children, asking nurses and PAs to diagnose respiratory conditions, blurry vision, emotional disturbances in urgicare or the ER. These are all important developments driven more out of necessity and demographics than policy. Having more allied health professionals is important, as is an emerging cause of using consumers to volunteer to provide healthcare education or social services to at-risk populations. But what will be equally important to evaluate is how well they are trained, how well versed they are in making clinical decisions and understanding when to treat, how and what the cause of the condition may be, and how quickly they can find the doctor.

1. 18 and Counting The number of ancillary contracting directors for insurers who have confirmed with me that they have had at least one conversation with Amazon in the last 2 years.

2. New #1: Orthopedics has moved past maternity as the #1 episodic payment contracting focus for payers.

3. 7 Wonders of the Lab World: Now that UnitedHealthcare has tapped 7 preferred clinical and anatomic path labs for its preferred network set to go live in July the question is can this mix of big chain and specialized genetic companies improve outcomes and satisfaction. UHC says it will work with the labs to track outcomes for patients using them to see whether labs can play a meaningful role in outcomes improvement. This will be a 5+ year effort. Mayo, LabCorp, Quest, Invitae, GeneDx, BioReference and Quest subsidiary AmeriPath made the cut.

4. Peter and Paul: Anthem Blue Cross in California is increasing reimbursement for evaluation and management services starting in July, but physicians in the state report some decreases for other services. We are looking into which ones and meantime, worker’s comp rates will change – physicians will be paid whatever is lower: 85% of the state’s work comp fee schedule, the physician’s billed charges or something called a prudent buyer fee schedule Anthem will put into contracts.

5. Enhanced Pay For Early Pain Diagnosis: In a move to reduce addiction and hospitalizations due to overdose, 14 of 31 medical management contracting managers for large group insurers say they are contemplating an enhanced payment rate initiative, either through contracting or a special code, whereby providers like physical therapists could identify addiction early, make an assessment and a streamlined referral to a behavioral health or addiction specialist. The 14 include 7 Medicaid plans and 7 commercial, and all said ‘they would pilot the concept first’. We had studied the issue on PT groups showing value by identifying addiction early in patients with pain. That story here for those who missed: click here

6. Don’t Get Caught Watchin’ Paint Dry: It’s the best line in Hoosiers, when a questionably sober Dennis Hopper tells the team to avoid standing still at the key point in the game….and it’s a good lesson for  traditional primary care and home care companies these days who, if they’re not careful, may find themselves stuck if they don’t get ahead of the social determinant wave. Caraline Coats, Vice President of Humana's Bold Goal and Population Health Strategy, says the insurer has a pilot program with a company called “Papa” in Tampa, FL connecting college students with lonely seniors. This is one of several initiatives to screen for things like depression and substance abuse and react to them. How information from screenings makes its way into EMRs and back to primary care physicians, or mom and dad’s caregivers or kids, will be important if this whole social determinant experiment is to work. That said, there will be a flurry of companies in the social-health arena continuing to seek a piece of the insurer’s Medicare Advantage budget. It’s already happening. For the Bold Gold story, click here

7. Extra Point: I was chatting last week with a soon-to-be UVM student who says she’ll help ‘pay her way’ at the Vermont University by working in a new 8-week outpatient pain management program that includes yoga, acupuncture and culinary medicine. For purposes of this example we’ll call the student Mary. Mary’s volunteering as a yoga teacher in high school landed her the gig. BCBS of Vermont confirmed that they are supporting the program. Doctors in the state must refer patients with chronic pain to the program. Lou McLaren, who directs provider relations and quality improvement for the insurer, says the program should reduce prescriptions and, as I predict, reduce the need for the oft-times ineffective injections. Mary says she’s motivated to participate because many of her high school friends have suffered chronic pain due to sports injury. Her dad says she’s motivated ‘because I told her it’s the only way we can afford the school…’

1. 345: The number of moms and dads we polled about a seemingly mundane question – how they decide where to go for healthcare. Moms seem more thoughtful – relying on their OBGYN or their neighbor who’s a pediatrician, or Dr. Oz and NPR, while Dads, somewhat predictably, rely on ‘it getting better without them doing anything or, increasingly, the nearest urgent care. Moms are more often changing doctors and more thoughtful about where to go and whose advice to use. Unlike Elaine of Seinfeld fame who failed to change doctors because her last one wrote in her medical record that she was too difficult, today’s generation of Elaines have more access and control over their records, and more say in where to go. They tend to rely more on what they know, hear and see every day, sometimes for good and sometimes not. In our study of 345 adult consumers there are some clues as to how people select specialists and how little people rely on insurance to guide them. Full study, click here.

2. Acupunture on Rise: BlueCross BlueShield of Tennessee will now cover acupuncture, a traditional Chinese medicine practice used to relieve pain and treat other conditions. Additionally, the insurer will replace Oxycontin with Xtampza and Morphabond, whose formulas make them more difficult to crush and “delay the high.” The replacement drugs cost more, but BCBS is keeping the member co-pays the same as they were for Oxycontin. BCBS is also lowering their daily morphine milligram equivalent (MME) of any opioid, patch, pill or syrup to 120 ml.

3. Circulation Devices: Effective July 15, 2019, Cigna will be updating their Pneumatic Compression Devices and Compression Garments medical coverage policy to deny pneumatic pump claims billed with international classification of diseases. Pneumatic compression devices are machines with an attached inflatable garment that has multiple chambers that inflate one after the other to stimulate circulation in the right direction. Additionally, they will deny claims billed with Healthcare Common Procedure Coding System (HCPCS) code EO676 as experimental, investigational and unproven for any indication in the home setting.

4. RadioPharma OP Approvals: Effective May 1, 2019, UnitedHealthcare will require prior authorization for therapeutic radiopharmaceuticals administered on an outpatient basis for UnitedHealthcare Community Plan members in Arizona, California, Florida, Iowa, Maryland, Michigan, Mississippi, Nebraska, Ohio, Rhode Island, Texas, Washington and Wisconsin. The process to request a PA for therapeutic radiopharmaceuticals for UnitedHealthcare commercial members changes too.

5. Urologists Complaining: Urologists in particular are seeing issues with prior authorizations. “More than nine in 10 doctors said prior authorization has a significant or somewhat negative impact on clinical outcomes. More than one-fourth (28%) said prior authorization has led to a serious adverse event such as a death, hospitalization, disability, or permanent bodily damage. Three-fourths of physicians said prior authorization can lead to treatment abandonment, and 91% indicated it results in care delays,” reported the Urology Times.

6. Marriage Vows: My parents enter their 50th this year and mom wants to do her vows at the same church her dad was baptized in the hills of Monte Cicerele, Italy, near Napoli, but their anniversary is on the same weekend when dad usually preps the garden and watches the US Open on TV so this vow exchange likely stays local. In managed care, the next marriage to watch now that Anthem has acquired Beacon, is United and Magellan – and these marriages will be far from “local.” These integrations can change contracting and network considerations particularly for behavioral health and primary care, and likely increase attention and use of things like centers of excellence and telepsych. As predicted here, Anthem this week announced they will be purchasing Beacon Health Options, which will add a national network of behavioral health services in an effort to care for “the whole person.” This transaction is expected to close in the fourth quarter of this year. Beacon currently manages mental health and substance abuse services for more than 36 million people in the United States.

7. Extra Point: My son complained of a sore throat last night. My wife said “it’s probably strep.” My daughter said it’s definitely because Tommy doesn’t wash his hands and hasn’t changed his clothes in 2 weeks, so he’s sick. Jack had another diagnosis – “Um, Tom, maybe it has something to do with the half bottle of Sprite you just chugged…” Indeed, drinking soda and fast can’t be good, and Tommy’s so-called sore throat was simply an acute version of GERD. On the downside, he was complaining all night, but on the upside, he is swearing off Sprite.

1. 67: My high schooler is getting roped into two things – kids asking him to do juul or vape and online gamers called Hofr urging him to predict results from the NBA finals without paying a dime. Jack isn’t biting on the juul offer, thankfully, but he and buddies are all-in on the latest pre-gambling addiction craze Hofr. It seems harmless, but in a straw poll of 74 boys in my son’s high school, 67 of them are betting on these games ‘almost daily.’ This may seem outside of managed care trends but if you look closely it’s another symptom of the iphone generation’s obsession with their apps – and perhaps a clue into how to reach young kids.
2. Best Buy, Really? The place with all the big TVs has a health strategy, and it’s not too far afield from the biggest trend in healthcare. In 2018, it 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 flatscreens 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 GeekSquad credentials to help reboot your laptop.
3. Golfers For Cataract: Not all of us have Danny Noooan to carry our bag down the fairway and track our wayward slices. The #1 question that ophthalmologists get from male patients who are about to get cataract surgery is, not surprisingly, ‘how soon after can I play golf….’ What is often not discussed, is just how important the surgery is for these golf-obsessed seniors who don’t hit it quite as straight and can’t see the ball off the tee like they used to. A Medicare Advantage plan’s utilization analyst, Mary Kellogg, says the plan is looking to study cataract utilization trends and related social factors, like surgery by gender, climate and even something as obscure as whether the patient is an avid golfer. ‘Do they need it to see the ball better, or do they need it to drive to the course…two different things’. While it seems unlikely that denials for cataracts increase drastically, with the increase in MA and medical management of vision, it wouldn’t be surprising to see greater analytics around medical necessity. A more likely debate and trend to at least acknowledge is the likely market move to more in-office cataract. 31% in the poll said they are thinking about it, if the reimbursement is there. Questions about infection and anesthesia safety factors exist but there are outcomes – a Kaiser spokesperson told us they have performed about 50,000 in-office cataract procedures without any eye inflammation complications.
4. Gonorrhea Precursor: Kramer made it look easy to diagnose Gonorrhea back on Seinfeld when he compared his ‘burning pain’ to the haunting memories of lost love. The theatrical performance for medical students in training was ahead of its time, correctly, if not comically depicting how it’s important to get to understand what’s going on with patients to best direct treatment. My dad says his ‘antenna is now up’ when he is struggling to get a teenage girl to improve range of motion from shoulder pain and spots potential depression or anxiousness. He asks about life at school and home while helping his patient’s in clinic, not as idle chatter but as a way to see if anything may be preventing improvement or causing the pain. He knows this since a past patient eventually divulged an eating disorder after 3 months of visits. I mention because as United and other insurers begin to pay for providers to identify, document and then address social determinants, there will come a time where the payer world will want to see results (lower cost for things like procedures, drugs and hospitalizations) for this investment, as well as earlier identification of the correct diagnosis. When evaluating your practices, think about how well your providers are trained in diagnostics – not just relying on a lab test or scan, but in the art of conversation.
5. Burrito Bowl Worker Accident: Chipotle is for my kids what KFC’s crispy chicken buckets were to a generation of kids who waited for dad to come home with dinner on payday in the 80s….well, for Chipotle and other big companies like Conagra, Geico, J&J, JP Morgan, Labcorp and Target, they use a third party called Broadspire to handle worker’s comp–all the claims and cost-saving services associated with these cases–and starting this month if your healthcare group or doctors provide treatment to a worker’s comp patient who works at one of these businesses, your reimbursement will be based on Anthem’s fee schedule. This change likely flows through to these employers in many Anthem states, not just Indiana which announced the change.
6. Fertility Pharmacy: Starting in July, two pharmacies – BriovaRx and Walgreens’s AllianceRx – are out of the Blue Massachusetts network for ‘fertility medications’ so doctors and referring providers are being advised to send patients to Freedom Fertility Pharmacy, Metro Drugs, Acaria or Village Fertility.
7. Site of Service Intervention: In a new but not surprising move, UnitedHealthcare’s Community/Medicaid plan starts to conduct so-called site of care reviews for PT, OT and Speech therapy starting in June. First, they’ll give a go-no go decision and, if authorized, will review the ‘outpatient hospital site of service’. This trend follows the emerging use of site of service for radiology/imaging and infusion.
8. Radiation Policy Change: Evicore, which handles medical policy development and pre-authorization for insurers, including its parent Cigna, has made some big changes to guidelines for radiation therapy for soft tissue sarcomas, treatment with Lutathera and proton beam therapy. MA and fully insured impacted.
9. Post-Traumatic Stress: PTSD benefits for first responders in Connecticut are likely under a new proposal. As a hard-to-treat condition, it seems to be one of the underappreciated and often missed side effects of pain, injury, and surgery, and of course grief, loss and trauma. Says Rachel Touncey, MD, an internist by training who’s now working with ‘physician groups trying to move into risk taking’: ‘I don’t see protocols trying to get at this. Completely avoided…and yet it’s often the thing that hinders recovery, or explains behavior change’
10. All Bets Off Kenny Rogers: More payers are covering therapy for gamblers but not in every setting and not as restrictive as you might think. Excellus BCBS allows OP therapy for gamblers without pre-approval. Residential, partial hospitalization and Inpatient services are thought to be investigational. The biological dad for our oldest foster kid has struggled for a number of years with this behavior–using salary to fuel the addiction, putting his family and our oldest in a tough place at times–but what is clear is that social factors have as much to do with the cause of this behavior as anything. How OP therapy addresses these factors will be important for this benefit and treatment to have any success.
11. Extra Point: At about the same time as my oldest son was leading the marching band down main street on Monday my dad was pulling a Richard Kimble back home, wrapping a deep shin wound with one hand using amateur tape and gauze like the Fugitive character, driving himself to the urgent care in what was a race against time. He had fallen in the garden trying to relocate a hosta only to slip or get dizzy and slam his right shin into a rock. He would later tell me he ‘wanted to get it stitched up before mom found out….’ But the so-called 24-7 urgent care was closed—two of them in fact—so I made my way to dad’s house to pick him up. We averted going to the hospital ER, finding the only urgent care open in the region. The PA was sharp, and a great teacher – allowing a Bay Path College student just enough independence to clean the wound and put in 8 stiches on his own, with a small bit of oversight. I think back to Memorial Day – yeah, I missed the barbeque, but I spent a day with a veteran, my dad, and stories about his penchant for falling and first aide. Here’s to all the vets out there.

1. 16: Number of cancer groups participating in Humana’s new oncology payment model for Medicare Advantage and commercial patients. The program is in its 5th month – but efforts to pay differently for cancer aren’t new by any stretch. Before the days of ‘value-based payment’ there were pioneers at Aetna and Humana designing shared savings models from scratch. The model is the fourth for the plan to target specialty services – orthopedics, maternity, and spinal fusion for MA patients.

2. The Cayman’s: Perhaps not a fit for the big insurers, but a handful of medical groups taking global risk told us they have started to use 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?

3. Consult Code Out: Starting in October, United Healthcare stops paying for so-called consultation services billed using codes 99241-99245 and 99251-99255. The appropriate evaluation and management codes must be used instead.

4. Cap Up Front: If you’re trying to contract for risk, make sure to get a payment up front to cover your PCPs services in advance rather than having to float until reconciliation of the payments takes place. The up-front cap can be something like $75 or 110% of Medicare – there’s a lag in the calculation, so this is one way to at least cover this until the claims for ER and IP are tallied.

5. Latest Social Measure: One unhealthy day equates to 10 hospital admits per 1,000 people or $15.64 per member per month in additional costs. This is the latest statistic that insurers are starting to lean on to shape programs to address social determinants of health. In what they’re calling Bold Gold, Humana says 5 of 7 communities reduced unhealthy days last year. Loneliness, for example, causes Medicare seniors to have an average of 24.4 unhealthy days a month; food insecurity averages 26.6. But there are community programs that are beginning to address these stats – and for provider groups like medical groups taking risk, these are indicators of a rapidly shifting trend in where the MA value dollar is headed. In New Orleans, those with CHF had a 9% improvement in unhealthy days due largely to a food bank program and San Antonio reports a nearly 10% decrease in unhealthy days. In contrast, some cities where Humana has members have struggled – including Broward County Florida where unhealthy days increased by 4% as did depression prevalence among members. By the end of the year, the insurer hopes to ‘screen’ 1 million for social related determinants of health.

6. Ankle Over Budget: An orthopedic group in Arkansas says it had been doing well in a bundled pay program but it is struggling lately ‘because a lot of our patients have chronic conditions and so rehabbing them is a lot harder….and we’ve had some situations where the patient didn’t comply and had complications….,’ Michael Slavan, the executive director for a Ortho Associates says. The group says that they have gone ‘over budget’ most commonly with foot and ankle procedure patients and with teenagers who play sports and are coming off of a diagnosis related to a baseball injury (like multiple directional instability, or MDI). Slavan agrees that one of the biggest gaps his group has faced is inability to have consistent PT as well as address the mental health/psych issues of patients in rehab…’If you’re doing bundles, and you don’t have the full suite of services, I’m not sure how you have success.’

7. Mawidge: As the Priest said in The Princess Bride, this is what brings us together, today….and if you’re in the healthcare field in one of these specialties, you may want to think about marrying or at least dating these insurers who we might argue will be the most important to your growth given their recent efforts to focus on specific diseases. For pain and PT, it may be Cigna and its Express Scripts and Evicore arm looking to create centers of excellence. For behavioral, it may soon be Anthem or Beacon (or perhaps a combined entity) given both companies recent investments in the psych arena. For social determinants, UnitedHealthcare. For home health and hospice, Humana – although be careful about the company’s Kindred and Curo ownership in some markets. For addiction, it may just be Shatterproof, the non-profit. And for surgical specialists like orthopedics, GI and ENT, and diagnostic services like lab and imaging, it may not be traditional large group insurers but more so large risk-taking medical groups who will need reliable specialists set up to do the right thing at the right cost.

8. College Course: When I struggled in college, I played late-night floor hockey and then hit the local Denny’s for a short stack of flapjacks….that was how we handled the anxiety of finals or the ups and downs of being away from home. But things are different now in the age of social media. Boston University has one of the nation’s only programs for students needing mental health support after having to leave the school due to depression or anxiety. In response to the needs to help college students, Beacon Health Option now has virtual counseling. For ‘primary care and psych providers’ the new program is important because it is the latest sign that the managed care is taking health inhouse, creating its own stable of practitioners

9. PTSD: 53% of parents who have senior moms and dads say at least one of their parents has had a post traumatic stress condition due to a childhood incident, time serving in the war, or most commonly due to the loss of a spouse. Of the 429 polled, about 220 said the PTSD ultimately led to alcohol abuse, dehydration or malnutrition, and eventually to a hospitalization due typically to a fall in the home. PTSD is likely top of mind for many veteran’s families during this Memorial Day weekend. Question is whether your businesses are equipped to train practitioners to identify this condition early enough in care.

10. Extra Point: Coach told us this past winter that our 8th grader, Sophie, will see significantly reduced minutes during Sunday hoop games because she wouldn’t be playing in Saturday games to attend dance classes. All in or sit pine basically. We said ‘sounds good.’ There’s a point when we recognized what our kid likes and doesn’t like, and what matters – she loves the arts and loves performing and if dancing 2 hours a week fills her up, it’s worth missing a basketball game. Going to practice and learning, being part of a team – all important. Playing a sport 5 days a week and giving up other things at age 13 – not a great idea. We called the coaches bluff in a way here as he was hopeful to keep Sophie in the mix as a starter for games because she can guard people and dribble. But there are 13 kids on the team and life is too short – Sophie said maybe missing Saturday is a blessing for her teammates who’ve been sitting pine and need a win if you know what I mean. We just saw statistics from Ditch the Label, a youth organization, about the percent of kids suffering from things like depression. Many of them bullied for how they look, or what team they’re on. Many conflicted by decisions made for them around sports. 50% suffer depression. A lower but meaningful number suffer eating disorders, and even try to take their own lives. The stats come to life starting at age 13. Doing what we can to encourage balance, reasonableness, and a bit of humility in our kids is our effort at helping them manage through adolescence. It’s a daily struggle…but here’s to the journey. For background on our study first published last week on the impact of sports on families and health, click here: https://thebehavioralhealthhour.com/2019/05/17/losing-beats-winning-2/

1. 30 for 30: According to the NCQA, patients with a new onset low back pain diagnosis normally should not receive imaging within the first 30 days of diagnosis but there may be instances when imaging should be considered. You can access an evaluation chart to use with patients presenting low back pain: click here

2. Fall Risk: In our poll of Medicare Advantage plan care managers and medical directors, 91 of 153 said this was the number one ‘avoidable outcome’ issue that their networks are struggling to reduce. My dad fell down stairs two years ago and, though he luckily survived, continues to struggle with vertigo and other issues ever since. ‘There are a host of root causes,’ Mary Flanders, RN, says, including dehydration or lack of physical activity, orthostatic balance issues, and often untreated PTSD that often can lead to substance abuse. It’s a hint to MA focused home care or physician groups to focus on fall risk, particularly since CMS has noted it as an issue they are honing in on over the coming months.

3. Drug Testing Change: Anthem has changed its policy for drug testing. When definitive drug testing is submitted on the same date of service as presumptive drug testing by instrumented chemistry analyzers for the same member by an independent clinical laboratory, Anthem will allow separate reimbursement for definitive drug testing of 1-7 drug classes, but won’t separately reimburse for definitive testing for 8 or more drug classes when performed on the same date of service as the presumptive testing.

4. Play Time: A physician in Nevada told us last week that he now ‘prescribes’ play to kids and teens – and seniors - during annual physicals and sick visits. Phil Smith, MD, said about 7 out of 10 parents ‘love the script’ but several parents still just tell him ‘can you prescribe a medicine’? A small software company, Advex, said they have asked their insurer (Aetna) to help develop a benefit that gives discounts for physical activity and includes coverage for applied behavioral analysis for kids on the autism spectrum, but they want ‘only certain programs’ in the network, including an ABA Sports model ‘that we think can be really helpful to our families … many are having to pull kids out of sports and bring them to a clinic for therapy at their own cost,’ Marge Youmens, an HR director, says.

5. Behavioral Roundtable Chatter: During our behavioral health roundtable in Chicago Tuesday, there were moments when we may have learned more from the silence in the room than the chatter. In one discussion, a debate centered around how to manage the rising cost of autism – a 40% increase in the number of providers in one insurer’s network, a 45% increase in total costs, more self-insured employers ‘being pushed’ to cover ABA therapy and a total lack of services for older teens and young adults…and yet at times Tuesday uncertainty manifested in stares and long pauses on how in the world managed care can handle what seems more like Tsunami than high tide. Payers here say they are trying to raise the bar on quality of care and outcomes for those on the spectrum but this is difficult given the supply and demand challenges. Efforts to cover more kids earlier and perhaps ‘reduce costs down the line’ have potential but ‘50% of those early autism diagnoses self correct’ one roundtable guest opined. The answer, at least for the next 2-3 years, seems to likely be increased scrutiny around the billing and compliance operations of ABA providers – doing the wrong thing, pushing the needle on hours or medical need, face an audit. In another moment, a school counselor talked about the importance of prevention and physical activity as underappreciated still in school curriculums, but few could wrap their head around how to invest in the solution when so much of the business of healthcare is focused on treatment.

6. Extra Point: We are nearing release of a 20-year study of parent behavior and the impact of sports on families. In full disclosure, both my wife and I participated but I don’t think we skewed the results, nor could we have envisioned how much we have changed our views in this time. The study began post Columbine and has tracked the views and outcomes of 362 families over 20 years. For a snapshot of the findings click here