Behavioral Health Insights

1. 49: Percent of 316 high school and college students we polled this month who say they ‘know someone’ with an eating disorder, ‘or think they do,’ but just 20% say they’ve told anyone about it. ‘It’s hard to talk about it. I’ve told a counselor,’ said one 11th grader, but others say they ‘aren’t sure exactly.’ One female polled said part of the issue is the classes and culture focus ‘so much on watching what we eat … and a lot of us don’t really know how to do that…and sometimes the issue ‘escalates.’ A freshman at a college in Texas says ‘it’s hard for a lot of kids who have had to deal with allergies and even been in the hospital for that so they’re already cautious,’ so add the stigma around weight, ‘and I know a number of kids who are anorexic, definitely bulimic too.’  Patrick Sweetland, a health teacher in my town, says they’ve struggled to manage kids who have been hospitalized due to a food allergy incident, who then ‘come back to school afraid to put anything in their mouth.’ One student, an eighth grader, was hospitalized in 2018 and eventually spent 3 months at a treatment center in Maryland ‘because there weren’t any options in our state,’ then came back to school with a better understanding that she needed to eat but ‘walked right back into a culture where kids are tough on you if you are fat’.

2. Payer Owes My Wife $7,200, Per Kid: United Healthcare is following the lead of other insurers we’ve noted here in fixing the payment rate for maternity services and likely opening the door for shared savings models for OGBYNs. My wife asked me if we will get a refund for ‘all the work she had to do to have our kids…estimating that our insurer during the time we had kids probably owes us around $7,200  ‘for avoiding c-sections and for dealing with the pain at home without going to the ER’. United’s change, announced yesterday, means OBGYNs will be paid per episode and incented to help the insurer limit c-sections and reduce pre-term ER trips. Rollout will be slow – two groups, Lifeline Medical Associates in New Jersey and Privia in Texas, are in the initial pilot, with their patients given a smart-phone app to communicate with the clinical team, ‘rather than just go to the hospital,’ with plans to roll out the initiative to 20 groups by next year. GE, a self-insured plan, Horizon Blue, Cigna and several Medicaid insurers have adopted similar approaches. The holy grail is addressing pre-term depression risk and stress that can lead to early labor and complications, as well as post-partum costs. The question for women’s health groups and multi-specialty practices with an OBGYN service line, is not whether the ‘bundle’ is better than the fee for service but when these payers will ‘require this approach’ for groups to be in the network. Being in these pilots early on brings more savings likely ‘given we’re more willing to share in the savings during the test phase’

3. Bundle Is Hip: 7 health systems and 64 surgeons have been participating in a bundled payment pilot that sets the goal for total cost of a total hip or knee replacement at about 10-12% lower than the typical level for ‘non-complex’ surgeries. The 90-day bundle will include costs for the surgery and rehab – if providers, on average, come in at the lower level they may be eligible for a share of the savings. Steve Anderson, who helps lead Blue Michigan’s contracting and networks, says fully insured employers with both the HMO and PPO networks have been eligible. Results due out soon.

4. Social Up, But Assessment Gaps Likely: Having spent the last 10 years working with refugee families and principally teen girls who are trying to play head of household and navigate home and health decisions for themselves, their parents and siblings, I’ve gotten to gain a moderately high level of understanding about how to talk to teens and sometimes their parents about healthcare. Trying to assess the root cause of a headache or back pain can’t be assessed in a checklist. The conversation, designed to help determine the reason for the pain and how to treat is, is more art than science.  We try to help the volunteers who are assigned to each of these teens in the program with how to assess and then triage. 71% of payers see value in addressing social determinants, according to our survey, but there are gaps in implementing this mission: just 2 in 10 payers in a Change Healthcare poll they are training physicians on how to identify social determinants and 3 in 10 are offering a social assessment along with their health risk assessments. Assume that these tactics will increase in use but there’s are potential flaws in a lot of the assessment tools as they are often cookie-cutter. ‘I can barely get patients to talk about their mental health much less what’s happening at home, and the checklists are nice but not sure they are accurate,’ says pediatrician Kay Fiorella who says ‘her whole day is shot if she sees a patient with a mental health or social related issue come in’. The assessments, she argues, are checklists that don’t help much. Doctors, nurses and social workers ideally need to engage differently in these conversations – ‘I would argue we’d better to do these over a web telehealth type system where you get better eye contact’

5. Mississippi Burning: Several hospital ERs are ticked over a change in payment policy. Payment for ER visits is now going to be downcoded based on the diagnosis severity under a new, albeit controversial policy from BCBS of Mississippi that is in effect this spring. One source said about 25-35% of their level 4 visits were changed to level 2 or level 1 this year, ‘where we were basically paid what they called a triage fee’.

6. Pre Authorization Removed: Amerigroup, an Anthem Company, no longer requires pre-approval for behavioral health medication training and support, behavioral health skills training and development, targeted case management for behavioral health, crisis intervention, psychosocial rehabilitation, day treatment, and training and education services related to mental health problems. The company says this change will impact STAR, CHIP, STAR+PLUS and STAR Kids. A spokesman says federal and state law, as well as state contract language and CMS guidelines take precedence over prior authorization rules and must be considered first when determining coverage.

7. HIV and Addiction Program: New York State’s Department of Health AIDS Institute is partnering with Erie County Medical Center to host a hepatitis C preceptorship program targeting substance use providers and addiction specialists. The goal is to increase capacity in substance use treatment programs to provide on-site hep C treatment to those most likely living with the disease, says. Anthony Martinez, an addiction and HIV specialist leading the program.

8. Shatter This: Wendy Sherry, a Cigna Board Member, says the insurer hit its 3-year goal of reducing the opioid prescribing rate by 25% but says ‘we’re not seeing the same level of drop-off in the overdose rate.’  Cigna is one of many insurers – 19 of them – partnering with Shatterproof to address stigma issues and help create centers of excellence. Pilots are underway in New York, Massachusetts and Louisiana to deploy principles of quality care for addiction treatment. If you’re not ‘among the centers on the Shatterproof portal,’ be warned, acknowledged Jasmine Bass, a spokesperson we chatted with at the National Council on Behavioral Health meeting. There will be recommended providers and insurers will incent members (e.g., no copays, education) to use these programs. Full story next week.

9. Extra Point: So only in my town would parents get in an uproar over high schoolers speeding in cars around cul de sacs, hiding in bushes and chasing each other with water pistols in a seemingly innocent game they call Assassins. Seems harmless, but our town’s helicopter families have gotten so upset over Assassins that the Police Log had more than 100 calls in one week and a town forum was held last week to ‘get to the bottom of this terrible game.’ They have a point, right? I mean very few parents ever drive fast, and very few of us have ever used a water gun. And kids running after school in the neighborhood, often sprinting to chase down their target. Working together in teams. Outside. Not inside. This IS terrible…..One kid, Ben, was hiding in the backyard of my house for so many hours that his phone was ‘losing juice’ so he asked for a charge. ‘Um, Mr. Cote, I know I’m here to get your son, but could I come in and charge my phone?’ The Helicopter parents complained about ‘kids wasting time’ and ‘trying to hurt each other’. I see the opposite – kids who never would interact are playing together, competing. Kids of all shapes, colors, backgrounds, economic and school status classes, are on an even playing field, brought together in a good ole fashion water fight. Many of them sit the bench on their high school team, or spend 7 hours learning algebraic formulas they’ll never use….a little community camaraderie shouldn’t scare us. In fact, Assassins may be healthiest thing I’ve seen in this town in years.

1. 25,000: People living with Parkinson’s in Michigan out of the roughly 1 million nationally. BCBS of Michigan is teaming up with the Kirk Gibson Foundation to raise awareness and provide resources. In the meantime, there continues to research on Parkinson’s. A new study released this year says a new device may be helpful in slowing or reversing the progression of the disease. The experimental study investigated whether using a novel delivery system could regenerate dying dopamine brain cells in patients with Parkinson’s and even reverse their condition. It could be ‘the first neuro-restorative treatment for people living with Parkinson's,’ according to Steven Gill, who designed the infusion device used in the study. My good friend is dealing with Parkinson these days with her dad in and out of the hospital. The attention to treating Parkinson’s is likely to increase inside managed care in the next 10 years with the increase in the number of insurers partnering with behavioral health companies. ‘Just our access to neuro-specialists alone will be helpful in guiding us to provide a more substantive benefit for patients and families, and to do more to help in earlier diagnosis and management.’

2. College Play: Beacon Health, the behavioral company, has launched a national program specifically for college age students. The model will include virtual counseling designed to head off suicide risk and address depression, anxiety and a host of other mental health challenges that stem from being away from home for the first time. Though Beacon says theirs is the first in the nation, there are smaller start-up models that exist featuring licensed psychologists or coaches who help colleges address shortages and deal with the flow of students who show up to the campus clinic. I would assume that the goal here is also to meet the demands of mental health parity and the Affordable Care Act and, over time, it would not be surprising to see the bigger managed care companies looking at this service as another entrée into managing behavioral, and an in-road to the youth population.

3. Middle America Capitation Conundrum: Anthem paid out more than 11 million in performance bonus payments to 43 medical groups back in 2008, at an average annual payment of $300,000 per group. There were 91 total groups that participated in the risk sharing initiative back then. The program was done to entice medical groups to reduce ER, hospital IP, and outpatient surgery. Flash forward more than a decade later and these risk sharing models continue, though the plans have largely tried to move more groups into taking more risk, even ‘global risk’. But in our poll of physicians from 131 groups in 11 midwestern or central US states, just 19 said they are willing and able to enter global risk. ‘We just got an EMR’ said one practice director, another said we ‘have had an EMR but don’t know what to do with all the reports…I keep asking my manager to help me see my data…my patient’s activity.’ Others complain about acuity, one saying ‘we have too many patients with 2 or 3 chronic conditions….[so] it’s really hard to avoid the hospital….’ That said, there is growing demand from both CMS and payers to gently push more doctor groups into risk in middle America. One of the chief issues cited by 94 of the 131 is the lack of resources to address the mental health needs of patients – ‘I’m just not trained to talk to people about this….I know hypertension and cardiovascular….it’s very time consuming and I often try to refer or else these eat up my entire morning…but referring isn’t really effective since I have no idea if the patients end up going to the therapist.’

4. School Walkout: Unless you have kids in the primary or secondary school system, you may have missed the wave of teacher strikes or protests across the country recently designed to help raise the debate about teacher pay and the new challenges educators face. Schools in West Virginia, North Carolina, Kentucky are among the recent districts impacted and there’s a hidden theme across all the protests – teachers want more money, and more help, to prevent suicide. To be blunt, teachers across these districts and others who’ve orchestrated 1-day walkouts say their jobs have shifted dramatically in the last 10 years….our school seems more like a healthcare facility or a doctor’s office at times than a school, said Val Stills, a 7th grade math teacher in North Carolina, who says she would like more staffing resources like aides and therapists available to teachers, embedded in the classrooms, in much the same way that special ed teachers are used. Behavioral health companies, particularly those focused on autism, have already begun to offer school-based services. A bigger debate will emerge in the next 5 years about the best way to deploy these services for kids both on the spectrum but also those facing adolescent challenges and potential suicide risk, and how to pay for it.

5. Tech Behavior Change: So I was given a hard time by my colleague Ruth today because I asked if I call the Hotel app she suggested I use to book my hotel. ‘You don’t call apps!,’ she laughed. Technology, while seemingly helpful to save time, can’t break old habits  . Innovations in technology was a key topic at Yale University’s annual healthcare event back in April. Trent Haywood, chief medical officer at BCBS, was on the panel and our correspondent Erin O’Donnell attended the session. Highlights here

6. Best Site of Care….Hospital: Counter to everything we talk about, there’s a little-known but growing trend of drug treatment shifting to certain hospitals in certain markets. 16 of 21 commercial insurers told us they are ‘being pursued’ by 340b hospital systems who are seeking to cut a deal to bring more volume to their hospital and affiliated providers in exchange for a lower reimbursement rate on Part B drugs. This is really only in more competitive markets and the arrangements give the payer a chance to close the network and shift volume to providers whose total cost of care is less than everyone else. Patients are pushed to use these lower-cost facilities for treatment through lower copayments or coinsurance. Said a pharmacy director: ‘It’s odd to think about but for as much as we are trying to shift care out of hospitals, when it comes to patients needing certain drug treatment, the 340b hospitals are a better deal on something like infusions particularly in cancer because so much of the total cost is tied up in the drug.’

7. 700: Measles cases topped this number nationwide and public health officials now worry that the disease is gaining significant foothold in the US, Kaiser Health News reported in their morning briefing this week. 13 individual outbreaks have occurred in 22 states in 2019 reports the CDC and New York officials have issued fines over people who are missing their measles shots. Officials in New York closed more schools to contain the measles outbreak and suburban Rockland County account for the majority of the cases.

8. Autism Meet GI: So many of you are following the growing autism treatment field or GI sector – well marry the two and you may solve a complex condition common in kids on the spectrum. Many children with autism have gastrointestinal issues. ‘The human gut and brain interact in complex ways, and abnormal conditions in the gut may predispose individuals to neurodevelopmental disorders,’ Arizona State University have found. 95% of children with autism have co-occurring conditions, almost 5 on average.

9. OON Change: Texas Blue removed 14 hospital emergency rooms after negotiations with the ER contractor fell through and the change took effect immediately in April. Many of ER’s are contracted by third-party companies, so many patients walking into the ER are often unaware of the additional costs. In the statement sent out to BCBS of Texas members, Texas Medicine Resources ER doctors who work at several Texas Health Resources hospitals will be out of network. This means the third-party company can charge members whatever they want for their services. The hospitals themselves, which include Texas Health Harris Methodist Hospital, Texas Health Presbyterian Hospital Dallas and Texas Health Arlington Memorial Hospital, will still be in the Blue Cross Blue Shield network, but their ERs will not.

10. Extra Point: 70% of 353 women age 35 to 52 we polled earlier this month about the health of their families told us they are getting Facebook ads from the likes of 23 and Me, AncestryDNA and Vitagene who are offering $29 to $99 intel to help women redesign their diets. My bride is interested in the service and says the local Orange Theory has ‘had discussions’ with these health genome services as part of a potential diet and exercise product. I told Janine that I’m all for it, and would be happy to do the swab myself, though I’m admittedly nervous 23andMe will tell me my SmartFood obsession is not good for me. These direct-to-patient services have implications for a few businesses: primary care, genetic testing services, women’s health providers, and oncology. Whether they will impact my health or my family’s….I’m skeptical, but like any good husband, I’ll be open to change.

1. 16,752. No, this isn’t another Rent song, it’s the average cost believe it or not that a diabetic person will spend on average each year on medical costs, according to a recent study by the ADA. Cigna and Express Scripts introduced a patient assurance program to cap the out of pocket costs at $25 for every 30-day insulin prescription. Cigna says this reduces the out-of-pocket costs for insulin by 40% or more and improves affordability of insulin costs for people with diabetes. The Patient Assurance Program will be available to members in participating non-government funded pharmacy plans managed by Express Scripts, including Cigna and many other health plans, with out-of-pocket costs for insulin greater than $25. Out of pocket costs for insulin include deductibles, copays or coinsurance.

2. Allergy UnBoost: Reimbursement for Allergan immunotherapy is going down, according to a policy effective this month from BCBS of Tennessee. The commercial payer used to define a dose of allergen immunology as 1cc of extract and limited reimbursement to 30 doses per day but it will now use an annual limit, allowing up to 160 doses per patient per year.

3. Evaluation Management Switch: Beginning in May, Anthem may deny your evaluation and management services if billed with a modifier 25 on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record. The reason is Anthem’s audit identified that providers often bill a duplicate E&M service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group) recently billed a service or procedure that included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with Anthem billing rules, a spokesman told us.

4. Autism Meet The GI: So many of you are following the growing autism treatment field or GI sector – well marry the two and you may solve a complex condition common in kids on the spectrum. Many children with autism have gastrointestinal issues. ‘The human gut and brain interact in complex ways, and abnormal conditions in the gut may predispose individuals to neurodevelopmental disorders,’ Arizona State University have found. 95% of children with autism have co-occurring conditions, almost 5 on average.

5. Genetic Hoop: UnitedHealthcare now requires genetic and molecular testing performed in an outpatient setting go through a pre-approval process if ordered for members in Rhode Island and New Jersey. Pennsylvania Medicaid members would need the ordering physician to get approval starting in July

6. Breaking Down Walls: Children’s Hospital & Medical Center in Omaha says it wants to expand access to its pediatric psychiatrists across the rural communities of Nebraska and Iowa and so it is designing a telehealth program allowing the specialists to treat new and existing psych patients remotely for all conditions typically seen in outpatient clinics: depression, anxiety, ADHD and autism. The marriage of clinic, hospital and psych services is emerging as a top focus in the health system – if you’re an owner of a private practice, think of these developments as either opportunity or threat, but at a minimum a sign that hospitals are coming downhill and breaking down the walls of the hospital campus.

7. Observation: In interviews with a lot of different medical directors I’ve come to appreciate that risk taking medical groups seem to take observation for granted – that many, in their quest to manage cost particularly for Medicare Advantage chronically ill patients, tend to ‘underutilize’ observation. IP days reduction and readmission reduction are established goals, but with patients who have a lot of chronic conditions, observation is a reasonable level of care. As you evaluate your own group’s risk taking capabilities or potential gaps, look at how often (or little) observation is used. There are rules to follow, too. BCBS of Michigan’s medical team noted that they use Interqual criteria to determine (a) whether the patient should have been in observation to begin with and (b) whether they’ve failed in this setting. Blue Michigan requires 48 hours of observation to complete workup, treat and/or stabilize the patient for discharge. An admission may be approved if the patient fails treatment for say, dehydration.

8. Out With The Insurer: CHRISTUS Health announced that hospitals in Texas and Louisiana will no longer be accepting Cigna health insurance due to the hospital group and the insurance company disagreeing on a financial compensation. The hospitals and clinic went out of network in March.  CHRISTUS Health is a not-for-profit health system that includes Good Shepherd Health System, CHRISTUS Mother Frances Hospitals - Tyler, South Tyler, Jacksonville and Winnsboro and CHRISTUS Trinity Clinic.

9. Alexa: I’m not going to lie – Alexa creeps me out but, say this, she’s making her mark in healthcare. Amazon announced new software this week that allows health care companies to use Alexa voice tools to securely transmit private patient information such as progress updates after surgery, prescription delivery notifications as well as trafficking patient information that is protected by the US's health privacy law (HIPAA). Large health businesses such as Cigna to Boston Children’s Hospital were among those who helped to build the six different voice programs. Alexa now has access to more sensitive details of patient’s medical conditions. Express Scripts, the pharmacy benefit manager acquired by Cigna, built a tool to allow people to check the status of home delivery prescriptions. Boston Children’s Hospital built a program enabling parents and caregivers to provide clinicians with updates on their progress after surgery and get information on post-operative appointments. Alexa will now be able to book patients their urgent care appointments.

10. Rehab Tweaked: Empire BCBS of New York has a new rehab program effective this July that will transition medical necessity review of rehab (restoring function) and habilitative (enhancing function) services for fully insured members to AIM Specialty Health (AIM). This means a AIM will make the call on whether PT, OT and Speech are necessary. Remember that AIM is highly focused on controlling UM for pain and imaging and gaining increasing share in the benefit management space with Blue plans, as well as Anthem (which owns them). How AIM uses data to influence future coverage, reimbursement and benefit design policies will be important to watch particularly for those in this space.

11.Social Experiment: The National Quality Forum (NQF) and Aetna Foundation have launched a 9-month project to find ways to promote payment methods that reduce health disparities and by addressing how things like housing, transportation, and nutrition can be barriers to better health. The duo will ‘look for pioneers across the country’ - payers or health systems, or even entire communities. The idea is to find those ideas that are repeatable and scalable. My own group that my wife and friends and I started 10 years ago is a small social service for refugee families in Hartford focused on helping teen girls from Thailand - it uses a volunteer-led model to reduce the impact of social and economic challenges on about 100+ kids. Scaling something like this depends largely on volunteers. Parallel to this NQF-Aetna effort, United and the AMA are creating two dozen new social determinant codes using a combination of medical data and self-reported social data. Details here: https://thebehavioralhealthhour.com/2019/03/29/560000-referrals-to-social-services/

12. Anesthesia Up: The conversion factor used to calculate anesthesia base units for anesthesia procedures will increase by 1.5 percent under a new BCBS of Michigan policy taking effect in July.

13. Extra Point:  Patagonia is not a real place I told a colleague this week. At best it sounds more like the name of the village in The Princess Bride. Which reminds me…the book is making a comeback in my house as is the film, particularly that scene when a fragile Wesley challenges Prince Humperdinck in a battle ‘to the pain’. It would seem the healthcare sector is trying to align with this mantra, if not going further. Policies to force physicians, PAs and NPs to encourage conservative treatment before pills and injections and devices are gaining momentum. Even Inland Pain Medicine, a large group practice in California, promotes Yoga as a means to avoid pain and reduce its triggers, like depression and anxiety. Chronic pain is often the result of undiagnosed PTSD – which I’ve learned is very common in teen girls who grew up in refugee camps….and Inland’s medical team notes that those pushing for higher cost procedures like spinal cord stimulation or injections without fully evaluating a patient’s history and mental health are not doing the right thing. Spinal cord stimulation needs to be carefully evaluated (as it will be by insurers), the group says. Pain appears to be moving away from something to merely manage, and toward something to avoid.

1. 700: Number of direct primary care practices in the US via a new coalition of doctors who provide a kind of low-cost monthly membership to serve people without insurance and those with high deductible plans. The new delivery model has a concierge feel with higher touch care and a new-age pricing model: Memberships are $75 a month for adults, $25 for those under 21, with unlimited telemedicine and office visits and house calls for $25. Labs and meds are charged at wholesale cost plus 10%, according to Jonathan Bushman, who runs Reliant, a practice in Oklahoma that’s part of the emerging delivery model. There’s sort of a split view of these models among insurers – on the one hand several have told me they think these groups ‘mostly cater to the worried well’ while others have said ‘we could learn a lot from these models’ in terms of how to manage care.’

2. One if by Land, Two if by IVF: Fertility benefits seem to be improving a bit and as they do it’s no surprise to see managed care tighten the reigns a bit on payment policy even as they expand coverage. Aetna, for its part, is trying to help employers find balance by offering a benefit but a cost effective one. Starting this year the plan will cover the entire cost of the first I.V.F cycle if one embryo is transferred instead of two or more, and if that attempt fails, the insurer will cover the cost of a second attempt using a single frozen embryo. (If the woman’s plan limits the number of cycles covered, the second attempt will not count against that limit.)

3. Shatter This: More important than a single payer, Shatterproof, starting this year, enters pilots with New York, Massachusetts and Louisiana to deploy its principles of quality care for addiction treatment as a guide for insurers, physicians, hospitals and ultimately families facing addiction, according to Jasmine Bass, a spokesman for the non-profit, who I chatted with at the National Council for Behavioral Health on Monday. Shatterproof has ~19 insurers signed on, including the BCBS Association, with a goal of eventually using state scoring of treatment programs to advise consumers via a national online portal on where to go for treatment in their area – think ‘the Mayo of addiction treatment,’ but based on a national set of data. Winners are those who make their way onto the list, several insurers confirmed to us at the meeting. A rollout to other states is likely, Bass said. To see parent views on this topic from a poll we did a couple years ago, click here/ and scroll down to ‘Addiction – What Do We Do?.’

4. Mommy Dearest: Parents-to-be will have a new metric to compare hospital labor and delivery sites as the Joint Commission will publicly report C-section rates starting in 2020. The data ‘will absolutely factor into my decision’ says Kelly Flores, who is set to be married this summer and ‘says she and her beau likely start ‘trying later this year…since I’m in my 30s.’ My dad would say wait a few years but given Kelly’s age it’s logical to start and with public data she and 79% in our poll of woman 25 to 35 say the ‘rates would definitely be a factor’ particularly if ‘my OBGYN were associated with the hospital that has the high rates. Until now, the Joint Commission has the data, but hasn’t made it public. C-Section rates above 30% in a single year or over a 2-year period will appear to future parents as having higher rates (denoted with a minus sign, which in consumer speak ‘sort of seems like an F’ said a mom we polled. More broadly, this trend is important when you think of the movement to better attract moms to woman’s health groups who are able to provide a great experience, spend time with woman, and head off complications before they arise. Hospitals have earmarked behavioral health and woman’s health as two ‘rising’ stars in their service-line efforts, and it’s no surprise that the two sectors are being touted as ‘likely partners’ in a marriage of services that could be attractive in addressing the cost of care for woman in their 30s to 50s – ‘a key audience from my perspective,’ said a network development director for Anthem, ‘because you’re talking about both the consumer of care and the influencer of it for teens, husbands, and seniors. If we can set up a network and benefit design that works for this population of woman, we may have found something…’

5. OffRoad to Value: ‘Someone said payment is a marathon and not a sprint….only difference is with a marathon you know where you’re going…we haven’t quite figured it out yet…’ This from Sander Koyfman, MD, behavioral medical director for Wellcare in New York who obviously hasn’t seen me wander off course on my bicycle marathons. Dr. Koyfman, a psychiatrist by training, said this with an earnest smile and a bit of a plea for providers to be patient with the government-sponsored health plan. He says they have great idea for a pilot but ‘it takes 3-4 years’ to get it going or to the next level. ‘You have to pick the right metric but that’s not easy…particularly with behavioral health.’ The key to value design in many respects is the willingness of the payer to share data with providers. Anthem’s Jeff Walter, a director of payment innovation, says they gave a large group in Texas their admission, discharge and transition data and ‘the group used it to create a crisis response team and target superutilizers.’ But there are barriers to consider too: ‘Candidly we have concerns about data integrity,’ says a Magellan Complete Care spokeswoman … ‘we have more than we can make sense of but want to make sure we’re giving you data that sets you up to be successful, that we’re not giving you the wrong data.’ The plan’s corporate compliance legal team is cautious, so Magellan is ‘in a catch-22’.

6. Clinical Measure Demand: In an audit of length of stay decisions for a subset of its members treated for eating disorders, one regional plan found that more than one third of discharges for anorexia patients occurred before the patient had reached 75% of their pre-condition weight and in a review of patients who were allowed back to the same program after relapse for bulimia, nearly one-half were found to have been abusing alcohol even though at discharge they were no longer vomiting. Commercial plans are acknowledging through these audits that they are paying a lot for care without any real post-rehab recovery or a sense of how to manage these patients or determine what’s a good outcome.

7. Rent Knockoff? This one sounds more like a Rent song than reality….but United Healthcare says it has made 560,000 referrals in the last couple years to social services for its Medicare enrollees. And it hopes to start creating diagnosis codes for social determinants of health, like housing, food and transportation…actual diagnosis codes (ICD-10 codes) have been rolled out first for helping address social determinants of health in Medicare patients. Medicaid related codes are next. About 1 million Medicare Advantage enrollees identified a social-related issue connected to their health, a United spokesman confirmed. The Parkland Center for Innovation in Texas has done this work too, focusing on finding psycho-social data to identify causes of hospitalization, such as a male who loses his apartment or sneakers for a couple months. How existing physician groups and health systems make use of these codes and services may be an important differentiator, particularly for MA and managed Medicaid positioning. Also watch out for new kinds of vendors entering into capitated arrangements with Medicaid and MA plans to focus exclusively on social services – the precedent is there and this kind of contracting is already beginning to occur in select markets. How much the social service sector takes from traditional healthcare providers is hard to project but it would seem they are at a minimum beginning to take a share of the value dollar.

8. ExtraPoint: My youngest, Tommy, was in the principal’s office Tuesday because he, get this, spread a rumor about two kids...it’s no surprise if you ask me. See Tommy is a sixth grader in limbo – a foot shorter than the shortest kid, anxious about doing anything new, fixated by Dude Perfect and FortNite, and finding his way with 3 older, confident siblings. He punished himself by angrily burying his head in his pillow for 3 hours. Wednesday, after a long day at school, he and I hit those low-compression tennis balls out on the street. He broke a good sweat and hasn’t touch the iPad in 3 days. He’s healthier. The power of movement is gaining momentum but remains underappreciated in my opinion. It ought to be a greater part of treatment plans and school curriculums , and it appears that some medical groups and health systems agree. Barry Ostrowsky, CEO of New Jersey-based Barnabas Health, has said that insurers don’t really reimburse for wellness initiatives but this mindset is starting to change as health systems take greater risk and insurers like BCBS of Rhode Island give grants for school-age play programs. Barnabas, like several systems, now operate fitness centers, and a medical group in Minnesota – a state with a lot of Medicare Advantage patients – is contemplating opening one in its building. United is going all in on housing investment featuring wellness centers for its Medicaid population and it wouldn’t surprise me if more medical groups that move into risk arrangements start to affiliate or operate their own ‘on-site track and fitness centers…’ But what would really be compelling is medical groups starting tournaments that match patients, ala the Biggest Loser, with a practice’s new ‘Physical Fitness Director’ ‘seeding’ patient groups ala the NCAA tourney. Teams of 5 would compete in relay races or hoops or swimming, featuring a cross section of patients like a diabetic with a 6.9% hemoglobin A1c level paired with patients with varying degrees of depression or cardiovascular disease. Make it to the Final Four, no cost share for a year. This all may seem more fantasy than reality, but then again who would have thought we’d be paying for things like housing, telepsych and applied behavioral analysis?

1. 64: Percent of high school seniors in our poll earlier this month who say they are interested in medical school or healthcare jobs, but when ‘breaking out the results’ by gender, the numbers change a lot—girls (73%) and boys (49%).

2. Stroke of Genius: A new remote monitoring program has reduced bad ‘LDL’ cholesterol by 40% in less than 12 weeks, and cut blood pressure values in half according to results we found from Always Health Partners, formally known as Neighborhood Health Plan of Massachusetts. The plan’s remote medical management program is focused on reducing the risk of heart attacks and stroke. The program became available recently for all of the plan’s commercial members.

3. Breaking Ankles: 57 percent of network contracting directors from 132 in our poll Monday who said they are going to create ‘tiers’ eventually of surgeons by specialty, and specify a top tier of providers who have the best outcomes for highly common, but often unsuccessful ankle surgeries. ‘Part of the issue is that the follow-up care isn’t good—some of the surgeons are better than others, and some do a much better job in getting the patient to the right PT and trainer, some just let the patient decide… we looked at claims for those who had an ankle surgery in 2017 and needed to have another one last year and nearly all of them, something like 90%, were with the surgeons who I’d say aren’t part of an integrated team. The best outcomes were from those who are with the University programs that have more of a musculoskeletal interdisciplinary team in place.’ The cost comparison, one network director said, was in the $16,000 to $20,000 range—meaning the top tier surgical groups cost that much less.

4. Autism Test Ruled Unnecessary: There’s not a day that goes by where one of my teenagers doesn’t complain about all the overtesting in school. ‘Dad, we had like 3 quizzes today on English and Math and Social Studies…. it was all stupid.’ I asked Sophie why the tests were stupid, and she said ‘they just are.’ Insurers are putting more evidence into their testing decisions, specifically whether to cover lab tests and genetic tests to the point where one insurer, Regence BCBS, puts out new coverage criteria weekly, and another, Aetna, said they have an internal group evaluating the cost and outcomes of testing by endocrinologists and primary care physicians. Behavioral health and autism are emerging sectors of attention. In one example, testing for metabolic markets in the blood, urine, tissue, and other biologic material is not medically necessary for Autism disorder screening and assessment under a revised Anthem of Georgia policy just released. One thing to keep in mind with all these decisions is how coverage criteria and testing decisions change over time as more insurers push physicians into risk-based payment models.

5. TeleHealth Impact: An urgent care provider in Texas told me its volume is down 48% in the last two years due to a range of factors—more competition, for one, but also an emerging trend in younger populations relying on hotlines, and payers ‘intervening’ to direct care or provide ‘over the phone treatment.’ United Healthcare now uses ‘virtual visits’ whenever a patient needs care 24 hours a day 7 days a week for treating colds and fevers to caring for migraines and allergies, a service that continues to increase in popularity among employers. Payment for telehealth continues to inch closer if not get paid at the same level as in-office visits, according to 64% of insurers we polled, who say ‘shortages’ in many of their markets are the reason. For providers like pediatricians, urgent care, or PCPs, these developments are creating volume challenges. In fact, 71% of pediatricians polled this week said they are looking to change their business model in the next 2 to 3 years, or ‘probably retire’ given the ‘headaches’ of ‘losing so much’ volume to both urgent care and now telehealth. This service is available on your mobile phone, tablets, and computers. Video chats with doctors are 20 minutes or less, and patients can receive prescriptions if needed in certain states. United claims this saves $1,500 in comparison to going to the ER. Two apps used often include “Dr. On Demand” and “Amwell”, which United recommends for pink eye, migraines, allergies, sinus problems, or a quick assessment of severity. They do not recommend using these apps for chronic conditions, anything that needs a test or hands-on exam, or broken bones and sprains.

6. Nashville: On Monday, we will be reporting live from the National Council on Behavioral Health and covering a number of panels, including one on payer outlook. Details next week.

7. Extra Point: Bryant University, a small school in Rhode Island with its roots in finance and business education, now has the nation’s 17th-ranked physician assistant program and is looking to expand its healthcare footprint, considering a physical therapy program ‘to attract young students who love being around sports’ and further broaden its business curriculum to include anatomy and other healthcare classes. I went to Bryant in the early 90s when it was a college known for two things: the Patriots pre-season practice facility and the school where Coach from Cheers went. We were 2,500 strong at the time, and 99% of students were accounting or finance majors without a lick of writing skills, much less healthcare acumen. I made money for weekend pizza my junior year by writing 50 some cover letters for seniors—back then, the Bryant students applied to Big 6 accounting, but they didn’t know how to stand out to Arthur Anderson. Today, they are pursuing CFO-type roles for startup healthcare businesses, or revenue cycle posts within health systems. Last night, it felt a bit like déjà vu as I was the only ‘communications’ major on the panel. There was a CFO for RallyBio, a genomics company, and a managed care executive who handles ‘contracting’ for a hospital system, and used to do managed Medicaid work in Wyoming and Connecticut (before it changed course), so you can imagine how we were getting a bit too excited talking about value-based payment and how colleges like Bryant are at an important crossroads: they need to prepare students for a new kind of healthcare. As my oldest kids get ready to choose a college, I look at their interests—jazz, the stage, and journalism—and I love it, don’t get me wrong, but suspect they could benefit from a little more business. I know I did.

Extra Point: Unlike my kids whose idea of a crisis is their iphone app froze or the dog licked the waffle, meaning they have to make another one, there are real crisis situations going on and they are sparking a flurry of new healthcare psych-focused models. The latest is a new mental health facility focused on helping Medicaid patients in Tennessee, and it’s already at capacity. The center focuses on both crisis intervention and other psych needs, but its model has led to some questions from those we interviewed about its designation, whether it turns away crisis patients, and more broadly about its role in mental health crisis intervention. That it doesn’t accept commercial insurance but won’t turn any patients away either has created some hurdles, particularly because most of the patients that police have brought here in the first month have, guess what, been people who have Aetna or BCBS of Tennessee through their employer coverage. We polled payers and physicians about the model and included that in our story. In the end, the findings and early returns suggest there’s growing demand for psych support throughout the health and educational system, particularly at the point of crisis. But as investors enter this space – focusing on outpatient psych, autism, telehealth, and addiction treatment - it will be interesting to see how state policy, payer networks, reimbursement and facility services adjust. Seems unlikely that these quasi psych ERs will fall into a similar quandary as freestanding ERs did in Texas by operating out of network, in part because of the uniqueness of the patient situations and their community partnership approach. Lou Hochheiser, medical director of clinical policy at Humana for many years, once told me he didn’t like the freestanding ERs because they split true emergencies, but this model would seem to be different, if not well-intentioned. Still, when new models emerge that are on the line between ERs, urgent care and social services, there are going to be questions about the best way to promote and pay for their services. Here’s the story: https://thebehavioralhealthhour.com/2019/02/21/mental-health-emergency-room/

1. 560,000: The number of referrals United Healthcare made over the last couple years to social services for its Medicare enrollees. United hopes to start creating diagnosis codes for social determinants of health, like housing, food and transportation…actual diagnosis codes (ICD-10 codes) have been rolled out first for helping address social determinants of health in Medicare patients. Medicaid related codes are next. About 1 million Medicare Advantage enrollees identified a social related issue connected to their health, a United spokesman confirmed. The Parkland Center for Innovation in Texas has done this work too, focusing on finding psycho-social data to identify causes of hospitalization, such as a male who loses his apartment or sneakers for a couple months. How existing physician groups and health systems make use of these codes and services may be an important differentiator, particularly for MA and managed Medicaid positioning. Also watch out for new kinds of vendors entering into capitated arrangements with Medicaid and MA plans to focus exclusively on social services – the precedent is there and this kind of contracting is already beginning to occur in select markets. How much the social service sector takes from traditional healthcare providers is hard to project but it would seem they are at a minimum beginning to take a share of the value dollar.
2. Snoring Solved?: A poll we did last February of 92 pediatricians revealed that two in five children ages 5 to 15 are overweight significantly and about 75% of those kids suffer breathing issues at night as a result, such as snoring. Regence BCBS has determined in a review that surgeries to fix snoring or obstructive sleep apnea in the pediatric population are investigational; its ‘formal’ policy took effect last June. It did not update its policy for adults.
3. Consumerism In The ICU: 19% of hospital ‘strategy executives’ we polled earlier this month are hiring ‘consumerism’ officers to help evaluate patient behavior, preferences and other trends, to help it better staff, build and buy. Perhaps they’d benefit from learning more about the differences in decisions and resulting utilization between those single and married. A utilization analyst I’ve worked with, Reena Sanderson, studied healthcare costs for married men and women vs. those divorced, and the total costs and utilization among the divorced population is significantly higher in certain healthcare services. The study was limited to 200 total patients but it was over a three-year period and Sanderson says the married couples who ‘were active together’ had the lowest utilization (based on interviews). Results by geography in a future issue, but meantime the findings make me think of the marriage vows and how they may need an update. See my essay here.
4. Tiered Network: My oldest son Jack has been firmly cemented as a third tier player on his varsity basketball team, playing left bench because his defense is a little questionable and his agility is below par. He’s 1 of 16 kids in all and he wants the minutes, the competition, but he will have to wait for the players ahead of him to turn the ball over. Well, he got his chance Wednesday night and capitalized by hitting a buzzer beater, but his position on the team remains as shaky as third tier healthcare practices who are struggling amid tightening referral rules, narrow networks and high deductible plans. Like Jack, a lot of healthcare practices are finding themselves--or will find themselves--on tier 2 or 3, needing to wait their turn to pick up volume or get promoted by the insurers. Part of their challenge, like Jack’s, is an inability to get the payer’s attention and show value. For those of you operating these specialty practices the movement to tier-based reimbursement will heat up and demonstrating value creatively will be important. BCBS of North Carolina is the latest to create a tiered network and their work in this area may be a national model to follow. The plan has 2 tiers. Tier 1 providers get better rates based on varying clinical quality and cost measures. Examples: Orthopedic physicians conducting imaging 28 days after a patient’s initial evaluation for low back pain or endocrinology groups (i.e. the proportion of adults prescribed a lipid-lowering therapy who have a diagnosis of hyperlipidemia and CAD but without diabetes). Gastroenterologists, neurologists, cardiologists and OBGYNs are included too. See here for the 2018 scoring methodology.

5. A New Kind of Center of Excellence: Physician Dan Matthews has offered life-long services, pro-bono, to a youngster and his family he helped last year to figure out the real cause of his behavior. The kid, Aaron, was a 2nd grader and was on an IEP, was diagnosed with an unspecified spectrum disorder and had been taking antipsychotic medications to address outbursts in class and home. Matthews, who heads up NeuroBehavioral Health Systems in Texas, righted the ship – spending about 1 week with Aaron and his mom, doing testing and eventually adjusting the diagnosis and medication. Aaron wasn’t on the spectrum, and the medicine had had been taking that led to 35 pounds of weight gain was completely wrong. His condition was primarily a frontal lobe issue related to Aaron’s development. His new medicine is easier to manage and those 35 pounds he gained are gone. He’s calmer, more engaged, and the stigma that followed him in the halls has been lifted. The diagnosis that Dr. Mathews practice made is an example of the real opportunity the healthcare system has in making better use of regional experts who understand the science of behaviors and can maneuver through confusing conditions like depression, anxiety and autism. While Aaron’s family still can use Dr. Matthews, the beauty of this model is the center is primarily steps away after creating the protocol. But for all these benefits, there are risks, like how to pay for these services to ensure access to them and to ensure the right protocols are established. What’s more, autism and psych practice providers today will likely need to make sure they are linked in with these regional diagnostic centers of excellence. An open question exists in terms of how the health system ought to value these centers. With cancer back in 2008, I recall that Wellpoint at the time was keen on paying for these so-called diagnostic weeks, where the family could go to an MD Anderson or City of Hope to get the right protocol in place. ‘We ought to just pay for the flight and trip to get it right the first time, avoid a lot of re-diagnosing and tumors that move from stage 2 to 3 just because the local oncologists lack the resources, the expertise,’ Dave Tofanelli, former VP of enterprise contracting told me. Tofanelli’s idea was ahead of its time in some respects. These models are now beginning to be discussed more across services, not just behavioral and cancer, but orthopedics and neurology and likely other fields.
6. Specialty: Hospitals are establishing their own specialty pharmacies to capture more of the savings from prescriptions and have more of the control of patients as they leave hospitals. The predominant feature of these hospitals – they are enrolled in the government’s 340B pharmacy program.
7. Extra Point: In 2010, my family and I started tracking the outcomes of about 20 adolescent girls who we were teaching at a school in Hartford – their backgrounds as refugees from war-torn Thailand had landed them in our backyard and proved how much was needed at that time to help these kids manage their health, and the health of their families. By 2012, we established a social service model, linking up a single volunteer with each teen and family, focusing on helping empower the girls with exposure to the arts, music, sports and support in managing healthcare. Think getting flu shots or how to talk to a doctor about pain. Or that ‘hospital’ wasn’t just another word for ‘doctor’. These mostly Medicaid eligible families are the very definition of a group needing social support and whose health issues would have almost been pre-determined if not for the volunteer support system. I mention this given United Healthcare’s play in social determinants and what is likely to be a similar move by other managed care companies and health systems, and I suspect that as these models get looked at their will be interest in scaling them, in turning them from local resources to national businesses. This may be a good trend if it happens – because it could increase use of models like this one that help teens who are struggling as defacto heads of household. But those who get involved in these should be careful to understand what makes these models tick, and how to carefully value the services. Wouldn’t surprise me to see a lot of low dollar PMPM arrangements pop up designed to address social determinants but perhaps undermine the value and mission of many of these entities.

1. Where There’s Smoke: People with schizophrenia are 3 times more likely to smoke than other people and tend to smoke more heavily in an effort to control their symptoms related to their mental illness, according to the Mental Health Foundation. Of note, Rhode Island’s BCBS insurer just partnered with OutcomesMTM and schizophrenia is among the focus areas. Overall, patients taking 8+ Part D drugs and have incurred at least one quarter of their annual drug cost in the last 3 months are ‘targeted’. Patients pay nothing to be involved.

2. Diamonds Are a Doctor’s Best Friend: A care manager and consulting psychiatrist embedded in primary care practices are able to bill Minnesota’s BCBS insurer monthly under a new depression improvement program across Minnesota dubbed DIAMOND. Using a special code (T2022) via a professional claim (form 837P), this new care team can earn $100 per month per enrolled patient. Teams needs to be ‘approved’ by the insurer and its benefit manager, New Directions, in order to bill up to 12 months a year. ‘2022’ is probably just coincidence, but if I’m doing my math that’s about the window healthcare investors are looking at for deals just initiated, and payers here in the Gopher state believe the model should begin to ‘give a window into whether this type of ongoing depression management saves money elsewhere’.

3. The New Addiction: 32% of 12th graders, up from 27% in our poll last year, said they have ‘vaped’ in the past year; the percentages are higher in more affluent communities. The trend of smoking e-cigarettes is on the rise with even younger people and researchers are afraid that it will normalize smoking regular cigarettes again. Even more concerning, young people are ‘vaping’ with illicit drugs. Full story here

4. Evaluation Up or Down: ‘I’m waiting for the day when we do a claims review and we find significant down-coding….I suppose that would mean that people are healthier and health reform has worked.’ This from Arnie Solter, MD, who admits evaluation and management in some practices is, indeed, becoming more complex as physicians and their staff try to decipher potential risks and adjust to a payment system rewarding outcomes. A recent BCBS of Louisiana claims review is proof times have yet to change. It revealed up-coding by physicians related to evaluation and management of patients, and the insurer has advised physicians to bill based on visit complexity; it’s possible audits of larger offenders may follow if the trend continues, a source told us.

5. Air Transport Trend: Newman once said that Zip Codes, well, ‘they are meaningless,’ a funny line from Seinfeld that made you wonder if the mailman was on to something. Well, BCBS of Tennessee doesn’t think so. The plan now requires pick-up and drop-off zip codes, plus mileage and a host of other details from air ambulance providers. Air transport companies must get pre-approval for any so-called non-emergent transports; basically anything other than from the scene of an accident when ground transport may pose a threat. The billing rule changes are a small step to help the plan manage the high cost of out of network. Another effort, initiated last year, had BCBS offering in-network payments to air transport companies at 5x the Medicare rate ‘to get them into the network.’ Results still being evaluated.

6. Izzy Mandelbaum Healthcare: This Seinfeld icon once barked at Jerry that ‘it’s go time’, a plea from the Lloyd Bridges character for the weaker, unhealthier comedian to shed some pounds. Managed care organizations are in a bit of their own go time these days, more willing to entertain contracts with medical groups offering a new site of care. One managed care medical director in Indiana is talking to a medical group here that is turning an old apartment building into a basketball court and gym for patients who need more activity – office visits, check-ups will take place at the facility. The health plan, Welborn, would try to pay the group a PMPY to track BMI, obesity and other measures, including presenteeism in school and work. ‘This is the sort of thing that gets my attention – rather than come in saying you want a 10% increase because you added a clinic, show me how you’ll change the course of life for these patients’

7. Separate Payment No More, Separate Ways Forever: I wore a Separate Ways t-shirt to school for nearly 30 days straight in 6th grade, just so my classmates knew that it was the best Journey song. But being separate isn’t so good for supplies these days. Syringes, catheters, parenteral infusion pumps and other equipment used in various procedures and settings are no longer separately reimbursable by Aetna, under a new payment policy in which it says items like these are ‘part of the overall episode.’

8. Where’s My Kid: 62% of families of children surveyed said they avoided bringing their children to activities outside the home due to fear of wandering, according to the National Autism Association. Accidental drowning, wandering and traffic injuries are worst case scenarios and Miami’s Police Department is holding training for its officers to better understand autism and how to communicate and react in various situations. 48% of children with an ASD attempt to elope from a safe environment, 4 times higher than their non-ASD siblings. Two in three parents of children with ASD “elopers” reported their missing children had a “close call” with a traffic injury.

9. Extra Point: My cousin Chris served two tours in Afghanistan and Iraq and his dad, a decorated Army Colonel served in Vietnam and in his later years helped manage Veteran’s services in Carlisle County Pennsylvania. Both used to tell my kids stories on their back porch about their zany times on base. There are two things that can definitely get you kicked out of the military, Uncle John would say with a serious look that had the youngsters scared – if you can’t play handball, and if you have bad teeth. ‘I haven’t had a checkup in 5 years,’ Chris quipped last month as we shared stories about his dad who was buried at Arlington National with full military honors. ‘Dad would always get on me about that.’  Chris said what many guys say, that there’s nothing wrong if you don’t go. But the emphasis on oral health prevention as a guard against other diseases is getting more traction these days, and the incentives for going are improving – in one case a commercial dental insurer in California is offering $100-200 to attract members to their plan for check-ups. In 2019 or 2020 it would not be surprising to see a marriage of dental and healthcare giants, or more dental-insurer practice acquisitions. 31% of pediatricians in our poll last October said they are contemplating ‘ways to innovate’ in the ‘face of urgent care’s stealing patients’ and many mentioned oral health as a possible extension service. Maybe that’ll help get my youngest, Chris’s godson, to the dentist. Tommy is 11 and actually likes going to the doctor because Tyler Stanley, PA, uses the word ‘boogies’ when diagnosing his colds. So if the dental hygienist chair is one door down, maybe it’ll be easier to get those teeth cleaned. A handball court in the waiting room may not hurt either. -BC