Behavioral Health Insights

If You Build It….Psych Field Gets Boost In Iowa

What It Means to the Emerging Trend in Psych Services

Wait times for seeing psychiatrists or psychologists average 2-4 months, according to our poll of 231 school counselors, PCPs, and hospital discharge planners in Iowa, but there is hope in a new program out of Broadlawns Medical Center. The hospital has a new psych residency program. University of Iowa Hospitals had the only psych training program here until this one. Several Iowa hospitals closed their mental health units in recent years, not due to low demand but low supply, says Martin Kellogg, who struggled in handing recruiting for these hospitals. The state of Iowa is helping fund the effort, and Mercy Hospital here will also add its own psychiatric residency training program. There is limited federal funding for programs like these from predominantly rural states, Iowa hospital sources lamented. About 82% of the PCPs or OBGYNs in our survey said they can treat mental health, ‘like the kids who come in with anxiety’ or ‘a mom with post-partum’ but ‘severe cases are outside of our comfort zone and scope of practice – it’s a disserve to the patients.’ Hospitals, healthcare investors and educators are trying to find solutions, but they’ll have to be prepared for a host of tough questions too – click here for the full story.

1. 7.7 Million: The number of adults who have co-occurring mental health and substance use disorders according to the National Institute on Drug Abuse. New information on comorbidity from a study done across the globe in Australia. The Queensland Brain Institute released a study this month with Aarhus University showing the risk of developing a second mental health disorder. People within the study who were younger than 20 at the onset of their mental disorder were more at risk than others for developing a second disorder in the next 10-15 years. This study is now the largest and most comprehensive look at comorbidity. The next step for this group is to extend the study to identify the risks between mental disorders and the subsequent onset of general medical conditions, such as epilepsy, migraine, heart attacks, and diabetes. If you are looking for how your practice can get a better deal from insurers in the next 5 years it may be in finding a way to prove how your services can help manage or prevent risks related to this mental health spiral.

2. Marriage of 2 Giants: Anthem is taking a bet that Wal-Mart can help them reduce falls in seniors that can cost thousands in avoidable hospital admissions. Its Medicare Advantage members can get a deal on over the counter household safety items like shower grab bars or elevated toilet seats as well as pain medication and other supplies – up to $330 per quarter for many Anthem MA plans starting this year – incenting their members to go to Walmart (or go online) for these purchases through a new partnership rolling out this month. My mother-in-law, an Anthem member, could use a shower bar now that she’s 80 and forgets to eat and drink enough water, but she won’t shop at Wal-Mart because the last time she was there she got so lost in the Tupperware department that she couldn’t find the exit for 2 hours and missed Saturday afternoon Mass.

3. Oncology Pre Approval For Rx: Medicaid managed care plan Sunshine Health has partnered with an oncology company, New Century, to implement a new pre-approval program for cancer treatment for adults. Starting this month, all oncology-related chemo drugs and support agents will require a preauthorization before administration in a doctor’s office, outpatient hospital or ambulatory setting. Optum, meanwhile, will start requiring pre-approval in February for all outpatient injectable chemo, and related therapies.

4. Hip & Knee Oversight Picks Up: Magellan, starting this month, is now doing pre-authorizations and post-service reviews for Florida Blue’s HMO and PPO Medicare Advantage members potentially needing hip and knee procedures.

5. 17.35: Per member per month savings in managing commercially insured members seen by practices doing value based medicine in Kansas, according to Michael Atwood, MD, who heads medical affairs for Blue Kansas. Atwood said the total PMPM in the value models was $6.50. Getting contracts in the future will essentially require providers to come to the table with a value model, according to 80% in our managed care poll last fall, particularly if they are physicians or practitioners treating patients with chronic conditions.

6. If You Build It, Will They Come? 340B hospitals hope so as more of them in 2019 will roll out their own in-house specialty pharmacy. 26%, in a poll we did, say they have one today, up from just 8% two years ago, and an additional 37% say they will or may build one over the next two years to help capture more prescriptions through the discount program. Yes, there’s been some recent angst about the program given more government attention to it, but in some ways this has forced hospitals to ‘go all in while we can’ given the importance of the program in allowing for ‘community programs to exist and service lines to grow.’ Mercy Health System is building a national in-house specialty pharmacy to be available for all of its patients across its integrated delivery network. 6 in 10 say their SPP is part of the preferred network of most national payers. Health plans are getting into the 340B opportunity – at least a third are trying to create arrangements that incent patients to use the 340B health systems and their clinics and specialty pharmacies. Patients ‘pay less’ by using these discount pharmacies and providers within the closed system.

7. Cardiology The Next Target: Several cardiology procedures will now require pre-approval and post-service medical necessity reviews under a new utilization management program that BCBS of Florida, BCBS of Louisiana and several other plans are starting. Procedures performed in an office or outpatient setting will be impacted, including non-emergency procedures like total knee arthroplasty, knee manipulation under anesthesia, knee ligament repair, hip arthroplasty, echocardiography, diagnostic coronary angiography and arterial ultrasound. The UM company AIM will run the program. Both commercial and Medicare plan patients are impacted.

8. School To Home Mental Health Pilot A Gamechanger? Lutheran Social Services of Wisconsin has hired a therapist and a family coach to work with families of students who are receiving mental health services at two Milwaukee area charter schools. The therapist works with children during the school day, and the family coach makes weekly in-home visits. The model, in my opinion, is likely to be a winner over time and be better positioned with managed Medicaid plans seeking more cost effective solutions to mental health. 14 children and their families are participating in the Wisconsin program; the goal is to expand this to 50 by June, and focus on helping those dealing with PTSD, anxiety, depression and other mental health issues. The group hopes to receive state funding to institute 5 other school-centered pilot programs. It has established a committee consisting of state and county representatives, mental health advocacy groups and community organizations to address local and state policy changes needed to sustain the programs. ‘What we’d like to do is achieve policy change for a more comprehensive model of school-based mental health,’ according to the group’s CEO, Hector Colon. ‘That could include higher Medicaid reimbursements for clinical consultations and in-home family coaching. Dr. Judith McMullen, a law professor at Marquette University and committee member, says getting into the home is key but there are challenges in documenting value, proving how the sessions can elevate overall health. Pascual Rodriguez, principal of one of the school’s involved in the pilot, says he is a firm believer in educating children physically, spiritually and emotionally, but acknowledges limitations on what the school guidance team can and cannot offer to some of the kids, so a program like this fills the gap. The future is integration – and therapy that helps not just the kid, but the family. Question is who will convince the policymakers and payers that their model works. See our story on schools and unmet needs here: PE Circa 1983

9. Extra Point: My eighth-grade daughter has the lead in her school play coming up in March and auditions this spring for the lead in an off-Broadway production of Mama Mia, a regional tour that would start in the fall. She has a good chance at the part and, if she gets it, she’d be doing her freshman year of high school on the road juggling algebraic equations, Catcher in the Rye, and learning Sophie’s lines. Her friends don’t understand why she would want to miss the first part of high school, but artists, musicians, they are cut from a different cloth and, to be honest, their healthcare is the stage. Performing, singing in hallways and backseats, and making up songs on the piano rather than studying for a science test – that’s their script. My Sophie asked me if I could tutor her in math on these road trips with the touring show when ‘mom can’t make it’ and I hesitated – not because I don’t want to spend time with her, but because I don’t know what it means when the math question says ‘Solve for X.’ I mean what kind of question is that?!  I will say that if I’ve learned anything from covering healthcare for nearly 25 years now it’s that the secret may be in spending less time doing what is expected and doing more of what just makes us feel good. To heck with high school Soph…break a leg.

1. 307: That’s the amount of mass shootings in the U.S in 2018 up until November but there are signs that the market is trying to reverse the trend. Walt Disney Company is expanding a national program focused on helping kids who suffer from social isolation in elementary school. Parents of some of the children killed in the Sandy Hook shooting are involved. The program will be available to schools at no cost and aims to train 2.8 million students in 6,000 schools by 2022.

2. Cardiology The Next Target: Several cardiology procedures will now require pre-approval and post-service medical necessity reviews under a new utilization management program that BCBS of Florida, BCBS of Louisiana and several other plans are starting. Procedures performed in an office or outpatient setting will be impacted, including non-emergency procedures like total knee arthroplasty, knee manipulation under anesthesia, knee ligament repair, hip arthroplasty, echocardiography, diagnostic coronary angiography and aterial ultrasound. The UM company AIM will run the program. Both commercial and Medicare plan patients are impacted.

3. ENT Treatment Investigational Status: Take note if you are exploring the ENT market. Several Blue plans have determined this month that drug eluting sinus stents and implants for post-op use following an endoscopic sinus surgery are investigational, in other words these stents and implants aren’t covered. The policy also will apply to patients with recurrent sinonasal polyposis.

4. Autism Oversight Change: Several Blue plans have adopted new coding guidelines for ABA services. In Louisiana, there’s a new rule that impacts the ABA supervisors (the BCBAs). When these BCBAs are doing a protocol modification visit with a child, they cannot also bill for the tech visit at the same time (billing the protocol medication 0364T code with 0368T is not allowed).

5. Essential Health: Health Care policies sold in Connecticut must cover treatment including emergency room trips, outpatient care, mental health services, prenatal care and ongoing care for a baby throughout childhood regardless of what happens to the Affordable Care Act, according to a new CT state law on essential health benefits.

6. MidLevel Cut: Beginning January 1, 2019, Anthem Medicaid in Kentucky will reduce the reimbursement rate for all midlevel practitioners, including but not limited to advanced practice registered nurses, physician assistants and nurse midwives, from 85% to 75% of the Department for Medicaid Services physician fee schedule.

7. TeleHealth Expands: BCBS of North Carolina has just added a new telehealth benefit for ACA plan members. MDLife is the vendor that will administer the program, with visits ‘equivalent’ to a primary care office visit. In our poll of 287 health plan network, medical and strategy officers last week, 59% said emerging areas of need and interest for them are finding ways to more effectively deliver telehealth and tele-psych services this year. One plan said they are ‘reviewing more than 3 dozen vendor proposals’ targeting a range of populations – employers, kids, seniors, rural, and Medicaid. Commercial plans are increasingly using telehealth to intercept urgent care patients, saving ‘$120-$175 on a typical urgent care case…..’many of these patient issues will just self-resolve, so the idea of the hotlines or telehealth encounters is to intervene earlier and advise the patient….but if it’s a psych issue, we can refer to a counselor,’ Marty Frestreiter, RN, a BCBS hotline department manager said. ‘Problem for us is amassing enough psychologists to handle that volume and making sure people are aware to use the hotline.’

8. College Health: Back when I went to college if you were home-sick you called mom or dad collect from a rotary dial phone in the dorm hall common area. It was never a good feeling when they wouldn’t accept the call. Today, home-sickness has taken on new meaning with more attention in colleges to the risks of depression and isolation. Colleges are likely going to invest more in telepsych services to try to alleviate pressures on their campus clinics. Many report getting inundated with psych visits they can’t handle – ‘we had 36 kids come in this week alone, about one-third we had to drive to the hospital because we were concerned about their emotional well-being,’ Rick Stippert, a health clinic manager said about students at his university in Illinois. ‘We aren’t equipped to handle the volume of students who are 19 and away from home and really struggling emotionally…’ notes Tracy Chamborg, a director for an Indiana University clinic. She says there is a need for a tele-health solution.

9. Extra Point: Tommy and I did a little math last night, counting up the number of games he and his 3 siblings and me and my wife had played since school started in September. Out of 106 contests, we had won 20 as a family collectively, lost 83 and tied 3 – and this has been a good stretch if you ask me. Losing is contagious and depressing but at times pretty funny to watch and almost always educational, at least in our household. I feel like my wife and I spend more time managing our kids emotional well-being on the heels of losing, as we do about just about anything else. Losing games, homework, friendships, parts in plays – it’s an endless conversation. Physicians and therapists face a similar challenge these days as they seem to more easily lose patients or reimbursement, and yet seem to have more pressure to prove they can help patients manage the ebbs and flows of disease, the loss of function, sight, hearing and mobility. I asked a group of pediatricians at a meeting last fall what was the number 1 thing they felt they were losing and at least 9 out of 10 said ‘patients to urgent care’.  It was an interesting comment because about the same number also said they felt like that this had forced them to re-think their practice and re-focus more on the patients they did have and how to help them. Three of them decided to add a service to help diagnose autism, others created a nutrition and exercise wellness center, and one created a ‘class for parents’ to educate them on raising kids. I think this new era of primary care will likely create more of this kind of innovation. I know personally, it’s not that easy managing the downsides of my own health, much less my aging parents and adolescent children when I’m so spread thin. Here’s my own list of the things I seem to be losing the most these days…hopeful that writing it down will motivate some change and, with any luck, some winning: click here

1. Nine: That’s the number of splat points I had at Orangetheory Fitness before Christmas, the lowest in the class, 15 worse than my bride and 25 worse than my daughter leading me to believe that managing my own care is exhausting, humiliating and undoubtedly hurting my status in the family. The hit gym classes aren’t just winning with families, millennials and 30 and 40 somethings, they are getting the attention of self insured employers and a few large group plans. We asked 12 different benefits administrators for leading employers with more than 15,000 employees – 10 of them said they are looking at developing a contract and perhaps a pilot program to measure productivity and wellness for employees. I’m hopeful splat points won’t be a measure companies or insurers use. At least not until I figure out how to do more than 5 burpees.

2. Ortho’s New Age: Starting this month, Blue Florida has expanded its utilization program to include non emergency hip and knee surgeries for ACA plans under 65; previously the policy only applied to Medicare HMO and PPO Medicare Advantage patients. Magellan handles the program.

3. California Advances: Anthem of California, in an effort to invest more in primary care, will reimburse chronic care management advance care planning for commercial patients starting in late February

4. PreEmption, Infusion Style: Home infusion provider will like this trend as Blue Michigan is tightening up its approach to infusions. Pre-approval will be needed for hospital-outpatient infusion of Xolair (the Asthma drug), Cinquair and Nucala

5. Genetic Test Oversight: New Jersey’s Blue Plan, Horizon, has tapped Evicore to intervene doing pre-authorizations for a litany of genetic and molecular tests starting in March 2019

6. In Sickness & In Health: You know what they say. Want to lose 10 pounds, get the flu. Most of my family had a version of it during Christmas break in what has become nearly an annual tradition. My grandfather, John Antonelli, who spent most of his youth in the mountains of Napoli, once told me that my great Uncle Cosimo infected the entire coast of Italy in 1913 simply because he didn’t wash his hands before supper. I still wash up before pasta to this day and I have more recently decided to get flu shots, even if this year’s shot didn’t prevent last week’s bout. The CDC, for what it’s worth, says getting the flu shot has benefits even if you get the flu, reducing ICU admits and length of stay for patients who get hospitalized from the virus. Health plans have been telling us that there has been a dip in the number of males getting flu shots in recent years, particularly at primary care offices, though the number of flu shots at urgent care sites has been steadily increasing.

7. Extra Point: 49% of schools in our December poll of middle school principals said their schedules are changing so much so that they are starting to look more like health and wellness centers than academic institutions. Gone are the days of home rooms where Billy steals the fish from the tank and Donnie plays hangman on the chalkboard. Now, it’s mindfulness class. Fourth period study hall is out. Mental health, taught by counselors and licensed psychologists, is in. Sessions are lecture based but ‘quickly seeming more like group therapy’ says Pamela Youmans, principal for a 5th through 8th grade junior high in Tennessee. Gym, which has in recent years lost out to budget cuts, is bouncing back with structured play sports blocks that allow kids to run relays or play small games of 2 on 2 basketball. The physical and mental coursework is also forcing school boards to look at staffing, some looking at hiring trained professionals to lead these new health-like departments and many plucking staff from local psychology practices. 81% said they are likely in 2019 to find some budget to partner with a local practice to help lead these classes as well as after school programs. These are all great developments and with states, like New York, mandating some of this, policy is helping drive the trend too. I will say I miss the days when home room was a guaranteed 20 minutes of sleep before Mr. Linardo’s geometry class, but perhaps that’s the tired parent in me talking.

1. 3: The number of physical therapists in a small group in my home state who are creating a training guide or course to help PTs identify and address depression, addiction, and eating disorders in patients. The PTs are trying to make a less standard approach to detecting these conditions, and engaging patients about delicate topics. ‘That sounds like the definition of value based medicine if you ask me,’ according to Michelle Feller, a network contracting manager for BCBS.

2. Cataract Policy Change: Recently, Anthem Blue Cross/Blue Shield of California announced it would no longer be covering anything but topical, local, or regional anesthesia for cataract surgery, as it had determined that deeper levels of anesthesia are not medically necessary according to the American Society of Cataract and Refractive Surgery. Anthem will only cover anesthesia services, such as moderate sedation or general anesthesia, in limited cases, such as pediatric cases or if the patient cannot cooperate or communicate.

3. Rise & Fall: DME has fallen out of the top 20 in the Managed Care Investment Index of health plan priorities for the first time in several years. Respiratory moved back into the top 5 and urgent and infusion moved into the Top 10 for the first time. To see the Top 20, click here for index.

4. Social Works To Manage Risk: ‘I’m not so sure it will work, but we are pursuing….the idea is to take a bit more control over our patients and our budget’ – Peter Weller, MD, who has hired a social worker team to do home visits and remote monitoring of Weller’s Medicare patients under a full-risk arrangement his group now has with two different insurers. Dr. Weller says ‘we lost our shirt in year 1 because a number of our patients are fairly healthy but weren’t eating enough or were dehydrated….we had 23 different patients who fell and needed to be hospitalized for hip breaks or shoulder breaks or other things’.

5. General Motors Expands Benefits, But With Oversight: BCBS of Michigan will cover mental health and substance abuse benefits for some General Motors members after January 1st (those with Health Savings Accounts). New Directions will handle prior authorizations.

6. Homeless Healthcare: Premara BCBS is getting involved in helping address homeless healthcare issues by partnering with a local organization while Bridgeport Hospital in Connecticut is trying to use intervention teams to deal with homeless patients in the ED. Andrew Franco, MD, fromt Yale New Haven, thinks more ‘CMS money’ should go to supportive housing (e.g. housing should be considered part of someone’s health). Dr. Franco says there are definitely gaps in how information gets used. ‘In some medical records it’ll say, ‘Hey, this patient has been here many times,’ which ought to trigger a social work evaluation. Click here for the full story.

7. Extra Point: My bride challenged me to Orange Theory last weekend. My theory is that it makes me nauseous. It was very sad, if not telling just how happy Bridget was to see me hunched over in painful delirium sometime between the push ups and burpees. ‘I’m glad this gives you so much joy,’ I said. Thirty minutes later, I called her: ‘Um, honey I don’t feel so good....and I lost my wallet.’ Turns out it was in my pocket the whole time. I recovered by Tuesday but had to pivot to help manage my teenage daughter’s second concussion. It kept her cooped up in the dark bedroom for a couple days, her clothes strewn and life on hold. Zaggy, our 1-year old lab, took advantage, guzzling the Reece’s pieces she left in the front pocket of her unwashed Capri pants. By 2am the next morning the ER vet was lecturing me on parenting a dog. It was my third trip to the ER for Zaggy this year, the first two for swallowing socks. ‘I think it’s time for insurance’ the vet said. I paid the $395 bill and was back in bed in time to hear Jack’s annoying 545am snooze session. So tired from the prior 2 days, I missed a conference call and was an hour late to my annual physical. My doctor understood and then called my health status ‘unremarkable’, as in my lab work was perfect, and my BP and cholesterol solid. Nothing was medically or emotionally wrong with me. ‘So why do I feel like I’m running fast up a hill but gaining no ground’ I said, laughing but serious. ‘You’re a parent of 5,’ he said. ‘Stop running so hard and take a minute to be still.’

1. 4: The number of vitamin D tests you can do per year, starting in January, if treating United California Medicaid patients with certain conditions, as a result of what the plan calls ‘recent clinical evidence about the test’. We would not be surprised to see this policy find its way into United coverage policies beyond California.

2. Homeless Healthcare: One woman’s story chronicles the positive impact of a program in Massachusetts designed to address gaps in care for this population: click here

3. Sound Off--Sorry Moms: United’s Community plan for Medicaid patients will no longer consider ultrasounds medically necessary if only done to determine the fetal sex or provide parents with that cool photo for the fridge. Detailed ultrasound fetal anatomic exams are also medically unnecessary for a routine screening of a normal pregnancy.

4. Family Ties Recent Index Results: Jen’s dad had to be admitted to a psych ward a couple weeks ago. The dad suffers from Parkinson’s. That day and those preceding required the family to be all in for dad. Missing work, being absent from their own life and families, stressed and helpless and eventually sick themselves. This is a real issue across the US as American’s get older and their conditions more complicated the families around them suffer, playing nurse, therapist, care coordinator and eventually….patient. The managed care investment index of priorities is out and there is a new number 1 and seven new entrants (index here) and a bit of a softer, gentler theme around services designed to help families. There are signs anyway:  better coverage emerging for things like family counseling in the home to respite benefits and pay to caregivers for providing personal care to family with Alzheimer’s or Parkinson’s. Addiction treatment has moved into the #1 spot this month, edging stalwarts like Orthopedics and Cancer Treatment. Autism, not even in the top 100 five years ago, cracked the Top 10, outpatient psych moved into 11th and telemedicine, even though it dropped 5 spots, remained on the list. What these services have in common–they are all hard to manage but designed to support family through crisis. And the broader theme if you listen to the payers lately is that there is an underlying wave of support growing for them, or at least to try to figure out a better way to manage and pay for them. As early as 2019, you’ll see more payers looking to move these services from fee for service into value based payment. We will see how quickly this evolves, particularly as it’s taken many years just to get attention. Click here for index

5. BluePrint: ‘We recognized that the providers were struggling and we needed to listen’ – Kelly Lange, who directs health reform for Vermont’s Blue plan, talked to us this week about an innovative effort underway to allow providers to take risk for managing addiction and mental health and other conditions. Magellan, the plan’s former benefit manager for behavioral health, was costing the plan many times more than what the plan is now able to spend to manage patients inhouse. Other plans, like Care1st, have moved behavioral inhouse. Providers, who complained about the hurdles to getting approvals, are now able to manage and treat without interference, but get support from the payer’s case management team.

6. Compounding: Individual Empire BCBS Medicare plans will move compound drugs off formulary beginning January 1, 2019 with the exception of home infusion drugs. Group-sponsored Medicare Advantage members will continue to have compounded drug coverage although these drugs will require prior authorization. Compounded home infusion drugs will continue to be covered for both Individual Medicare and group-sponsored members without prior authorization. Members and/or providers can request a non-formulary exception for compounded drugs.

7. Capitation Debate: In case you missed it, check out our 30-minute podcast on managed care developments and capitation: Friday Forum

8. Extra Point: Coach told us today that our 8th grader, Sophie, will see significantly reduced minutes during Sunday hoop games because she won’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; I hear more and more counselors tell me that the root of adolescent crisis is often pushing kids too much. We called the coach's 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 – and Sophie says 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 or club 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.

1. 41: The percentage of parents in our poll who said they are hiring a home health aide for their mom or dad to help prevent another fall. Falls have increased in New England (during the winter months ), largely due to dehydration, lack of a consistent diet, orthostatic/BP issues, and a range of dementia or psych influences, parents said. Of those hiring an aide, 46% said their mom or dad has a Medicare Advantage plan with Humana, United Healthcare, or BCBS, though nearly all (90%) said they aren’t sure what if any of these aide services are covered by insurance. About 85% of those hiring an aide said mom or dad are widowed.

2. Podcast on Capitation: Check out our 30-minute podcast on managed care developments and capitation: Friday Forum

3. Pre-Pay Review Intensifies: 39 of 46 health plans in our poll said they are intensifying pre-payment review policies. Blue Massachusetts, for example, has partnered with Equian to help it improve payment accuracy. The vendor will focus on high dollar claims. Services will be done before payment is sent to physicians, hospitals, and other providers. The actual BCBS pre-pay review process began in April for fully insured accounts and members, while administrative services accounts will be impacted starting in January. Claims will be automatically selected for review based on cost and other factors.

4. Wins and Losses: Starting in January, several medications will not be covered any longer due to recent P&T committee formulary changes. We attended a P&T meeting at BCBS of Massachusetts and found that six drugs won’t be covered including Pradaxa, an anticoagulant for blood-clot prevention; Mirapex for Parkinson’s; Victoza for diabetes; the chemotherapy Neupogen; and several  short-term ophthalmic anti-inflammatories (reach out if you’re interested to know which ophthalmic drugs). Several drugs stay on formulary but move to a higher-cost tier, including infliximab drugs for patients with psoriasis or Crohn’s or rheumatoid arthritis like Remicade. Aubagio, an oral drug for multiple sclerosis, and Glyxambi, an oral for diabetes, will move to lower-cost tiers .

5. Extra Point: I’ll report live from the BRG Healthcare Leadership Conference in DC next week, moderating a panel on addiction with leaders from Geisinger, Optum, BCBS of Vermont, and Duke, and debating the future of treatment for opioids. True to form, my kids asked me some really helpful questions about my trip. ‘Dad,’ said Jack, our high schooler who is now looking at colleges, ‘can you ask Duke if they have a good cafeteria? That’s one of the key things I care about in a college.’ I told him he might need to rethink his criteria. My daughter, Sophia, was far more on point: ‘Can you ask them how to solve Tommy’s addiction to watching the YouTube guy playing Fortnight?’ Thank you, Sophie! It’s a fair question and an emerging crisis for many kids, not just my own. Tommy sits too close to the screen, avoids reading to watch this kid play video games, and says he’s got headaches and eyesight issues. This ‘addiction’ to the screen may just be the next big ‘addiction’ crisis after opioids, if you ask me. If you’re in healthcare fields like ophthalmology, optometry, psychology, or primary care, there’s opportunity in this trend. If you are interested and able to attend the event last minute, please email me for information. If you are unable to attend and interested in notes from the session, let me know.