Behavioral Health Insights

1. 181%: Rise in total ER costs in the last few years according to a Blue Texas study of its membership. The increase correlates in part to the rise in freestanding ERs in this state. Blue TX is taking on more of an effort to do claims reviews to manage claims – described to us as a soup to nuts review for HMO patients using OON ERs. The plan is going to be ‘holding the claim requesting medical records, checking the bill to make sure that’s what happened in ER matches the record, and combing the record to assess patient history and whether the patient’s decision to go to the ER was what a ‘prudent layperson’ would do; in other words, was it reasonable based on history and symptoms. There was one case, in Atlanta, where a 55-year old Male last month said he was confused and worried about the cost of health care and ‘had seen a newspaper story about ER coverage’ so he didn’t go to the ER for what he described as itchy scalp. Joe, a tire salesman, eventually went to urgent care which his daughter Frailey says ‘missed what was happening and just sent him home with a cream.’ He was about to have a stroke and was hospitalized 2 days later. These insurers are not denying off the bat and don’t want patients to avoid the ER. There is no secret list of codes as some news stories have reported; the insurers are trying to find evidence to support the prudent layperson argument and have a physician only review the records to make that decision. In some cases, they can save the patient money. Blue TX says there are occasionally times when there’s ‘a CAT scan’ for example billed but the record shows the patient got penicillin and a throat swab for a sore throat, so by finding this before the patient is balanced billed the insurer saves the patient a high bill due to their coinsurance.

2. Free Ride Halted: This BCBS Blue Card benefit has been useful tool for patients to access specialists and doctors out of the state, not just emergency care if on vacation, but starting in January Blue Shield of California wants to reign in who can go where. California PPO and HMO individual and family plan members will still have access to the BlueCard Program but they will have to get pre approval first if going out of state unless it’s for an emergency or urgent care. ‘It may be hard to get Blue Shield to authorize health care services for an out-of-state provider unless there’s an access issue’

3. I-Man:  I may need giant spectacles like Jerry Seinfeld once used in an episode where he and Lloyd Braun were on a search for gum….I blame the iPhone and my affinity for writing. If many of us keep up using technology at such a pace, the shortage of ophthalmologists may become a bigger deal. There are 19,216. ophthalmologists in the United States today, according to the American Academy of Ophthalmology, but it is estimated that approximately 450 new ophthalmology residents graduate every year and 550 established ophthalmologists will retire. This coupled with the aging of the population and there’s a worsening shortage unfolding. The Academy says that many ophthalmologists are seeing a dissatisfaction with decreasing reimbursement trends, which makes it difficult to regenerate early investments of costly technology of starting up a practice.

4. Guard Up: Anthem’s MA plans have been promoting Colorguard in mailers to patients as an alternative for colonoscopy. A Columbus area couple, both with an Anthem MA plan, showed me a letter they received with suggestions on how Cologuard works and why it would beneficial for them. They both are due for their colonoscopy soon

5. Home Care Middle Man: MyNexus, a home care benefit manager, has won the role of delegated utilization management for Anthem Medicare Advantage. The question for home care providers is can they offer an alternative to UM firms by taking on the risk of chronically ill seniors, keeping them out of the hospital for a PMPM that saves the health plan money, reduces family and patient stress and effectively cuts out the middleman in healthcare. ‘I think the best model is having a nurse and therapy team who can be on the front lines with the patient, doing remote monitoring, helping make sure patients are hydrated and safe and paid to help them manage all of things going on – dementia, depression, heart disease, maybe diabetes. ‘It’s hard,’ says Springfield IL based home health business co-owner Norman Hughes: ‘these intermediaries are trying to make a difference but it seems they are more so just adding cost and getting in the way….I would think a better model is just paying us to take on the risk of keeping patients at home’

6. Predicting Admissions: Availity has had success getting insurers to use its cancer treatment profiling technology, a predictive analytics model with a report scoring chemotherapy patients by practice showing their risk for a potentially avoidable admission. The weekly report uses many variables to determine a patient’s risk.

7. Psych Testing Monitoring: 9 In our poll of 11 benefit manager directors this week, 9 out of 11 say they are relaxing requirements around routine psychological and neuropsychological testing. All 9, including Blue TX, say they no longer will require a pre approval for such tests and only would start to change this if ‘a provider’s pattern of testing varies significantly from their provider peer group.’

8. Imaging Check: Starting in December, National Imaging Associations and Magellan will start doing clinical validation of records as part of a new process for codes that are part of the advanced imaging series. This will be done for Blue Florida, as well as other plans for which Magellan/NIA are contracted. The validation takes place during the PA process; they basically ask the ordering provider for more information to justify the request.

9. PMPM Swing: Blue Kansas says it is saving $17 per member per month via its commercial value based programs, with cost of care about $6.50 less on a PMPM basis chronics in these programs vs. those who aren’t.

10. In case you missed it: A health plan in the east has created an episodic payment model for those treating Crohn’s disease.  Payment includes behavioral health treatment for those with depression or anxiety stemming from the disease. 50 patients were involved in the initial pilot at the Digestive Healthcare Center in New Jersey. The payer, Horizon Blue, pays them a fee for service, then shares savings with the group after a year of service based on the group’s quality metrics performance. If I’m reading this, part of the story here is not just about how to pay and incent good care but it’s a roadmap for the group practices of the future – those who can integrate the right specialists and services to manage the cost ‘in the clinic’ setting rather than rely on others. In a quick poll of GI doctors, 31 of 43 said they would or have entertained the idea of bringing in a therapist as part of the practice offering to help patients deal with the mental health effects of their conditions. This model, and the inclusion of behavioral treatment in the episode, is somewhat similar to Horizon’s payment structure for maternity and post-partum

11. Extra Point: My 15-year-old son Jack wants to be a physical therapist so he was looking up colleges and found this cool website. ‘What’s it called?’ I asked. ‘Nike I think – it’s really cool, lists all the colleges with PT programs.’ I asked Jack to spell it. ‘N-I-C-H-E’.  ‘Um, kido, I think you have a bigger problem than which school to go to.’ After we got through a quick spelling and vocab lesson, I helped Jack deal with some teen angst over choosing colleges and careers. He’s really interested in sports broadcast journalism, and in PT. ‘Why choose? Certainly not now,’ I said. ‘And look, who says you can’t broadcast the hoops game from the sideline and then during the injury timeout put the microphone down and go be the trainer, assess the need for one of those boots, braces or casts…you could call yourself the ‘Cast Man’.’ He looked at me like I had no idea what I was talking about…but if you ask me, it’s not a half bad idea.

Managed Care Friday Forum: Today, Nov. 16th, 11am, 800-874-4559 (Passcode: COTE37301). Recording will be made available.

1. 511: In our poll of 511 primary care providers with board certification in geriatric medicine, a startling 84%, up slightly from last year, said that physical therapy services for seniors are likely unnecessary or at least need deeper evaluation to determine whether the patient has other comorbidities or causes of pain, such as substance abuse, dehydration, untreated PTSD or depression, or a sedentary lifestyle.

2. GI Bundle, With A Twist: A health plan in the east has created an episodic payment model for those treating Crohn’s disease.  Payment includes behavioral health treatment for those with depression or anxiety stemming from the disease. 50 patients were involved in the initial pilot at the Digestive Healthcare Center in New Jersey. The payer, Horizon Blue, pays them a fee for service, then shares savings with the group after a year of service based on the group’s quality metrics performance. If I’m reading this, part of the story here is not just about how to pay and incent good care but it’s a roadmap for the group practices of the future – those who can integrate the right specialists and services to manage the cost ‘in the clinic’ setting rather than rely on others. In a quick poll of GI doctors, 31 of 43 said they would or have entertained the idea of bringing in a therapist as part of the practice offering to help patients deal with the mental health effects of their conditions. This model, and the inclusion of behavioral treatment in the episode, is somewhat similar to Horizon’s payment structure for maternity and post-partum.

3. Hip & Knee 10% Cut Goal: Blue Michigan is looking to save 10% on total joint replacement costs that can go up to $55,000, kicking off an episodic payment that goes for 90 days after surgery, says Steve Anderson, who heads up contracting and networks. 64 orthopedic surgeons will be part of the program’s initial roll out, spanning 7 health systems and 9 counties; they represent about 1 in 3 surgeries today. Both HMO and PPO patients needing total hip and knee surgery will be involved. One of the goals of the program is to reduce variation in costs and outcomes and encourage ‘at-home’ rehab if it can work for the patient, vs. facility based.

4. Radiation Oncology Middle Man: Blue Kansas, starting in January, will require HMO, EPO and PPO patients in its plan to get pre-approval from EviCore for oncology and radiation therapy.

5. Dermatology Drug Refund: Regence BCBS is asking for refunds for a drug they overpaid. The drug, Ameluz, is prescribed by dermatologists often and used to treat mild to moderate keratosis. It was initially reimbursed using standard rules for drugs covered under the medical benefit. The health plan paid for it based on a complicated calculation related to the drug’s strength. A Regence spokesman said they ‘originally calculated’ reimbursement using ’20 billing units per tube based on the drug’s strength but ‘we found out that CMS calculates 200 billing units per tube based on the weight of the tube, not the strength of the drug.’ The code for this drug, HCPCS J7345, corresponds to the number of units of service in a single 2gm tube but CMS’s Part B average sales price fee schedule doesn’t include any billing unit per package information for Amelux, Regence said. The new reimbursement level will be retroactive to the beginning of this year.

6. Puzzle Pieces: If you’re like me, puzzles are a great way to work a different part of your brain but boy are they frustrating, particularly when your kids use pieces for their Halloween costumes. For addiction treatment, health insurers are finding it similarly frustrating – they don’t have all the data and evidence. ‘We don’t have all the puzzle pieces to say what’s good care,” Jennifer Atkins, a VP for network development with the BCBS Association, told us at the Payer Behavioral Summitt late last month. She says the organization is working with Shatterproof around finding the best centers of distinction for medication assistance therapy, as well as filling the gap in evidence based care for treatment. A multi-year pilot using a quality rating system is going on to help with determining the best centers and the best way to pay for treatment. Other payers, like United, are also working with Shatterproof, a spokesman said.

7. Overdose Help: Narcan®' and naloxone, two common drugs for treating a narcotic overdose, will be available at no cost to BCBS Massachusetts members under a new pharmacy benefit for all of its ASC accounts starting in January.

8. Billing Attention In PA: Independence Blue Cross says it is adding a host of procedures to ensure physicians bill correctly. They will hone in on several modifier codes (26, 77, 59 and 78, as well as coding for services done during a global surgery period and use of ‘add-on’ codes. These will be denied or returned to be corrected.

9. App Frenzy: Beginning January, Happify and iPrevail will be available as part of Cigna’s Total Behavioral Health® program, a comprehensive suite of solutions offered to employers to support the health and well-being of their workforce.

10. Infusion Site of Care Changes: Since October, nurse reviewers for 2 national MCOs have started to work with patients needing specialty pharmacy infusions to determine the appropriate setting for the infusion – home, infusion center, physician office or, if necessary, the hospital. ‘We believe that there’s a problem on both sides – underuse of the low-cost home setting and possibly underuse of hospital infusions in some cases when the physicians perhaps overlook patient factors or safety factors. The case manager serves as independent check to protect the patient and make the best use of home infusion’, Barb Taylor, RN, a nurse reviewer told us. Taylor says that out of the last 10 reviews she’s done, she changed 6 of them, three to home infusion (when the patient was unaware of this option), two to the infusion center for IVIG (due to patient concerns about having the procedure in the physician office), and one to the hospital.

11. The Relapse Cycle: In our poll of 90 parents from our consumer panel whose kids have suffered from substance abuse and been in treatment at least once, 71% said their kids didn’t go to treatment initially because the program took too long to get approval for treatment from an insurer, and in an estimated 85% of those situations, the kid relapsed and was eventually hospitalized. ‘The window is short. That was the case for our son,’ said Angela Filler, 57, of Oklahoma. ‘There has to be a better system to get these kids into programs that work’

12. Risk Contracting Commission: 13 of 20 health plans we polled in April said they have recently created ‘risk contracting’ teams and directors of contracting expressly responsible for studying options for risk contracting (upside vs. downside risk) and working with providers from different sectors to create risk arrangements. In most cases, plans are looking from within their organizations to staff these groups, reassigning responsibilities if needed, although 6 of the 20 say they are ‘looking for outside experts’ for these roles. The most difficult ‘staff position’ to fill, however, has been ‘pharmacy’ risk contracting staff who can be liaisons between the plan, providers and pharmaceutical manufacturers and work toward finding common ground on three fronts: the best measures on which to base success (i.e. readmissions), how to determine what’s a good outcome (i.e. remission rate), and perhaps the Holy grail issue that may ultimately stall these contracts—how to share in success/savings.

13. Extra Point: Tommy came home with an A, C and F on his most recent round of tests at school. ‘It’s like the good bad and ugly,’ I quipped. He was upset he did so poorly but resisted talking to the teachers to figure out what happened. I told him I was capping his allowance and increasing his chores unless he talked to the teacher. ‘But dad, I don’t get an allowance…remember!!!’  This parenting thing seems a lot harder than healthcare sometimes doesn’t it?  If only I had a map or metrics of some kind. Next Friday, we’ll try to find our way around the latest challenge in healthcare business—modern day capitation. I’ll have two guests from the field of capitation and managed care contracting chat about what they have seen lately – the good, the bad and the ugly. Call details: Managed Care Friday Forum – Nov. 16th, 11am, 800-874-4559 (Passcode: COTE37301)

1. 380,000: The number of premature births a year or about 10% of the US births, according to a Cigna source we interviewed who says the managed care plan is improving coverage and reimbursement for ultrasonagraphy in the first trimester, particularly for those women unclear about the timing of their menstrual cycle.

2. AIM Higher, Radiation: In 2019, new approval rules will take effect for radiation oncology, and most ease some of the existing requirements, which would be a plus for providers in states where Anthem is the major payer. AIM, the Anthem company that determines clinical appropriateness and site of care for services including cancer treatment, will remove age and tumor size criteria for determining the appropriateness of treatment of accelerated whole breast irradiation, no longer limit treatment with IMRT for rectal adenocarcinoma and will add criteria to allow for IMRT for head and neck lymphomas.

3. What’s Your Place MAT? If you’re in the world of addiction treatment, including medication assisted treatment, there’s a new ‘ranking’ coming out that will place some centers ahead of others on the wish list of payers. The BCBS Association is going to be using ShatterProof to help create centers of distinction for opioid addiction treatment, and eventually for various behavioral health conditions that can benefit from promoting centers of excellence.

4. United will use Optum Fertility Solutions to start doing clinical coverage reviews for a host of infertility treatments. This is kicking off this month. Drugs impacted include Bravelle, Follistim, Gonal and Menopur. The reviews will apply to patients on plans with outpatient prescription drug coverage through the pharmacy benefit for injectable infertility medications.

5. Perfusion: Starting in December, Aetna won’t pay for perfusionist services when billed by an agency or individual. Perfusionists, who help manage a patient’s physiological status during cardiac and cardiopulmonary procedures, must look to the hospital for reimbursement, both for inpatients and outpatients. The MCO will pay the hospital for the technicians responsible for assembly and operation of pumps with an oxygenator or heat exchanger.

6. Rickets Check: In November, Aetna will join the bandwagon and put criteria in place for both a drug’s medical necessity, and the site of its administration. The most recent pharma agent to require this two-prong pre-approval is Crysvita, the first treatment for a rare inherited form of Rickets. The FDA approved it in the spring.

7. Extra Point: My daughter tries out today for the spring musical and hopes to eventually tour around cities like Chicago and Paris to, in her words, ‘get a little culture dad.’ She can act, sing and dance and has great pitch and stage presence for a teen. But like a lot of us, I see the time with her changing. No longer are the days when she would sing countless renditions of Part of My World then share a black and white cookie. But there may be a way to prolong things. In a surprising and bold move, a health insurance company has started a playhouse. George Street, the brainchild of Horizon BlueCross BlueShield, is touring schools nationally with a show about the challenges of addiction. Other shows, even musicals are ‘likely’ says a source and the insurer is hoping to use the format to reach a new audience about tough issues. It’s prevention and innovative and a new page for the usual tepid reactive strategies of insurers to address crisis and cost. And, who knows, maybe Soph’s next audition will land her a role touring with Horizon’s George Street company, and she and I can practice her lines and split a black and white cookie on Amtrak’s caboose.

Save the Date: Friday, November 2nd and 16th, Managed Care Friday Forum

Extra Point

Managed care plans and healthcare providers have been struggling of late to make value-based payments work, but this may be changing. Payers in more than 6 states serving Medicaid patients are now being told from the state that 25% of their premium must be spent on value and, under contracts with the state, 33% up to 50% in the near future, our sources say. But this isn’t so clear to define. Thankfully, a few of the MCOs, and a few in other managed Medicaid states we’ve interviewed, say they think the states will give them ‘wiggle room’ to define value on their terms. One Medicaid MCO in the south spends about 27 million annually on the speech, occupational and physical therapy bucket for Medicaid for instance, mostly speech, so they are going to develop a pay model that looks at each provider’s average cost per member and reward those who have less than the average with ‘preferred designation’ and continued volume, while ‘the rest have a year to get into compliance’ or be removed from the network. ‘Either way I save $7 million,’ a plan medical director told us. But these are the easy fixes, others aren’t. Take Texas, which has held out covering applied behavioral analysis for autism for its Medicaid population. Several Medicaid MCO directors here aren’t so sure this makes sense given the evidence on ABA. But some of these MCOs say were given the greenlight by the state to pay for ABA or other treatments for autism if under a value model. Even if the state doesn’t cover the service or code, the MCOs say they will be able to ‘justify’ it as value based and ‘can count it that way for the purposes of the plan’s financial services review, or FSR, or essentially their allowable rate. This is an early example of how value pay will shake out – state coverage matters, but maybe less so as the states put in these requirements, and as plans think creatively about spending.

Note: We will reporting live from the Payer’s Behavioral Health Summit in DC Oct 16-17; the first Managed Care Friday Forum series will be held at the end of this month; guests and topics to be announced.

1. 1 in 5: That’s the number of women who suffer from post-partum depression in some states according to CDC research. New studies show that most post-partum depression symptoms actually occur during pregnancy. 1 in 4 men can also experience post-partum. Read more from an interview with a Connecticut delivery nurse by clicking here.

2. MA Drug Step Down: United’s step therapy program for its Medicare Advantage enrollees kicks off in January. The pre-approval strategy will take United around 2 weeks to approve a drug that’s not preferred. There must be evidence patients have tried and failed preferred drugs. When patients use the preferred, lower cost drug, United says it will share the savings with them as part of their participation in the plan’s care coordination program.  8 acid polymers, 1 immunomodulator (Remicade) and a pair of ESAs (Aranesp and Procrit used for cancer) are among the Part B drugs that will be subject to these guidelines as non-preferred agents.

3. PT Continues To Ride Wave: Starting today, the Newman’s of the world get physical therapy without pre-approval under a new coverage policy from the health plan for federal and postal employees and retirees. The plan, called MHBP, is supported by Aetna’s national network and impacts members enrolled in the Mail Handlers Benefit Plan, the Foreign Service Benefit Plan, or the Rural Carrier Benefit Plan. Pre-certification is not required for cardiac catheterization, cardiac imaging, chiropractic services, transthoracic echocardiogram and physical and occupational therapy.

4. Out of Site: Starting in January, United joins Anthem in doing site of service reviews for outpatient imaging, the goal being to pre-approve and if necessary will decide where the imaging should take place. To promote its favorite facilities, not just in imaging but other so-called premium physicians, the MCO started this month designating preferred providers in its directors; if not listed, physician groups have a process to appeal the payer’s commercial decision.

5. A New Curriculum: In our poll last year of teachers, 411 of 633 said they dislike what’s known nationally as the ‘common core’ but they would welcome more standardization and support to help address the behavioral health of the kids in their classrooms. New York became the first state to launch mandatory mental health classes in all schools from kindergarten to 12th grade. The nine key points that are being taught include: identifying signs of mental health issues, negative stigma that surround mental illness and resources for help. This is a new state law that took effect on July 1st.

6. AstroGames: NASA has released a virtual reality game called “Mentalblock” to predict astronaut behavioral health on future missions into space.

7. Cosmetic See-Saw: Kaiser Permanente released their payment policies for cosmetic procedures to include chin implants, dermabrasion and septoplasty. Kaiser will consider coverage of these on a case-by-case basis.

8. Survey Says: Richard Dawson will not be coming to your office but an email from Medica Behavioral Health will be later this month in hopes of parsing through unmet needs and issues facing primary care and specialty practices. Medica will ask for feedback on patient access to care, care coordination, referrals to specialists and availability of clinic appointments. PCPs, cardiologists, OBGyns, oncologists, neurologists and behavioral health care practitioners will be sent the survey electronically in late October.

9. Extra Point: My dad is retired now but in recent years was a PT in a University clinic in Hartford working about 12 hours a week mostly with athletes. A college athletic trainer and coach for 35 years, dad told me about this one kid who was having pain around her knee, what he described as patellofemoral pain. But after 2 months, she wasn’t progressing much at all and dad was frustrated. He expressed this to the 19-year-old and asked how she was feeling, what she wanted to do, given that the lack of progress was keeping her from the soccer field. She opens up, telling him she has an eating disorder and anxiety. The condition, dad said, was in total control – it was as though she couldn’t deal with her pain or that her pain wasn’t really pain at all. “It was preventing her from getting better … and I couldn’t do anything for her, didn’t even know how to help her deal with that’ And here I was thinking dad always had the answers.  It would seem that doctors, let alone coaches, PTs and educators, no doubt struggle with identifying these sorts of conditions. Finding a better way to assess, treat and transition those facing these mental health hurdles seems to be exactly the point of value based care.

I ranked my kids last weekend and let’s just say 4 of the 5 kids stormed out of the room, arguing with both my methodology and motives. That I gave my daughter Sophie 20 bonus points simply because I like her best didn’t go over well. The rankings have consequences – fewer chores, better snacks to the top ranked, fewer TV remote privileges to the bottom tier. Rankings matter, maybe not so much in college sports where post-season committees at times pick tournament teams based more so on popularity and history than performance; but they matter, and increasingly in healthcare. Jodie, 58, told me she’s now seriously considering knee surgery now that she has grandkids and during a flight back home to Virginia recently she picked up US News & World Report – ‘he looks good,’ she muttered, as she began to tear out the page before folding it tightly and placing it into her knapsack. ‘I want the best,’ Jodie said. Consumers tend to make healthcare decisions based on what they see, hear and know – 306 out of 412 in a poll we did this time last year said they rely mostly on ‘word of mouth’ when it comes to healthcare, although about the same number were ‘getting tired of having to call their PCP for approval’. Those, like Jodie, without local connections or a healthcare degree tend to be more willing to rely on rankings and go out of the state to find the best, even if ‘best’ is defined by an arbitrary list. Not that the magazine’s annual rankings are arbitrary, but there are those who see these lists as more marketing ambition than medical recognition; 59% surveyed said they discount them, 35% said they assumed they were based at least on some level on the success and reputation of the physicians. Behind the scenes, managed care insurers are trying to create their own rankings that score and rank physicians. All the key measures used to evaluate providers are being evaluated though some aren’t and some seem to perhaps be countermeasures. One—capacity to assess, diagnose and treat depression or other behavioral health challenges—seems to be missing from all or most of the ranking criteria, though I suspect we’ll see more recognition for providers who can screen for and identify depression. Other payers tend to measure certain outpatient providers based more so on utilization or visits than on outcomes. In case you missed it, here are results of our own poll of both consumers and insurers on the emerging trend of ranking providers and tiering networks as a means to drive patients to the best, whatever ‘best’ means. Click here

1. 25: That’s the number of attempts of suicide estimated per suicide death. It’s a tragic stat and one that has created a new support model in Europe. Emergency medical services obviously can play an incredible role in managing patients who have attempted suicide in getting them to proper care. In London, the Ambulance Services NHS Trust is recruiting Mental Health Practitioners to increase their 24/7 specialist-enhanced clinical assessments and to support people who have called the service for mental health issues. They are looking for practitioners who can make clinical decisions, and coordinate complex situations. The very first Mental Health Ambulance was operated in Sweden in late 2017 after it was revealed that more than 1,500 people die by suicide annually in the country. Called the Psychiatric Emergency Response Team the group responds to over 130 calls a month in Stockholm related to suicide risk. At the University of York in London, about 50% of ambulance emergencies were for self-harm or suicide attempts at the university in 2016, according to the BBC. Studies point to that number being higher in 2018. ‘Very interesting concept. I see it as a positive to prevent suicide, defuse situations, but I’m a bit concerned it could be seen as an alternative to psych care. That would be a major misuse and disservice, so not sure how this would work here,’ says neuroscientist Paola Sandroni MD, PhD. For the full story, click here

2. A New Specialty Benefit: 41% of 212 payer pharmacy and medical directors we polled said they are discussing alternative benefit design models to better address the shifts in patient care and rise in specialty medications. The health plans said they want to try and create a benefit that manages the pharmacy utilization and cost, ensures adherence, but allows for medical management in the home setting supported by strong care management services. ‘Right now the existing benefit structure doesn’t really allow us to pay the provider appropriately and it creates more hurdles and administrative costs – ideally, we move to a specialty benefit that is focused on the patient’s disease, medications and care needs that limits multiple copays and hurdles to treatment…,’ one medical director said. The poll, which included representatives from more than 37 MCOs, found that these payers are ‘forming committees’ to discuss alternative approaches. The trend is a plus potentially for businesses with integrated offerings for specialty populations.

3. Home Health Encounter Policy: Highmark BCBS has amended its commercial policy in Pennsylvania for home health services, releasing new time frame requirements for an encounter with an RN, nurse-midwife, or physician assistant. In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or an allowed professional provider must see the patient again within 30 days after the start of care.

4. Extra Point: So I entered a capitation arrangement with my 5 kids - $5 per kid per month, baking in bed-making, walking the pup, making their own breakfast and lunch, getting themselves to school, and doing their own laundry. My model was flawed as there was significant underutilization this month. The kids school, sports and music commitments were to blame. I’m not the only one struggling with capitation – many physician groups have gone down this path of late, not just in primary care but in other services. One group took full risk but never shared its data with doctors. Another never did follow up calls with its female patients who were pregnant, many who would use the ER throughout their pregnancies. Next Friday, we’re going to share some of the strange but true stories and new lessons from the recent wave of provider capitation. In our first in what will be an ongoing series, we’ll kick off a radio-style chat – I’ll have guests from medical, pharmacy positions and those involved in various aspects of health reform, either providers, managed care or employers. The Managed Care ‘Friday Forum’ will be a 15-20 minute chat and call-in show. Recordings will be available. We will kick off on the 28th. Stay tuned for call-in details next week.

1. 29: That’s the number out of every 1,000 children age 8 that have autism in the state of New Jersey according to a study found conducted by the CDC. New Jersey is the state with the highest rate and Arkansas is the lowest with 13. Rates increased to 1 out of every 59 8-year-olds with autism according to the same study conducted in public schools, health care facilities and special education programs. The 11 states that have shown increases are Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee and Wisconsin. To read more about autism into adulthood click here.

2. 93: That’s the amount of cents, not dollars, spent on eating disorder research per affected individual according to the U.S. Department of Health and Human Services online research portfolio. The small number pales to the  $44 spent per person on autism, $81 spent on schizophrenia, and $88 spent on Alzheimer/s disease. Anorexia nervosa has the highest mortality rate of any psychiatric disorder.

3. Tails California: Aetna is partnering up with four California health systems in what they are calling Regional Aetna Whole Health, a Southern California managed care plan with access to 1,400 primary care doctors, 8,300 specialists, 51 hospitals, and 122 urgent care facilities across five counties. The partnership includes Sharp, MemorialCare, Primecare and Providence.

4. Pharma Safety School: Kroger Pharmaceutical Company announced a prescription drug safety program for teens in a partnership with EVERFI to provide classrooms and high school students with drug abuse prevention education. The Prescription Drug Safety Network broadcasts the interactive scenarios and self-guided activities to help students learn about drug safety. The Prescription Drug Safety Network partners include a diverse group of state leaders, healthcare companies, pharmaceutical manufacturers, pharmacies, and foundations.

5. Binge Worthy: Netflix released its second season of the popular series “Atypical” a show about a family working through the challenges of having an autistic son in high school transitioning into college. The series has added 5 actors on the spectrum to more accurately depict young adults with the developmental disorder. The characters are in a peer group in the show and make for a more genuine and fun representation.  Read more on the popular Netflix show here.

6. Proton Pumps Out: Beginning January 1, 2019, all proton pump inhibitors will be excluded from Blue Massachusetts’ pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori, a bacterial stomach infection). Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for kids under the age of 18 and those taking combination medications to treat H. Pylori.

7. Hurricane Help: Back after Katrina, the number of approved pre-authorizations spiked from BCBS of Louisiana. Today, there’s almost an even more active strategy by insurers to ensure patients have limited access during storms. Aetna was helping patients affected by Tropical Storm Gordon in Louisiana, Mississippi and Alabama with early script refills, and they extended claim and appeal filing times. Magellan, for its part, created a help line for those in the path of Hurricane Florence.

8. Gender Dysphoria Surgery: In another sign that gender related procedures are getting more attention from managed care, BCBS of Minnesota’s Medicare Advantage (PPO) released an updated prior authorization list for 19 different gender dysphoria procedures this month. Let us know if you’d like to see the list.

9. Extra Point: We brought in this sweet Romanian gal Carla for a fall house cleaning this week, sort of our family’s version of the annual dental check-up. Usually our 5 kids rotate the vacuuming and scrubbing (and complaining), but with school back and homework at a red alert stage already, the house was starting to resemble a decayed tooth. The fridge, not just the food in it, needed an extraction. That rolling dust ball was building up faster than a teenager’s tarter. Our kitchen tile began to take on a red spaghetti sauce hue like coffee staining on those lower molars. Carla billed us for a deep clean, 4 extractions, a pair of sealants, and a restorative procedure inside Jack and Tommy’s closet that she described as ‘you don’t want to know what was there Mister Cote – maybe it was guacamole at one time.’ But not 5 hours after she left, the house was a hot mess – a dog hair walkway was re-emerging, an apple sauce pond had formed on the couch, and a ‘are you kidding me who spilled cranberry juice’ sticky path was now guarding the fridge. That deep clean was more cosmetic lift than preventive lifestyle changer. Our kids’ compliance was dismal. I now know why dental and health insurers complain, and why dentists have a job. Insurers in many states seem to putting more resources into evaluating the necessity and efficacy of certain services, from oral health procedures to pain management, and putting more cost share on families. My family, for its part, wants Carla back once a month, not once a year. But there need to be limits. That $150 may have seemed necessary at the time, but upon review, it was wasted. ‘We don’t need more cleaning,’ I told them. ‘We need more accountability around here.’ Either that, or we eat all our meals outside.

1. 84: Percent of primary care providers in our poll of 406 PCPs, OBGYNs, physician assistants and nurse practitioners under the age of 35 who say the number one condition they see in patients today….stress.

2. Physicians Finishing 2nd: In youth sports, all the kids get trophies and cupcakes, even kids like mine who score for the other team sometimes or little Bobby who spends the entire game offsides yet celebrates as though he’s Pele or Messi after every goal. In healthcare, breaking the rules and then celebrating them is a problem but giving one over to the other team (like discharging a patient early to refer them to the right provider or level of care) is actually encouraged. See highlights from our research study on managed care insurers categorizing physician groups based on their decisions, their quality and cost. Click here

3. Inpatient Psych: Data we analyzed and a poll we did around the new demand for IP psych. Click here

4. Autism’s Cliff: It’s a field in the early innings with new advances in treatment and diagnostics and much of the opportunity in the near term around early intervention and finding ways to align payment with faster, more reliable outcomes. Said Allison Lloyd, a therapist in the school system, ‘I think the big thing is who can get to goal faster – the spending, number of kids diagnosed is only going to go up so you need models that work but don’t take 5 years to take effect. The policymakers, the insurers won’t be that patient’. But there is a looming issue to consider in autism that few are talking about – the kids who will move into teenage years and then young adulthood and leave the security of services and support. Click here for our story.

5. Where Art Thou Behavioral: I was scanning the United Healthcare provider network on my phone the other day. United rents its network to other health insurers, unions and others. On the website you could find pretty much any type of in-network provider, neatly categorized by location, site of care, specialty, zip code – you name it. I was impressed about the ease with which I could find endocrinologists, urgent care, imaging. But there was one condition completely missing, one type of provider nowhere to be found. Behavioral health. There may be a good explanation for this and a spokesperson said they’d look into it. Still, if you’re a provider in this space, and contracted with major health plans like this, you should check these fancy consumer friendly sites – make sure the health plan is doing its part.

6. Extra Point: My wife wants us to get a camera of some kind to monitor our high schoolers while we’re away this weekend. I think this is nonsense – they will either do something dumb or will do what I think they will do which is play video games, eat pizza, play wiffle ball, not clean up.  But I’m living in a fog sometimes about what our kids are and are not capable of, and I sometimes forget that snapgram or instachats—or whatever the kids call this now—are a party of 100 waiting to happen. So maybe a camera isn’t such a horrible idea. A group of physicians we polled are having their own debate about remote monitoring, though their wish list seems far more necessary. 71 of the 106 in the poll said there’s a real place for these tools in value-based medicine. Ideas and unmet needs cited as the things they would like to see: a history of all tests and interactions real-time, automated treatment algorithms, graphical display of deviation from target/baseline by monitoring interval (like every day or week) reports on the frequency of interventions or events, and reimbursement for analyzing data as it comes in. Now this last one caught my attention – in terms of your own companies and how you might think about the services around monitoring as both a revenue generator and a tool to provide better care, and in terms of my own family. If I can get paid in peace and quiet for telling my wife that the invasive home monitor is showing there’s a party at my house, I’m in.

1. 45: Dr Karens felt a bit like Larry David did during that classic Curb Your Enthusiasm scene when a woman got called in to see the doctor before Larry, only because she signed in first, even though Larry’s appointment was earlier. ‘I call Shenanigans!’ Larry argued. Dr. Karens, a pediatrician at a busy practice in the northeast I’ve known for about a decade, told me this week that she had to cancel our monthly chat because she lost her two best NPs to the local hospital and was knee deep in patient visits for sniffles and ‘the angry mob of helicopter moms’ whose children’s ‘red finger tips are somehow emergency cases…’.  ‘These aren’t emergencies,’ Karens laments. ‘The kids were swimmers – so their finger tips got red from pressing up on the cement to get out from the pool.’ The parents, she says, didn’t have appointments and just treated ‘my office like an urgent care.’ She apologized for missing our conversation but ‘I’m losing my mind…’. We can all relate on some level. Here’s my list of the top 45 things I seem to be losing:  See the list here

2. Santa Fee On Schedule: New Mexico’s new fee schedule for behavioral health providers is now in effect for evaluating and treating Medicaid patients: Click here to access it

3. Drug Screen Limit: A new BCBS of Tennessee policy now limits urine/serum testing to 20 episodes a year per patient. An episode is either a screening/presumptive test or a confirmatory test. Billing for both for the same patient on the same day is one episode.

4. Genetics: Evicore now requires 9 more genetic tests to run through their pre-approval department, starting in September. If you are involved in genetic testing, reach out for the list.

5. Labor & Delivery: Alternative payment models are taking shape in the maternity world, Horizon BCBS of NJ the first commercial payer to launch a pregnancy bundle a few years ago with a retrospective, upside risk-only model. The bundle now includes over 300 practice sites, covers all pregnancies, and extends to 30 days following birth. I asked a group of moms at my wife’s book club last week what they thought about pregnancy bundles and Ruth, a case manager in the work comp world who’s a mom of four, laughed: ‘That’s nice they are paying the doctors more…let me know when they will pay moms!’ So far in 2018, a pair of national payers have announced bundles: Cigna with an upside risk-only model that includes 1,700 providers from the U.S. Women’s Health Alliance, who get bonuses for limiting C-sections, infections, and postpartum depression. Humana has contracted with practices from IN, KS, OH and TX for its retrospective model that covers the perinatal period spanning from 200 days before birth to 45 days after discharge. Medicaid is also entering the dance: A non-profit Medicaid HMO launched a pilot program for a maternity bundle in the Houston/Galveston area, in which providers took no downside risk in the first year but partial risk in the second year.

6. Bookworm: Our behavioral reporter Erin O’Donnell sat down with thirty-something Damian Smith, who admits to a lifelong struggle with depression and other mental health challenges, and has turned this into a social media business. Check out their conversation here: https://thebehavioralhealthhour.com/

7. Pick up a shovel and dig a hole: It’s my kids’ favorite line from an underappreciated Matt Damon flick and a good metaphor for this healthcare story—Joe Filler, who has run a solo geriatrics practice in Nebraska for several decades, has turned a weekend hobby fixing sheds into a new preventive care model. The story goes like this: last year, Dr. Filler started fixing up an old run down warehouse, giving a few of his underworked Medicaid patients who had carpenter skills a chance to help with the restoration. He invited a couple larger contractors in to ‘see their work’ and one of them hired these patients for part time jobs. The area schools and sports teams needed indoor gym space during winter months so one of the floors was converted into a track and gym. Filler appointed two of his patients to ‘manage the gym’ and eventually Filler moved his office there. The ‘mixed-use’ building is now part community center, part housing. Before and after each appointment, Filler requires patients to take part in a workout – 2 times around the track…’not asking for much,’ he says. I asked him what he thought about value based reimbursement. ‘Oh, I don’t know much about that. I just like to fix things. This has been good for the people here. They don’t have much, but now they have a nice place to come together.’ Turns out Dr. Filler got a message from a local hospital this month as well as one of the insurers (he didn’t remember which one), inquiring about the property. It’s another sign that the health system is thinking more and more about community as its patients.

8. Sugar, Butter, Flour: Remember when dad slung a heaping tablespoon of sugar onto the cheerios at breakfast and, in his version of affection, handed you the back page of the sports section – the one with all the AL and NL standings. He’d hand it over and then grunt a bit, his mouth still working through a piece of rye-toast and jelly. My pop would tell me to figure out how many games back the Sox were from the Yanks, and what Marty Barrett’s batting average was. This was before the newspapers did this for you, and many years before ESPN ruined moments like these. Labor Day mornings were the best because the US Open was usually on that day and pops and I would take out the old Bancrofts and volley down at the local park before Borg and MacEnroe would duel. Mom and my sister would bake a cake with red white and blue frosting left over from independence day. My dad worked really hard so I liked these days. Ironically, despite our caloric intake, they feel a whole lot healthier than today’s version of the end of summer holiday. When you wake up Monday, what will you do?