Behavioral Health Insights

1. 64: That’s the percentage of Americans who reported they would attend an appointment via video telehealth, according to an American Well Telehealth study. The Council of Accountable Physician Practices and the Electronic Data Interchange released new documents designed to help healthcare providers in developing and launching telelhealth and telemedicine services. These documents, called “A Roadmap to Telehealth Adoption: From Vision to Business Model,” contain information designed to help identify resources of federal and state regulations as well as policies, pilot programs and use cases. These documents will be updated twice a year.

2. Social SoundBite: ‘So we have this accountable care budget model for health systems and some large groups here. It’s evolved over the years…And I finally realized we had it all wrong. We had been so focused on individual patients and making sure they got in to see the doctor, and took their meds on time that we missed everything around them….we need to start treating and managing the places these people live as the patients. Their homes, their communities – if unhealthy, if community centers are old, if homes are unsafe or unaffordable, they can set off a spiral of costs for more than just one woman or man, but an entire community, their kids and their neighbors.’  -- Paulette Storm, a case worker for the Mercy health system in Springfield, who has worked for Health New England, an insurer, and is working on a task force to spur payer and health system investment in housing and urban development. The main driver: value based models whereby the system has to stay under budget for a population in their community. How your practices can support these new payer and system-led urban communities may be a key question for you in 2019.

3. Medical Student Steering: BlueCross BlueShield of Alabama is expanding its initiative to improve access to primary care and behavioral health through a $3.6 million scholarship fund to the School of Medicine at the University of Alabama at Birmingham (UAB).  Med students qualify if agreeing to practice as a primary care or behavioral health physician in an underserved area.

4. 20-20 Vision: Cited by more than 60% of three-hundred 20-30 year olds in our consumer poll as one of their only true health concerns. ‘I don’t smoke, I run a lot and I work about 25 hours a week outside – I’m not sure I have to worry about the same health risks my parents and grandparents have to….but I do wonder about my eyesight. I mean, all I do is look at a screen…’

5. 2019 Diagnosis: United Healthcare will expand its national network of labs in 2019, adding Quest to its list and cementing its relationships with LabCorp. These partnerships will include a number of value based components such as real-time data sharing.

6. Extra Point: Taking a page from pharma formularies, more than three quarters of health plans in our poll anticipate using some kind of tiered network for specialty physicians and facilities in the future, many already with ‘tiering’ models, and to see consumer reaction, click here). The trend, says network manager Paul Willis, is akin to the oft times harsh realities of youth sports where kids are observed, ranked and grouped by ‘value’ to the program. Unqualified former athletes turned couch potatoes carry clipboard, scoring kids with archaic methods, 1=Good, 2=Average, 3=Poor. ‘It’s not much different if you think about – we will steer schools, colleges, our own families to the kids who are in the A grouping – choose them, because they are the best; watch them, because they are just better,’ Willis says. Heck I told my own dad to skip Tommy’s game and go watch Sophie because, well, the game would be better. Last fall, I watched my own kids be put on the so-called B and C teams – they weren’t as good at soccer, Jackie admittedly runs like he has a piano on his back, and Mukue seems to kick the ball backwards at times, including in a game last year when she rolled one back into her own net. Good kids, but some of their in-game decisions cost the team goals. It’s life and makes for a good laugh at supper but reality is they were on the 2nd tier. Physicians, hospitals and other providers are facing a similar threat – or opportunity – and if you think it’s not coming, you’re already missing the point. It’s here. Question is how these initiatives change our behavior – both as clinicians and practice managers, and as patients. Click here for our short primer on some of the tiered network models—their objectives and scoring methods.

1. 12.8: That’s the percentage of adolescents In the US who experience at least one episode of major depression according to the National Institute of Mental Health. New research shows depression in teens is linked to parents, and when treating it, their parent’s mental health improves as well. As social creatures, treating one member of the family helps the other. Check out this story and study we did related to the impact of sports on parents and their kids. Click here

2. Palliative Outsourcing Avalanche: Several Anthem MCOs now use a vendor called Aspire to provide Palliative support to ‘commercially insured’ patients in the last 12 months of life. A full team is made available – to help the patient, family and to help the physicians in the ‘co-management’ of the patient, either embedded in the medical oncologist’s office, or available for in-home NP visits or via a telehealth system. These programs likely continue to get traction with all types of payers, particularly for cancer patient populations, but likely for others. A question will be how the payment for these vendors evolves and who is credited down the line with reduced hospitalization costs. It would seem, based on the 90%+ of 134 payers we polled about this, that the demand is here for these services for 3 simple reasons – there aren’t enough physicians, disease is complicated, and families want this help.

3. Guidelines Change For Behavioral: If you own or are looking at owning a behavioral health provider – or treat patients with behavioral conditions including Autism - check out MCG care guidelines as several Blue plans tell us they will  adopt these to help determine what’s medically necessary. This October, Blue Georgia will start to use these for a number of conditions, including for the diagnosis and treatment of autism.

4. Home Cancer Treatment: BCBS of Illinois and Illinois Cancer Specialists announced their first Oncology Intensive Medical Home Pilot in the State for intensive medical home care. The program started as identifying PPO patients who were being treated by an ICS physician who qualified from receiving chemotherapy or hormone therapy and who had breast, colon, lung, pancreatic, prostrate or any non-Hodgkin’s lymphoma diagnosis. The program intends to enroll 150-200 patients per year.

5. Antibody Tests for Neurologic Diseases: In a small but interesting example of the widening attention and favorable coverage that managed care organizations are giving to understanding the science of our behaviors, Aetna released a policy update this month that now considers antibody tests medically necessary for the diagnosis and treatment of neurologic disorders, as long as a definitive diagnosis remains unclear after history, physical exam and conventional diagnostic studies.  To approve these tests, there must be evidence that the patient displays clinical features of the paraneoplastic neurologic disease in question and information to show Aetna that the result of the test will directly impact the treatment being delivered. One of the following antibodies must be suspected: Anti-amphiphysin, Anti-bipolar cells of the retina or anti-Recoverin.

6. Gender Dysphoria Treatment: UnitedHealth Care updated in August its Commercial Medical Policy for Gender Dysphoria Treatment including an updated rationale for why certain treatments or reconstructive procedures are considered cosmetic and not medically necessary.  The list has expanded since and has far more detail than the original policy. United relies in part on clinical care guidelines from MCG, formerly Milliman.

7. Opioid Policy Change: Cigna released its Non-Medicare Formulary Change for July 1, 2018 to change opioid coverage determinations for both short acting and long acting opioids. This change doesn’t affect opioid utilizers currently being treated for cancer risks or sickle cell disease, or in hospice. For new opioid utilizers, the first time refill in a total daily dose of 120+ MME will require a prior authorization for coverage of their medications. Cigna says it will make a coverage decision within 24 hours after receiving the providers request.

8. Crohns Starter Pack: Humira’s starter pack treatment for children with Crohns disease now requires pre-authorization from Cigna Health Arizona for a number of its HMO plan members and special needs plans. Humira itself must be pre-approved. Physicians must document past medication history of arthritis.

9. Shortage Poll: 1 of 73 managed care executives in our poll last month say that while they are embracing telehealth they are skeptical and have discussed the idea of allowing medical students to finish education but treat earlier. The idea has been floated by others, including in a recent Washington Post op-ed. There are many issues with this concept, one obvious one is that we have ‘trained PAs and MDs today’ in places like urgent care who mis-diagnose and over or under treat, so allowing medical students into these roles would seem to only exacerbate the issue. But that more insurers are discussing this and engaging policy-makers is compelling for all of us. One idea floated in a meeting I was in out in central PA last year was to pay for medical education in exchange for having students serve in rural areas doing primary care alongside an experienced NP.

10. Extra Point: Race, Gender & A Better Outcome. That’s the ‘working title’ of a study we have going that looks at disparities in healthcare but more so the science behind our healthcare decisions. The early finding: Who treats us matters. Take George Costanza. He was so excited about having insurance coverage for a massage back in a 90s episode of Seinfeld only to become completely anxious when he found out his masseuse was a dude. His neck pain worsened but for all his indiosyncracies, George was on to something. Recent studies prove it: Having a black doctor has led black men to receive more effective care, a Harvard Business Study revealed, and nearly 600,000 heart patients admitted over 2-decades from Florida ERs were less likely to survive if treated by a male doctor (study here). But it’s not necessarily one gender or race over another or that for non-emergency situations you fare better with someone of your own race or gender. My own bride went against a hospital’s advice after ripping up her ankle and chose Dr. Lauren Ganey at a university medical center over the hospital’s all male surgery staff, saying she preferred to have ‘a mom’ who could appreciate her need to get back to running again, but then chose a male physical therapist over a female. My girls all prefer Tyler Stanley, a PA at our pediatrician’s office because he says the word ‘boogies’ a lot. Say this, they seem to take those antibiotics much better when Tyler prescribes them.

1. 60: That’s the percentage of people suffering from Alzheimer’s who are women. Recent studies show women endure Alzheimer’s disease more than men. For years it was written off as an age issue because women live longer than men. Now, neurologists are studying that it could be for more reasons than just life expectancy. Read the full story on the Kaiser Permanente studyhere.

2. Asthma City: Asthma Capitals and the Asthma and Allergy Foundation of America (AAFA) released research on the “Most Challenging places to live with Asthma” including Springfield, MA, Richmond, VA and Dayton, OH. New York ranked Number 20th and the city with the highest estimated asthma prevalence is Louisville, KY.  Asthma causes 2 million visits to emergency rooms each year and each visit averages in $1,502 in cost. Total per member per year costs for asthma decreased by more than $500 due to a local Medicaid plan’s program. Poorly controlled asthma is very prevalent in the Medicaid population but asthma exacerbations are potentially preventable. ‘PCPs lack timely data and outcomes depend on an appropriate system of care,’ says Barry Lachman, MD, who is Parkland’s Community Health Plan medical director. The Medicaid MCO developed a predictive model, care coordination system and EHR alerts for asthma patients, and the results were significant: Asthma related ED visit rates decreased by 30% (from 16% to 11%), hospitalization rates by 43% (from 3.44% to 1.97%), and total costs by 40% (from $1285 to $766 per member per year). The asthma medication ratio increased by 15%, from 0.39 to 0.45. Results to be presented in an upcoming discussion on asthma.

3. United Giveth and Taketh Away: United Healthcare has made 3 interesting payment adjustments – certain outpatient injectable drugs for cancer patients will require pre-approval starting in November, including chemo drugs with a Q-code, colony-stimulating factors like Neulasta or Neupogen, as well as Xgeva and Prolia. Medicaid patients in 4 states are impacted (Rhode Island, New Mexico, Iowa and Nebraska). OBGYN groups will get paid less for c-section deliveries if the documentation doesn’t have the right diagnosis, coding or documentation. On the plus side, United will no longer require medical records to be submitted when reporting both an evaluation and management service along with a radiologist’s interpretation.

4. Cost Share Hike: Aetna’s Kansas City metro area HMO has increased cost sharing for home infusion to 25-30% of the plan allowance in two of its benefit plans, and added cost sharing for professional mental health and substance abuse services, outpatient services including ABA, and skilled behavioral health services.

5. Tiered Network: For those of you operating specialty practices the movement to tier-based reimbursement continues as BCBS of North Carolina is the latest to create a tiered network. The plan has 2 tiers: Tier 1 providers get better rates based on varying clinical quality and cost measures, such as orthopedic physicians conducting imaging 28 days after a patient’s initial evaluation for low back pain or endocrinology groups prescribing a lipid-lowering therapy to adults who have a diagnosis of hyperlipidemia and CAD but without diabetes). Gastroenterologists, neurologists, cardiologists and OBGYNs are included too. Reach out if you’re interested in discussing the scoring methodology used by the plan as it is in some ways a roadmap to success in the new value-based world.

6. The End of Prior Authorization: Think about it – a world without pre-authorization and less concern about how your physicians document. As predicted here, there continues to be signs of more progressive payers seeing the benefit of unleashing successful health systems and physician groups by taking shared risk with them to manage a population minus all the administrative redtape. We’ve long since discussed here the idea that your companies need to think not just in terms of how to negotiate higher reimbursement rates but how to become the defacto benefit manager for health plans – evaluating what’s needed and making treatment decisions without worrying about the economics. Therapy companies too – PTs and behavioral businesses – have an opportunity here Patrick Conway, MD, president of BCBS of North Carolina, recently told a health informatics convention that the goal ought to be to get the provider and payer unlocked from rigid rules and that perhaps we ought to ‘turn off all prior authorization’ and, other than risk coding and STARS measure reporting, worry less about documentation.

7. Therapy in a Box: Subscription boxes are all the rage these days. Therapists have come together to produce “TheraBox: Ingredients to Happiness,” a monthly subscription box filled with items designed with the patient in mind. Each box is curated by therapists and includes a happiness activity inspired by neuroscience and positive psychology research and includes full-sized wellness items shipped to a doorstep.

8. Tech App for Therapy: A new therapy app as is on the market and no it’s not Talkspace. BetterHelp is its competitor as the largest online counseling platform worldwide. Whether by phone, text or video, patients have access to professional counseling 24/7. These counselors are licensed, trained, and accredited psychologists, marriage and family therapists, and clinical social workers. Health insurance coverage can be very limited but there are signs of interest in these models from the managed care community, such as behavioral network New Directions. Financial Aid can be applied in some situations.

9. Extra Point: A great white swam by us Tuesday at Head of the Meadow beach in Cape Cod. I pulled a George Costanza, toppling over little kids and grandparents enroute to safety. Thankfully the great white didn’t get anybody and no one (except maybe God above) saw my cowardice. My oldest kids, Jack and Mukue, sprinted along the water’s edge chasing the shark. Jaws was maybe 35 feet from the coastline at this point, eventually disappearing into darker waters. 45 minutes later the beach guards put up a green flag alerting us that we could go swimming again. My kids, and the couple hundred other beachgoers, ran into the water without much fear. A humid day will do that, though it is bewildering that people have so much faith in the lifeguard system and their own ability to get out of the water before Jaws bites. I will say that the generation that grew up watching Quinn get eaten off the shores of Amityville seemed a bit more cautious. But, look, if you read the science about sharks, our collective fascination with these ocean giants isn’t all that misguided. Healthcare researchers say shark cartilage can be used to treat cancer, arthritis, psoriasis, diabetes, and in healing wounds. Amazing to think about the possibilities – but I’ll be honest, I’m still going to forever hear the Jaws theme.

1. By the Numbers: Of 54 million adults suffering from arthritis, 44 percent have limitations that affect mental health. According to the American Psychological Association, anxiety affects blood pressure and high blood  pressure often goes untreated in those with rheumatoid arthritis (RA). Chronic daily pain can change the levels of the brain and nervous system chemicals. This changes thinking, behavior and depression.

2. ADHD: Insurance coverage for ADHD drugs and therapy programs is inconsistent between healthcare providers. Cigna released their prescription drug list changes for attention deficit hyperactivity disorder and said that the medications not covered are Desoxyn and Dexedrine. Instead, only the generic alternative is covered  in tablet form.

3. Aetna & Epilepsy: What was previously an excluded Aetna behavioral benefit, Vagus nerve stimulation is now covered. This is a procedure that treats epilepsy when other treatments haven’t worked. It is also a treatment for hard-to-treat depression that hasn’t responded to typical therapies.  Federal law requires Aetna to cover mental health and substance abuse services in parity with coverage of medical and surgical services.

4. Anthem Enrollment Changes: Anthem reports that medical enrollment totaled 39.5 million members as of June 30, 2018, a decline of 129,000  members during the quarter. The enrollment decline was driven by a reduced footprint in the Individual ACA-compliant marketplace in addition to membership losses in Medicaid. Medicare enrollment grew by 254 thousand, year-over-year as a result of acquisitions and organic growth. Medical enrollment was down 129,000 lives sequentially, reflecting declines in Medicaid, continued attrition in Individual, and declines in the Local Group business. The decline was partially offset by growth in Medicare enrollment, said an Anthem spokesperson.

5. Shingles: Anthem updated its Affordable Care Act (ACA) preventive care coverage to include Shingrix, the new zoster shingles vaccine based on a new recommendation by the Advisory Committee on Immunization Practices (ACIP). Medicare coverage for the shingles shot is only available if you’re enrolled in a stand-alone Part D drug plan or a Medicare Advantage plan that includes Part D drug coverage.

6. Extra Point:  In 1978 I’ll never forget the time dad cut my allowance from $2 a week to a nickel after I cut corners cleaning the bathrooms and that same week he took my sister to the baseball game and mini golf. I sulked for a whole weekend, which isn’t a good look for a kind of quiet kid who wears polyester bellbottoms and only listens to Survivor cassette tapes. In managed care speak, Dad cut my rate and my utilization. We were talking yesterday about how managed care plans often do one of the other, but not both when trying to get control of costs for a service or specialty. They’ve often addressed radiology over the years through utilization controls, now in effect forcing these physicians to think about the medical necessity of the scan before ordering it. They’ve typically done the opposite to lab and DME rates, or payment for out of network services, reducing reimbursement rather than managing the volume. In managing autism, a service with coverage mandates, they’re beginning in some markets to do both – evaluating areas where rate cuts make sense and managing visits more closely. Over time, the best way to avoid both rate and volume pressure likely lies with being able to be the true benefit manager for these health plans, showing them you can say no or re-direct care to a more conservative treatment, that you can evaluate and adjust the diagnosis, take some risk and even be willing to forgo reimbursement. Home health, PT, autism all have opportunities to serve this role, so do DME companies, surgeons and those circling around disease management, such as endocrinologists who work with diabetics, or allergy professionals who are dealing with patients with asthma. I would encourage owners of healthcare businesses to think less about what tactics are more likely but more so how your physicians, therapists, and nurses can turn these tactics into opportunity. My dad certainly did. By the following weekend he was down on our red linoleum floor helping me scrub and giving me a few tips to make it more of a game. He even took me early to see batting practice at a Red Sox game. I bought my own $2 pretzel.

1. One Million: Number of people over 5 years of age that are considered functionally deaf. More than half of those people are over the age of 65. With the great popularity of the ear buds and beat headphones at the gym, hearing loss is becoming more of an issue. Letting your kids playing video games at full volume can be more damaging to their hearing than you think. A recent study  involving participants aged 18-41 shows those who showed small amounts of hearing loss had unusual activity in their right frontal cortex of their brain. The study concluded these changes show signs of dementia later in life.

2. Dementia Guidelines: The Gerontological Society of America has developed them. Read the full list of recommendations here.

3. Behavioral Guidelines: Starting in October, Blue Georgia is among the health plans who will start using MCG’s clinical guidelines for coverage of behavioral services including autism screening and in-home services.

4. GI Technology Impact: Cologuard has gotten a boost lately with full coverage decisions in place – or about to be, including no copay for the patient and no pre approval requirement for the physician.

5. PA Lifted For Psych Testing: BCBS of Illinois no longer will require pre approval for psych and neuropsych testing for its Medicaid and Medicare members starting this summer, as long as the provider ordering the test is part of the payer’s network. The exception is if BCBS determines a provider’s testing varies a lot from peer groups. Periodic auditing will also be done to ensure medical necessity.

6. Diabetes Monitoring: Asked for the features of remote monitoring systems that would be particularly valuable under more risk-based and bundled payment models, 79% of endocrinologists suggest "stickless" monitoring for glucose without the use of continuous glucose monitoring by subcutaneous needle, while 54% want blood sugar monitors to be able to enter diet and automatically upload blood sugar levels so the doctors can make ‘more real time adjustments’ may be made’. Endocrinologists received modest reimbursement increases from a number of health plans in 2018, mostly for sharing data with the health plan on a number of measures, including one where the health plan encourages longer sessions with patients to ‘head off’ adherence risks. Our story on endocrinologists and monitoring by clicking here.

7. ABA Owners: They may want to take a cue from a memo one Blue plan in the south sent to therapists there, acknowledging that ‘evidence that supports ABA continues to be limited because of wide variations in method, findings and philosophical bias,’ which BCBS of Tennessee medical directors say makes conclusions about coverage difficult. That the broader market considers ABA standard of care for autism is one thing; health plans will continue to play the role of skeptic and manage the benefit tightly.

8. Pathology All In: Blue Tennessee has adjusted payment for anatomic pathology at facilities and, starting in 2019, will pay facilities an ‘all inclusive rate’ for inpatient and outpatient services, including pay for services and supplies. There may be contractual exceptions. The facility payment includes the technical component for professional services provided while a patient is in a facility setting. The policy applies regardless of the relationship between the pathologist and the facility (e.g. the hospital).

9. Readmission Policy Change: 32 plans out of 68 polled recently on readmissions said that if an inpatient service claim is fully denied for a Medicare Advantage patient who is readmitted to a hospital within 48 hours of an acute hospital discharge, then any associated professional (e.g. physician) service claims will also be denied.

10. Extra Point: Perhaps coincidence but in a summer when my wife broke her ankle ala Gordon Hayward, my son had his second bout with multi-directional instability in his shoulder and a cast on his wrist, and my daughter had a hard-to-diagnosis hip issue common to refugees from Thailand, orthopedics has jumped to the #1 spot in both the Managed Care Index of health plan priorities, and the top service line of focus among hospitals. We have so many bands and boots, band-Aides and braces in our hallway-turned-mudroom that I thought about selling some of them on Amazon. Turns out Amazon had the same thought. As of this this fall, they are in pilot programs with a couple of major hospitals, including UPMC and Seattle Providence Health, whereby doctors recommend bundles of medical products to their patients before they're sent home and have those products delivered to patients' homes at discharge.

1. 6157: The name of a Senate bill in Washington state that forced Regence BCBS to do away with a policy requiring pre-approval for PT, chiropractic, massage, OT and speech therapy for the first 6 visits after an initial evaluation. A source with Evicore, which handles these requests for the insurer, told us it will identify patients who won’t need the authorization in this state. Pre-approval is required for visits after 7 and, due to the policy, an Evicore therapy evaluator said, ‘this sort of makes it harder to get approval for more than 3-5’ unless it’s a youth injury situation or a patient coming off of a surgery. ‘The chronic cases will be lucky to get 1 or 2 more at a time, we will need to see a lot of evidence, notes’

2. Tiered Network, By Specialty: North Carolina’s Blue plan uses administrative claims data to tier providers into 2 groups based on their cost and quality, using specific metrics for each specialty, like cervical cancer screening for OBGYNs and imaging studies done more than 28 days after initial visit for low back pain for orthopedics. Other specialties included are cardiology, endocrinology, GI, neurology and general surgery. See the metrics by specialty by clicking here.

3. Homeward Bound Addiction: Anthem New Hampshire has added a home-based addiction treatment provider to its network cut from the VNA model where addiction nurses and psychiatrists, recovery specialists and therapists team to treat patients at a lower cost for longer periods or help payers more rapidly and safely transition patients out of residential or inpatient settings. According to our poll of 136 families nationally this past quarter whose son, daughter or relative has suffered from a substance use addiction, 57%, up from 49% in an earlier poll, said their family member has been in treatment more than 4 times and 73% said they have been treated at least twice in a residential program. The program initially has had success in Connecticut.

4. Shoulders, Hips, Knees & Toes: Boeing, Walmart and others are among the narrow network pioneers, putting out RFPs to let hospitals ‘compete for our business’ and include ‘free primary care’ without copays and deductibles or offer an exclusive on all major surgeries. It’s narrow and limited choice, ‘but people don’t care’ says a Home Depot HR manager Suzie Nicols – ‘they want it to be easy.’ 77% of 50 large self insured plan directors in our poll this fall, up from 63% last year, are opting for more of a ‘procedure driven’ approach, selecting specific hospitals or centers for knee procedures, for instance, and ‘paying full travel to send patients and a caregiver, if needed.’  Next on the horizon by 2020, although I suspect sooner, will be exclusive national contracts for substance abuse or behavioral health centers with insurers who manage the ‘healthy/younger millennials – like age 21 to 34’. ‘Makes sense to have 1 contract, agree on a single rate, fly patients, and give the provider risk,’ says Sal Gentile, chief executive of a soon-to-be startup ‘millenial’ focused insurer called Melody.

5. Up in The Air No More: 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. Starting in January, the plan will require 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, starting in 2018, 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. This same plan has instituted a max pricing policy that gives contracted providers a rate 5x Medicare rates and others out of the network 3x Medicare—both substantially lower than the typical charges, which in recent years have been around 10x Medicare. In 2016, more than 2,000 BlueCross members received air transport as part of their care in Tennessee. ‘We paid more than $50 million for those services, which reflects a 73% increase from just three years ago (29m),’ a source for BCBS of Tennessee reports. About half of payments were for non-emergent situations, one in which the plan paid more than 450k for a fixed wing transport for a patient coming from Arizona back home and $25k for a patient being transferred between hospitals just 2 miles apart. Details on the results of the plan’s strategy to increase rotary and fixed wing contracts will be discussed in an interview in a couple weeks.

6. Cigna’s Opioid Change: Cigna made changes to their drug formulary list effective July 1, 2018, for non-Medicare customers filling an opioid prescription for the first time in a total daily dose of 120+ MME will require a prior authorization for coverage of their medications. A decision will be made within 24 hours after receiving the provider’s request. This change does not affect opioid utilizers currently being treated for cancer or sickle cell disease or in hospice.

7. Women’s Health: The demand for Women’s health services is on the rise 6% by 2020 says the US National Library of Medicine and National Institute of Health. They estimate 81% of OB-GYN related services will be for women of reproductive age (18-44 years old). This growth will translate to a need for physicians or non-physician clinicians which is equivalent to 2,090 full time ob-gyns. This will require a larger provider workforce. Read the study here.

8. Dakota: North Dakota was the 39th state admitted to the union and became the 48th to require autism insurance coverage for all state-regulated plans that have mental health coverage. The law prohibits caps and limitations on other coverage including speech therapy, occupational therapy, and physical therapy. Grandfathered plans are required to include the coverage as of October 1, 2018, and non-grandfathered plans are required to include coverage as of January 1, 2019. A school administrator in the state capitol, Bismark, said this will help meet a backlog of more than 700 kids in her district needing services. ‘We haven’t been able to handle it and parents have been at a loss, juggling on their own’, Peg Florence said.

9. Therapy Pups Help In Behavioral Crisis: College students experiencing both anxiety and depression is one the rise, 52% citing psych related needs up from 44% according to a survey of college counseling centers. One way universities are helping their students is through therapy dogs. Our own Erin O’Donnell interviewed the President of the Alliance of Therapy dogs. Read full story here.

10. Extra Point: On August 4th  and 5th I’ll be traipsing through southeastern Massachusetts on a road bike for the Pan-Mass Challenge, a fundraiser for Dana Farber and The Jimmy Fund. I took the Trek out of the garage last weekend. My 10-year-old thinks it’s too tall and needs stickers and some “puffed handle cushioners,” whatever those are. But what does he know anyway? I admired it for a whole day until my wife said, “You going to ride it sometime or just let it collect dust?” The Trek represents opportunity, for peace from screaming kids and poop stains, a sort of flashback to those days riding the Huffy in the backwoods by Archie Lane. Riding a bike is now an Rx too, as an increasing number of PCPs are encouraging adults and seniors to get a bike and ride to address hypertension among other risks. To read my essay about one of my first Pan Mass rides in 2012, click here

1. 26: Percent of plan premium dollars, according to a poll of 19 regional insurers, that goes to physician services, 25% to inpatient, 21% to outpatient facility care, and 10% to Rx, but pharmacy varies by plan and over the last few years has definitely taken a larger chunk of the total premium dollar, driven by specialty pharmacy cost. Today, the annual trend in specialty pharmacy net of rebates is 15-20% (e.g. the PMPM on total drug costs), say some sources, compared to the 9-11% it was a few years ago, whereas whereas for traditional (non-specialty drugs) the trend is in some cases negative. Medicaid has highest trend due to lower generic options and its covered population which see higher prevalence of asthma, ADHD, mental health, and substance abuse, conditions where drugs are less often generic.

2. Three if by Air: A southeastern Blue plan is getting tougher on air transports instituting a max pricing policy that gives contracted providers a rate 5x Medicare rates and others out of the network 3x Medicare—both substantially lower than the typical charges, which in recent years have been around 10x Medicare. In 2016, more than 2,000 BlueCross members received air transport as part of their care in Tennessee. ‘We paid more than $50 million for those services, which reflects a 73% increase from just three years ago (29m),’ a source for BCBS of Tennessee reports. About half of payments were for non-emergent situations, one in which the plan paid more than 450k for a fixed wing transport for a patient coming from Arizona back home and $25k for a patient being transferred between hospitals just 2 miles apart. Details on the results of the plan’s strategy to increase rotary and fixed wing contracts will be discussed in an interview in a couple weeks.

3. Working For The Weekend: United Healthcare just dipped into the 1980s for a new policy that it hopes will help doctors add hours. The MCO is going to be increasing PCP reimbursement for evaluating and treating patients on weekends and after hours, which may help those of you in this area either extend hours, add staff, or compete with urgent care. We shall see if this works. If the PCP provides what UHC calls ‘acute care services’ after hours or weekends, they can bill a code called 99051. Policy takes effect August 18th.

4. NeuroMonitoring: A new policy from United Healthcare takes effect in September. It will deny neuromonitoring if performed outside of the hospital, like a surgery center. Separate reimbursement will only be considered if done by someone other than the surgeon or anesthesiologist.

5. TeleMed Takes Direction: New Directions, the specialty benefit manager, has entered into a national arrangement with a tele-mental health company, TalkSpace, that allows 24/7 access to a licensed therapist via an app. For owners of brick and mortar mental health practices in places like Minnesota where New Directions manages behavioral health for insurers, the partnership should impact utilization. Our earlier story on this by clicking here .

6. Vape Nation: 28% of 12th graders surveyed said they have ‘vaped’ in the past year nationally, one study revealed, while our own poll suggested higher numbers 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

7. Extra Point:  My high schooler took one of those single-credit summer classes last week, a health class where the kids watched endless streams of videos about stress and marijuana, both gateways if you will to a host of medical problems in life. The latter, marijuana, is interesting given what’s happening in some states with medical marijuana dispensaries. Legalization is creating a host of challenges for worker’s comp insurers according to my neighbor who manages work comp cases, given the amount of time marijuana stays in the system and prescribing challenges for pain management doctors who are used to knowing the exact dose when prescribing pills, but are now entering an unknown. Jack got a solid 97 on his final exam. Like any good dad, I said, ‘What tripped you up?’ He said there was one of those questions where the teacher asked students to pick the one option from a list that wasn’t an STD. ‘I thought pumonia sounded like an STD, right?, he said laughing’ I suppose you’re right Jack, but the word on his paper was pneumonia! ‘I’m not sure what’s more concerning kiddo, that you got an A in a class watching videos or that you couldn’t pronounce pneumonia, the grandfather of diseases!’