Behavioral Health Insights

5.4: The amount employers expect health benefit costs per employee to rise in 2024, largely due to market wide factors like inflation and labor shortages, along with healthcare specific costs like the approval of more gene and cellular therapies and increased utilization of the GLP-1 drugs for weight loss. This projected increase is larger than what employers have seen year over year in the past, which means self-insured employers will likely put additional pressure on health plans to try to keep costs down. “Expect continued emphasis on preventive measures, using telehealth to guide employees to the right services,” says Max Valencia, an HR manager. “At one company we are raising copays quite a bit for the services that get used a lot but aren’t always necessary, like urgent care.”

No More Pre-Approval: BCBS Minnesota will no longer require prior authorization for any commercial members who need skilled nursing visits. And in Michigan, BCBS announced they will remove 20% of PAs for procedures like bariatric surgery, breast biopsy, and cardiac rehab services across both Medicare and commercial members. BCBS will also amp up its gold card program where physicians can be excluded from needing to seek prior authorization based on past approval rates.

Hold On: Not all insurers are taking off the controls. Florida Blue joins a growing number that will more aggressively manage cardiology services. They will use Evolent Health for its Medicare Advantage members.

Changing Partners: In December 2023, Highmark Blue is moving from third party benefit manager Tivity to Helion Arc to manage outpatient physical therapy services. The announcement notes that qualifying providers may still receive up to 20 auto-approved visits per member, likely in some form of a gold card program.

Finding Specialists: One of the biggest challenges for consumers is getting to the right specialist at the right time – in our poll of 1,600 adults, 67% said after referral to a cardiologist the earliest appointment was 7-9 months out, “which is not a great system – you don’t see that kind of a wait for cancer,” lamented 53 year-old Shirley Feeley, whose high calcium scores were troubling to her internist given family history. Anthem is offering Medicare Advantage members a new way to search for specialists called Personalized Match Phase 1. When members access the Find Care tool online, providers will be listed or ranked by their quality and cost scores relative to their peers in the member’s preferred mileage search radius. Patients will be able to sort provider results in other ways, but the default will be based on providers’ scores, though the actual scores won’t be visible to patients.

Retailer Spread: Walmart is reportedly in talks to purchase primary care practice ChenMed. If the deal goes through, Walmart will be the latest retailer to move into the primary care delivery space, following similar purchases by Amazon, CVS and Walgreens. And speaking of Walgreens, they announced a new partnership with Pearl Health, which has a platform to help enable value-based care. The platform will be used in Walgreens’ relationships with community-based primary care physicians.

AI Tool: Microsoft and Paige, a pathology AI company, are developing a new generative AI model focused on cancer diagnosis. Paige will use up to 4 million digitalized microscopy slides to develop new clinical applications and biomarkers with the goal of deploying them in hospitals and labs.

Check It Out: GoodRx launched a new feature that allows providers to check a patient's insurance benefits when prescribing medications to better understand the final cost. The real-time benefit check is available in GoodRx's "Provider Mode," which offers providers a dashboard with drug cost comparison tools and other resources for patients.

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

Extra Point: Something seems lost in translation these days around helping people in crisis. Just 13 states and DC by my count provide reimbursement for the cost of medical interpreters through Medicaid and states that don’t say that the cost is part of existing reimbursement, like to a hospital.  But there is a growing need for interpreters – in a survey we did of 550 hospitals about 35% don’t offer them at all and another 40% said they have had trouble staffing the function, partly due to the rising demand, the influx of the refugee population in the US, and the lack of reimbursement. Our oldest daughter does interpretation and says one of the underappreciated issues is interpreters sometimes cut corners. “I’ve seen so many interpreters not doing their jobs properly…especially not interpreting everything that the doctors and nurses say to them. It’s just not accurate most of the times.” Kyoe, 23, who grew up in a refugee camp in Myanmar learned Thai other languages as a kid, says she has had to hold back many times when listening to interpreters who are interpreting for her family members and friends. “I feel like hospitals and schools should allow third parties to interpret - it’s not fair on elderly folks who don’t understand English have someone to interpret for them who they don’t understand and who doesn’t know them.”  Maggie Fleeter, an ER nurse, says she feels like it’s a big gap in the discharge process – definitely for seniors and for people with mental health conditions. “We see a lot of back here because something was lost in translation. I think we can do better for these patients.”

77: The percentage of mental health students and young practitioners ages 20-30 we polled who are both working toward a license as a therapist, psychologist or psychiatrist and would prefer to have or join a virtual practice.

Injection At The Rx Counter: Bicycle Health, a telehealth provider of opioid use disorder treatment, is partnering with Albertsons to make prescriptions for Sublocade available at Albertsons pharmacies, which also include Safeway and Acme. The injection can be administered monthly as an alternative to taking a daily oral version. Once Bicycle Health patients receive a prescription virtually, Albertsons pharmacists will be able to administer the treatment.

OTC To Stop Overdose: BCBS Massachusetts recently announced they will cover the drug designed to reverse opioid overdose as an over-the-counter medication, now that naloxone is available without a prescription. Most health plans have not yet issued any guidance on whether naloxone will be reimbursable similar to aspirin or vitamins, but the AMA is calling on insurers to do this, in order to help increase access.

Autism Policy Change: As of September 1, 2023, Blue Cross NC now will recognize North Carolina Board Certified Behavioral Analysts (BCBAs) as eligible for direct participation in their provider networks. Previously, the state used to require that BCBAs could only practice under licensed psychologists so the state did not require them to be independently licensed, so they likely couldn’t get credentialed directly or contract with plans.

Bringing It Inside: Just like radiology a decade ago and physical therapy currently, commercial payers continue to move benefit management of behavioral health in-house, a positive for outpatient providers. Point 32 and BCBS Michigan announced plans to move behavioral health prior authorization decisions and case management internally – Point 32 this fall, Blue Michigan starting January 2024. Lucet, formerly known as New Directions, currently handles these operations for BCBS Michigan’s commercial members. With the move in-house, BCBS is also dropping some prior authorization requirements, like those for IOP and neurofeedback services.

Referral Questions: A new study published in JAMA found that primary care physicians affiliated with large health systems drive up spending on patient care through increased referrals to specialists within those health systems. The study looked at data from 2013-2017 and found that a primary care health system relationship drove up specialist visits by around 23%, along with a roughly 14% increase in ER visits and a 22% increase in hospitalizations.  Referrals to behavioral specialists, however, tend to go outside the health system according to our polling.

TelePsych: Castell, the Intermountain health system’s value-based care subsidiary, is partnering with Headspace to increase access to virtual mental health services. Headspace is now the first digital mental health provider in Castell's network.

Maternal Mental Health: We confirmed a study is underway by at least one insurer into the long-term cost of poor maternal mental healthcare both pre-term and after birth. One plan is considering adding reimbursement into its bundled rate for up to 3 pre-term therapy visits. While policies have improved to cover depression screening and services, improvements are needed and the cost of poor maternal care plays out over many decades, said Angela Glyder, RN, during our women’s health forum yesterday. Glyder, the VP of Clinical Operations for Lucina Analytics, agreed that payers should consider long-term costs as they develop value-based programs. Our paper on this issue can be found here.

Extra Point: I ran 5 miles with Julio Perez, Mike Udell, and Rory Tulienth a couple of weeks ago. The trio has been addicted to heroin, fentanyl, steroids and alcohol – and now they run in a club called The Boston Bulldogs. Clubs like this that empower people through movement are gaining traction in society. For the most part, they don’t require a pill or injection, no Zoom connection or copay – just a $52 pair of sneakers and an open mind. In Rory’s case, she had tried three to four residential programs at various points in a 10-year battle that started in her mid-20s – “good people, but it just didn’t stick – maybe I wasn’t ready – maybe the addiction was still in charge,” the 36-year-old said as we stumbled through a shady stretch in Quincy. “I found a home running–I’m not sure why, but it feels right,” I asked her how much it cost to pay for all the care she had during her 10 years. “How much?” she laughed. “I was in the hospital maybe 20 times…in prison, lost my job, my husband, my relationship with my daughter–am I supposed to put a number to that?”

53%: The increase in spend on mental health services between March 2020 and August 2022, according to a new study in JAMA Health Forum. The study from the Rand Corporation and Castlight Health analyzed claims from about 7 million privately insured adults who are covered through workplace health plans, which means this number may not accurately reflect the true demand for these services. Those with government-sponsored plans and with coverage through the exchanges likely also saw an increase in mental health spend over the past few years.

5 Pillars: Severe mental illness and substance use disorder are 2 of the 5 pillars of behavioral spend and insurers are realizing that the portion of people with “multiple” behavioral conditions like these is growing. In efforts to continue leading way among insurers on behavioral health, Blue Cross NC launched a new program August 25 for members with serious mental illness and/or substance use disorder. The program will replace the Blue Premier Behavioral Health Advanced program in partnership with Mindoula. 12 new counties will be added to the 14 participating in the previous program. Behavioral health care coordination services will be provided for commercial, FEP and MA members.  Blue NC organizes its behavioral spend into 5 pillars – SUD, SMI, Anxiety and Depression, Co-Occurring Medical and Multi Behavioral.

Biosimilarity: CVS Health, parent of Aetna, launched a new subsidiary, Cordavis, that will work with drug manufacturers to commercialize and/or co-produce lower cost biosimilars. The first partnership is with Sandoz to produce its Humira biosimilar, Hyrimoz. The drug will be available in the first quarter of 2024 at a list price around 80% cheaper than the Humira list price.

Talk About A Site Of Service Shift: In Airplane circa 1980 actor Leslie Nielsen’s Dr. Rumack asked Ted Stryker, “Can you fly this plane, and land it?” Today, Stryker might need to take care of the health of the passengers too. Delta and other airlines are partnering with MedAire to provide telemedicine 35,000 feet above the ground. Services include on-demand medical advice to flight crews via audio or text messages and, in the future, may even include video-based telemedicine similar to what you can access in your living room.

Nurse UnShortage: Optum-owned MedExpress urgent care centers announced plans earlier this month to lay off registered nurses at roughly 150 locations across the country as part of a restructuring to cut costs. The urgent care model may be under some stress as we settle into a new normal post-COVID – while needed in some markets, most payers would prefer members seek care from primary care providers and start, if needed, with telehealth, given the widespread belief that 30-50% of urgicare visits are for the worried well.

Consumer Misconception: Only 26% of consumers surveyed by insurer EmblemHealth had familiarity with the term “value-based care” but when given the definition, 61% say they prefer it over fee-for-service. We are not entirely sure consumers fully understand the implications but the survey may at least guide the NY insurer’s strategies. Many employers also misunderstood the value-based concept, only one-third of those familiar could actually provide a definition. Additional education on value-based care for both employers and consumers is likely needed to achieve healthier outcomes. In our own poll of consumers, we got more cynicism than clarity—“Is value-based care when they give me a room with a window while I wait 45 minutes for the NP who has no idea about my medical history.”

Shooting Par: For pro golfers, par is like a bogey but for amateurs, it’s like a birdie and we would argue that a recent decision in Nebraska may feel like a hole-in-one for providers. BCBS Nebraska recently informed providers that all who are eligible to provide telemedicine services will be reimbursed at 100% of the in-person allowed amount – or “at par” – as mandated by the Nebraska Department of Insurance as of September 1, 2023. Previously, BCBS had lowered telemedicine rates to 50% of in-person except for behavioral health, which has and will remain at par.

Kidney Bean: There seems to be a new focus on kidney care, with a couple of high-profile partnerships launched this month. Oak Street Health is collaborating with Strive Health to provide value-based kidney care to people with stage 4 and end-stage chronic kidney disease. And Interwell will begin providing kidney care services to Humana’s Medicare Advantage members in 13 states. Multiple other payers also work with Interwell or Monogram Health in similar partnerships.

Correction: 23.5% of middle-class Americans have medical debt according to a KFF estimate – the number with debt previously reported in the August 25^th edition was incorrect. Middle-income Americans, who earn $50,000-$100,000 a year, are more likely than those with lower incomes to seek care but they don't qualify for Medicaid or charity care to help pay for it and often fall into the gap between affordable ACA plans and Medicaid.

Extra Point: My bright, kind and hard working 16-year-old is oddly happy about his health class syllabus but on upon further inspection I think he ought to drop it. “Dad, it’s going to be an easy A. We have to write 5 paragraphs just describing what different doctors do—isn’t that your job?” Tommy said.  Kind of, I said, which doctors – do you want to interview me? “I was just going to use ChatGPT,” he said, smirking, “but you’re probably right.” So Tommy pulled out the syllabus and started to read off the 5 doctors he figured he’d write about. “There’s All Hair Gists, whatever they do?” I said I think they do a lot of their work in August when people are sneezing outside. “Really?,” he said. “How about Ofailmolgists – wonder if they fail at things?”  “I hope not,” I said, helping him understand that ophthalmologists fix people’s eyes.  “What about Pu Hy Cal The Repeatists,” he said, “is that a good one to write about? “Yes, because maybe they do stuff twice when they shouldn’t when rehabbing your knee,” I said, “plus this is Papa’s profession.” Tommy said he also liked “New Rol Guy,” looking at me somewhat desperate to know if he pronounced it right. “Um, well, whatever this doctor is, they have a new role apparently so we’ll have to look that one up - my hunch is they study the brain.” I asked Tommy when his assignment was due. “After Labor Day, so I’m in great shape,” he said. "Well, maybe, I said. “I’m fairly sure you might want to actually drop this class and re-take English – just a hunch.”

3.5: Percent of middle-class Americans with medical debt, more than any other class, according to a KFF estimate. Experts think this is because middle-income Americans, who earn $50,000-$100,000 a year, are more likely than those with lower incomes to seek care but they don't qualify for Medicaid or charity care to help pay for it and often fall into the gap between affordable ACA plans and Medicaid. Those with higher incomes, and typically better insurance coverage, have the least amount of medical debt unsurprisingly.

Wait For It: Unranked in 2023, the #1 payer priority heading into 2024 will be managing GLP1 weight loss medications. “It’s dominating our time,” one source said. A southern Blue plan pharmacy director told us this week that the plan is undergoing a study into the outcomes and costs for members with diabetes taking GLP1 medications and an antidepressant, as well as members taking medication for anxiety or another mental health condition and a GLP1.

Say Cheese: Cigna uses SmartScan technology to provide at-home oral health scans to ~16.5 million dental members via mobile phone. Members will take 5 guided photos of their teeth and mouth at no cost, which will be analyzed by SmartScan and reviewed by a dentist. The photos should help screen members for oral health issues such as cavities and gum disease.

4-Headed PBM: Blue Shield CA is making changes to its pharmacy benefit management operations next year, scaling back its reliance on CVS Caremark and spreading operations across four other companies, including the Mark Cuban company. They will handle pricing models while Amazon Pharmacy will handle delivery for nonspecialty drugs, PBM Prime will develop a value-based care approach to negotiating discounts with pharmaceutical manufacturers and claims will be processed by Abarca. Blue Shield projects they will cut drug spending by 15% though they will still use Caremark for all specialty drugs, which are often much more expensive than others.

And On The 7th Day: Blue Cross NC is updating its behavioral health length of stay guidelines in order to more effectively manage transition of care and reduce total length of stay, according to the health plan. Concurrent review approvals for inpatient and residential treatment centers receive no more than a 7-day length of stay that took effect earlier this month.

Late Diagnosis: Families often wait six to 12 months to get their child an evaluation for autism and other neurodivergent conditions, and in some parts of the country, it can be up to two years, according to Meliora Health’s chief medical officer Cheryl Tierney. Bend Health, a virtual pediatric mental health company, is now offering virtual psychological and neuropsychological assessments with the ability to get children into testing within two to three weeks, and digital health companies Meliora Health and As You Are offer similar digital diagnostic tools to improve access to evaluations.

Don’t Call It A Comeback, Yet: St. Charles Health System in Oregon is considering ending all contracts with Medicare Advantage plans and urging seniors to opt for traditional Medicare instead. The hospital says that dealing with MA plans has led to interruptions in care, higher denials and differing outcomes based on the type of insurance patients have. They haven’t left any networks yet but said they will be considering their participation with Humana, PacificSource and others over the next few months.

Aisle 7: Grocery chain Kroger is launching its third Medicare Advantage plan partnership with Intermountain’s health plan SelectHealth. The plans target Medicare-eligible Kroger shoppers and will be offered in Colorado, Idaho, Nevada and Utah next year. Kroger already operates plans with Elevance and Michigan insurer Priority Health.

Extra Point: Our 22-year-old got her first job out of college this month at, of all places, an architecture firm and her first assignment involves the design of an urgent care psychiatric facility in New England. There are now more than 4,000 such same-day mental health emergency centers in the US by our count though just a fraction are dedicated solely as a triage system for mental health emergencies. They were configured initially to give police an alternative place to take people other than hospital ERs. “It was really first a lot about helping in domestic violence situations and has now emerged to become quite critical for families who are in the midst of a potential suicide situation,” says Allie King, a communications director for a Missouri county police force. The urgent care centers sometimes open up to help the uninsured as The Collaborative did in Nashville in 2018 but “we ended up having waiting lines” due to the influx of people with employer insurance, Adam Graham, the program’s emergency director told us at the time. It’s interesting how so much of the public is on board – in Florida, The West Central Mental Wellness Coalition was formed in 2019 with support from the Rays baseball foundation, Florida Blue, and many hospital systems, including leader Baycare. Now called “Tampa Bay Thrives,” funding for these centers is not just from patients and insurance but also grant-funded as a community service. The question for healthcare investors is just how many of these centers are truly needed, how to staff them, and perhaps underappreciated how to quickly connect patients to the next level of care. Amy Flutes said the 10-12 cases she sees a day at her center in Missouri are “high crisis” and “we stabilize” but “sometimes struggle with finding a suitable facility or available psychiatrist for their situation.” Roughly half of psychiatrists in the US are only taking cash pay and many more have full panels. Flutes said they often have to look out of state or “have to settle” for helping the family get their loved one to a center that “isn’t perfect.” For investors, can you design a system that limits wait time, is efficient in a suicide process and importantly can help find that next level of care? Said our daughter, “I didn’t realize all of this Dad….we just need to figure out how to design the space and the waiting area to be suited to people in a mental health crisis.” I know kiddo. And it’s great you're doing this important job. “You know that it’s George Costanza’s dream job,” I told her. “Dad! Seriously, why does everything have to be a Seinfeld reference?”

66: Percent of adults in the US who have a personal or familial experience with alcohol or drug addiction, according to a new KFF poll, highlighting how substance use disorders affect not only individuals but also their friends and family. 27% of adults who have a relative with an addiction report that their mental health was significantly affected by it, but only 46% got treatment.

Bye Bye Pre Approval? United Healthcare will begin a two-phased approach to eliminating some prior authorization requirements in September. This will occur across commercial, MA and Medicaid plans and most procedures that will no longer require authorization are in the genetic testing, imaging, and physical therapy families, along with a few DME, hysterectomy, cardiology and spine surgery codes. In 2024, the health plan will implement a national Gold Card program where eligible providers only need to follow a “simple administrative notification process” rather than the PA process for most procedures.

Nurse Recruits: UnitedHealth’s Optum is working with the online school Capella University to launch a new educational program for nurse practitioners. Students in the program can practice real-world skills through Optum’s network of clinics. The first offering will be a Master of Science in Nursing, with classes starting in October, and they plan to launch a Family Nurse Practitioner program at a later date.

Behavior Change: Horizon BCBS will end its relationship with behavioral health provider Quartet Health in September in what is the latest sign of big insurers moving behavioral health spending from 3rd parties to network providers. The health plan partnered with Quartet to help integrate medical and behavioral health care and identify people who needed mental health support but were not getting treatment. As some context, not that long ago, in 2019, Horizon started a value-based program to recruit outpatient providers to its substance use treatment network offering case rates, no pre-authorization requirements and incentive payments (e.g. 10% of commercial claims and 15% of Medicaid claims paid out per year if meeting outcomes measures like readmit penalty reduction).

Pay For Follow-Up: Priority Health in Michigan recently updated how they pay for case management/collaborative care services. PCPs or their employees can now be reimbursed for any care management telephone services within seven days of an in-person visit or leading up to a procedure within the next 24 hours. Back in 2005, this sort of coverage was unheard of even for cancer patients until another Michigan insurer finally agreed to pay for follow-up telephone calls after an internal study found they reduced avoidable hospitalizations. Under Priority’s policy, providers can rebill for any previously denied claims going back to January, and effective July 1, waived member copays and deductibles for fully insured commercial members receiving behavioral health collaborative care services.

20 Visits For Diabetes: Insurer CareFirst is partnering with Ryse Health, a company focused on the treatment of Type 2 diabetes, to improve long-term outcomes through a value-based arrangement. Members with diabetes can see Ryse providers 20 times in their first three months through either virtual or in-person visits. The program will also ensure follow-up appointments with endocrinologists happen more quickly, within two weeks. CareFirst said clinicians will have the final say in treatment decisions, but one imagines a value-based program like this may be less reliant on pricey GLP-1 medications, at least as a first option.

Student Referral Gap: Charlie Health and Mantra Health, both behavioral health companies focused on adolescents and young adults, are partnering to broaden access for undergraduate and graduate students seeking behavioral health care. Mantra Health already focuses on students but only offers virtual care and other services like peer support and education. The partnership will allow Mantra to refer students needing more intensive services to Charlie’s IOP program. One gap that we know remains for college-age students is a system for campuses to flag when students are isolated – a kind of software system that would prompt student services to reach out rather than “passively” offer a clinic or hotline. “I like the database idea because you create a more holistic set of information,” says Haley Gregory, an MSW from New Jersey. “Leaving it up to one professor at these big schools, even small ones, is asking a lot – the students will invariably find their person – maybe it’s a coach, a roommate, a waiter at the diner – but oftentimes they will insulate after trauma or due to depression or the transition to school, so having some data that student services can monitor makes sense.”

Strange But True Partners: Home health provider MedArrive has partnered with virtual cardiology company Heartbeat Health to bring cardiovascular services to the home. MedArrive nurses and technicians assess patients and connect them virtually with a Heartbeat Health cardiologist for more comprehensive treatment, medication prescriptions, and referrals to in-person treatment.

Extra Point (From The Archives): I slid the old Peter Gabriel cassette into the boom box last night, rewound for 10 seconds, flipped the tape, hit PLAY, then STOP, then flipped and rewound 3 more times and alas there it was, In Your Eyes. I held it high like Lloyd Dobbler, stood atop the coffee table, and told my kids, “This was a quintessential 80s moment,” epitomizing an era of persistence, optimism, big hair, great songs, and surprising yet perfect marriages like Lloyd’s with Diane Court. When we rewind healthcare in 10 years, I suspect we may see the same thing – partnerships that come out of left field but oddly work: like insurers with universities to train nurses, dentists and allergists teaming to treat gum disease in those with asthma, autism therapists and gastroenterologists linking up to address GERD in kids on the spectrum and dermatologists and teen therapists working in concert to halt acne-induced suicide attempts. As Diane told Lloyd, “No one really thinks it will work, do they?” No, said Lloyd. “You’ve just described every great success story.”

20: The percentage of adults diagnosed with opioid use disorder in 2021 who received medication to treat it according to federal data. Encouragingly, people who utilized telehealth for substance treatment were ~38 times more likely to receive medication compared to those who were not treated virtually. We’ve seen a rise in telehealth companies focused on these disorders over the past several years, which hopefully means the percentage of those treated will continue to rise – especially considering the data also showed disparities by ethnicity, gender and location. For instance, those in urban areas were three times more likely to receive treatment than those in non-urban areas. The DEA recently announced they’d be holding public sessions to get input on prescribing controlled substances on telemedicine platforms and may consider a special registration allowing more telehealth providers to prescribe controlled substances without in-person visits.

New Behavioral Policy: Premera BCBS in Washington state has updated its residential treatment center behavioral health policy, effective August 1, to require a nursing assessment upon admission and subsequent nursing staff observation 24 hours a day. Treatment centers relying on outside nursing staff would benefit from a plan to recruit and retain addiction-trained nurses.

Screen This:  In our poll of 1,136 people – a mix of teens, young adults and older adults, 68% said they had lied often on depression screens.

Cat A Racket: Humana has ended its cataract surgery prior authorization policy for Medicare Advantage members in Georgia a year after officially announcing it. The policy faced backlash from provider groups that argued the policy “caused unnecessary treatment delays and denials for people in Georgia.” Aetna announced a similar policy two years ago but later rescinded it in all but two states, one of which is Georgia, which these physician groups say they will aim for next.

VBC Wire: Two new value-based partnerships were announced recently – the first between the ACO ApolloMed and the value-based primary care network IntraCare from Texas and Oklahoma as part of the ACO REACH program. The second is between the nephrology group National Kidney Partners and Duo Health, a tech-enabled physician group that focuses on supporting patients with chronic kidney disease and end-stage kidney disease. The partnership will focus on a new care model for Medicare patients in Florida.

Rx Switch: Blue Cross NC is launching a new specialty pharmacy program for fully-insured commercial members through Free Market Health (FMH). The program utilizes an automated system that looks at each specialty medication authorization request and then matches the request to the “best fit” contracted specialty pharmacy in the network. Patients or providers can request their preferred pharmacy, but if they don’t, FMH uses a competitive bidding process to determine where to send the prescription. The health plan says this will allow more specialty pharmacies to fill prescriptions they previously couldn’t.

Milk, It Does A Body Good Until It Doesn’t: Did you know that in the late 19th century, milk was believed to be the perfect substitute for blood, and the fatty/oily qualities would become white blood cells? Despite a few successful procedures, most using milk led to death. In one instance, the injection immediately dropped the patient’s pulse, so they had to be resuscitated with a combination of morphine and whiskey. The patient apparently lived for ten days. The story is a lesson about nothing ventured, nothing gained and the more things change, the more they remain the same – in 2023, a study of nearly 150,000 adults from 20 countries found that a glass of whole milk can prevent heart disease – and not if combined with exercise, but combined with cheese of all things. The results, organized into the Prospective Urban and Rural Epidemiological Diet Score, could be helpful to mention during office visits.

Menopause Or Play: Progyny, mostly known as a fertility benefits management company, is now playing at the other end of the women’s health continuum by including specialized providers of menopause care in its network. Menopause services will include nutrition, sleep, mental health, and hormonal health support. Employers who already use Progyny can include these additional services “for a nominal fee.”  To read more about the growth of menopause treatment, click here to read our recent Women’s Health whitepaper.

Telehealth Clinic: Amazon Clinic, the direct-to-consumer telehealth platform, is now available to people in all 50 states. The service relies on outside networks Curai, SteadyMD, Wheel Health, and Hello Alpha. Patients cannot use health insurance but can utilize HSA or FSA funds.

Run Forrest:  I ran 5 miles with Julio Perez, Mike Udell, and Rory Tulienth this week – the trio has been addicted to heroin, fentanyl, steroids and alcohol – now they run in a club called The Boston Bulldogs. Clubs like this that empower people through movement are gaining traction in society. For the most part, they don’t require a pill or injection, no Zoom connection or copay – just a $52 pair of sneakers and an open mind. In Rory’s case, she had tried three to four residential programs at various points in a 10-year battle that started in her mid-20s – “good people, but it just didn’t stick – maybe I wasn’t ready – maybe the addiction was still in charge,” the 36-year-old said as we stumbled through a shady stretch in Quincy. “I found a home running – I’m not sure why, but it feels right​.” I asked her how much it cost to pay for all the care she had during her ten years. “How much?” she laughed. “I was in the hospital maybe 20 times, in prison, lost my job, my husband, my relationship with my daughter – is there supposed to be a number?”

Extra Point: If my grandfather Henry were around today, I’m pretty sure he would shake his head in disbelief – there’s talk that Cal Berkeley and Stanford may join Notre Dame in the ACC football league – that’s the Atlantic Coast Conference, which last I checked isn’t near the Pacific. I remember watching the famous Cal-Stanford college game with Grandpa in 1982 when Cal lateralled five times through the Stanford defense and its marching band on the way to the shocking last-second victory. Cal’s runner knocked over Stanford trombone player Gary Tyrrell in the endzone, which incidentally is partly why our oldest Jack didn’t join his college marching band. Having the two California schools join the ACC would be like when a western medical group or a hospital joins a health system out east or when hospitals start moving their locations into people's homes – wait, this is actually happening. In fact, it wouldn’t surprise me if by 2030 nearly every hospital system in the US had a hospital-at-home service offering. Hospitals and home health are at two ends of the spectrum – opposite points in the continuum – and just like the potential college football realignment, the question will be, will it work? “I’m pretty convinced it will if you can staff the heart and lung patients adequately and set up very good screening systems – what I worry about,” Patty Joerns, MD, says, “is if this adds cost and avoidable mortality, the need for an ambulance back to the hospital during a cardiac event or sepsis.”

83: Percent of acute care hospitals that collect data on patients’ social determinants of health, according to a 2022 American Hospital Association survey, though only 54% are doing this routinely. Small, rural, critical access and independent hospitals are the least likely to do so – likely due to lack of resources – but these hospitals are probably seeing the highest numbers of patients who are experiencing SDoH challenges.

Refugee Breathe Easy: 20% of the ~600,900 refugees admitted to the US from 2010 to 2020 were from Myanmar/Burma and nearly 70% of these households reportedly have multiple members with undiagnosed, undertreated or mismanaged asthma, typically developed after arrival – their story is a lesson on challenges managing subsets of the Medicaid population. Click here to read the full story in the first of a new 6-part series called Fairness Factor, created by BRG, and supported by Equality Health.

Oral Health Fixture: A panel of dental experts, including BCBS of Massachusetts’ Dr. Robert Lewando and former Metlife dental director Dr. Alan Vogel, outlined a list of quality measures key for dental companies to track to get value based/outcomes-based payment. Click here to access the recording. Passcode: 7x#0CBtK

Embryo Policy: Highmark is updating its assisted reproductive technology policy to require that all viable embryos from a previous cycle, along with any previously frozen oocytes, must be utilized prior to beginning a fresh cycle. This update will only apply to members in Delaware, Pennsylvania and West Virginia, not to members in New York.

Relief Pitcher: Effective September 1, BCBS Kansas will provide a 0.7% cost relief adjustment to all providers except for labs, ambulances and pharmacies, a decrease from last year’s 1% adjustment. The adjustment is not keeping up with the cost to recruit and retain labor, 91% in a recent poll said.

Modify Weight: Starting in September, BCBS Michigan plans to shorten the initial pre-authorization approval to four months from 12 months for weight loss medications and requires healthcare providers to attest that patients are actively engaged in “appropriate lifestyle modifications” while taking these drugs. In related news, the virtual care platform Hello Alpa launched a weight management program for employers that will focus on “whole-person primary care.” The program, Ahead with Alpha, combines weight loss support with care for more than 100 other medical conditions. Patients who successfully lose weight will be migrated into a lower-cost maintenance program, likely an enticing option for employers.

Rebrand: Elevance is going old school and rebranding its Amerigroup business as Wellpoint, which was its original name from its founding. The health plan says the new (old) name signifies its “commitment to whole person health.” Amerigroup plans in Maryland were already rebranded as Wellpoint earlier this year and plans in six states will follow in January 2024. A few other states are on a separate timeline for rebranding. Amerigroup is owned by Anthem, which is now Elevance, which is not to be confused with the 90s band Evanescence.

DME Narrows: Humana is partnering with two national DME providers – AdaptHealth and Rotech – for its Medicare Advantage HMO members. Effective October 1, HMO members will need to get all durable medical equipment from these providers.

Algorithm: Cigna and United are both being accused of improperly rejecting thousands of medical claims. In Cigna’s case, the health insurer used an algorithm called PXDX, shorthand for ''procedure-to-diagnosis,” to identify whether claims met certain requirements, spending an average of just 1.2 seconds on each, according to the lawsuit. Providers and members have long been frustrated with why certain procedures are approved or covered and looks like health plans will now have some explaining to do.

Behavioral Back Inhouse: Following a delay due to a cyber security incident, Point32 will move forward with insourcing behavioral health management for Harvard Pilgrim commercial members, effective November 1. Some Medicare Advantage members will still be managed by Optum, but the health insurer’s move follows a broader trend of more payers bringing behavioral in-house, in an effort to better integrate care.

Extra Point:  So, for most of Saturday’s Pan Mass Challenge bike ride last year, it felt as though all 5,454 riders passed me at some point during the nearly 7 hours on the road. It’s always a great feeling when a wave of cyclists blows by you like an 18-wheeler on I-95. But you battle through, gobbling three peanut butter Clif bars for extra energy, taking short breaks on rest stops, and somehow, with all of your body telling you to stop, you finish. My bike crossed the line in Bourne, Massachusetts among one of the first 2,500. “So basically what you’re saying Dad, is you lost” Jack said later. I suppose he’s right, but thankfully we like to think of this ride not as a race, but as a charity. I rode with different people that day during the event that raises money for cancer research – most imaginary, but some real.  Mary Ellen from York Maine, a 72-year-old, was riding in her 19th Pan Mass Challenge. Cancer had never affected her family until 1998 when she felt her first lump. “It was like I was putting a downpayment on my medical care,” she quipped as we approached a flat stretch of the ride. “I go at my own pace, not as fast as I did back in my 60s.” Mary was easy to spot in the sea of bicycles and blue jerseys. She had an orange bike, purple and yellow streamers dangling from her helmet and hair the color of a perfect cloud on a sunny day. Mary’s breast cancer treatment worked, thanks to Dana Farber. Six years after Mary’s first infusion, her sister was diagnosed with a more aggressive tumor, found in stage III, and despite a great fight ultimately lost her life in 2006. Mary says she feels her sister grab hold of the pedals on heartbreak hill every year. “Maybe it’s my imagination, but I feel something.” Money raised for Cancer research is important given that many who get cancer may not be able to access one of the best centers, but the research is used to improve treatment and protocols that make their way to local oncologists. I’ll be out riding again this weekend – if you’re there, give a holler, I’ll be the one with the wobbly bike going about 7 miles an hour.

7: The percentage of medical residents who feel adequately prepared to manage women experiencing menopause. More women are seeking hormone therapy and menopausal treatment services, with 83 percent in a recent BRG survey reporting an increase in these claims, but more women are growing dissatisfied with the care they’re offered. Alternative care models, including virtual menopausal treatment companies like Midi Health and Gennev, have risen in popularity. Read more about this and more in our recent Women’s Health whitepaper – click here.

UTI Response: Blue Cross NC recently began sending members free urinary tract infection kits after being seen in the ER for a UTI. The kits contain a water bottle, UTI test strips and educational materials. Anthem also launched a similar initiative for members in most states.

Follow Up Visits: A review of more than 40 million specialty and 32 million primary care visits – both in person and virtual – from January 2022 to March 2023 found that in-person visits were overall more likely to result in follow-up visits in the 90 days after. There were some differences between specialties with mental health, physical medicine and pain medicine having at least a 20% higher follow-up rate after an in-person visit. Conversely, specialties like podiatry and OBGYN had higher follow up rates after telehealth visits.

Herself Health: This primary care clinic focused on women 65 and up has received funding to expand beyond its St. Paul, Minnesota location and open two new clinics in Minneapolis this year.

Upside Down Rx: It feels like Seinfeld’s Bizarro World episode these days in the pharma sector. The Mark Cuban Cost Plus Drug Company is trying for example to disrupt the pharmaceutical chain – now selling medications directly to hospitals and clinics. The company will focus on manufacturing drugs that are currently in shortage and they hope to start shipping in September or October. This follows recent news of their offer of biosimilar Yusimry at a 90% discount off the cost of brand drug Humira in a partnership with PBM SmithRx.

Inpatient Psych: Acadia Healthcare recently opened a new 96-bed behavioral health center in Pennsylvania through a joint venture with Geisinger. The JV expects to open another center elsewhere in the state sometime in 2025. Acadia also just formed a JV with Nebraska Methodist Health to open similar centers in that state.

Imagine That: Like getting an A for three quarters in science and getting to skip the final exam, earlier this month, BCBS Louisiana rolled out a new Gold Card program through benefit manager Carelon that will allow imaging providers to have all their high-tech scan requests automatically approved at least for a period of time if they’ve maintained a 95%+ approval rating on at least 50 requests in a year.

New Payer Rule: The Biden Administration proposed new regulations to improve access to and cost of mental health care and, if finalized, the rules would require payers to study outcomes and ensure people have equal access to mental health benefits.

Let’s Talk Dental Consolidation: A conference call August 3^rd with dental insurers will discuss recent consolidation and trends in value-based reimbursement. The number of dentists affiliated with DSOs has grown modestly over the past 5 years, and commercial payers have taken different approaches to this trend. You can register for the call here.

Extra Point: Maybe it’s me but I’m pretty sure some of these labs are giving up on us, and I don’t mean doodles. I was in one last month for a lab test and it was just an empty room with a few chairs and a little kiosk. I felt like I was John Locke in an episode of LOST.  Just the look of bewilderment on 76-year-old Mary’s face reminded me of how my kids look when I hand them a broom. It’s like these labs are saying ‘you do it – check yourself in.’ Poor Fred, a spry 72-year-old, mumbled a few f-bombs and just up and left. In their defense, Covid may have caused this, and the staffing shortage is exacerbating it but it’s brutally frustrating.  “I have an appointment,” said Mary, “at least I thought I did.” We weren’t properly trained on these kiosks – this requires like weeks of instruction. I’m still having nightmares from that red light scanner that tried to take a picture of my ID. I punched Mary’s birthdate in, 6-14-47, but it just popped back to the home screen. “Does that mean we are checked in?” Mary said. I sighed. “I don’t know Mary. I don’t know.” There’s a lab now open til midnight near us, which is a story for another day, but earlier this month I went in at 11 pm and decided to do a self-training – with no one there, I used my wife’s ID, my son’s, my dad’s. I made fake appointments the night before and became an expert. I’ve thought about setting up shop from these lab kiosk areas – free wifi, help a few confused souls. Of course the grocery stores aren’t much better. My mom called me on her cell phone at 10am yesterday – “Bry, I know you’re working and can’t talk but I’m trying to pay for bananas for your dad’s leg cramps and it’s not working.”  Um, there’s a lot there to digest, but I could tell from the background noise she was at the market and got sent into the kiosk lane.  “Ma, Ma – put the bananas down – abort mission – just drive over by Rosedale Farm and get them there – they will help you.” “Bry, Bry – buy roses? What, I can’t hear you…”