Behavioral Health Insights

1) 2040: The year when Alzheimer’s disease will consume about 25% of the Medicare budget, according to a new study, aided in part by addiction to smart phones that can cause plaque buildup in the brain, the same plaque linked to Alzheimer’s. Brain scan of people in their 20s showed high levels of buildup due to excessive iphone use. The findings and outlook have implications for policymakers as well as families and employers given the massive direct and indirect cost of the disease. Read neurologist reaction by clicking here

2) Genetic Test Plus: Testing for Cadasil, a hereditary stroke disorder, no longer will require providers to try other tests first under a new Regence BCBS policy. This payer is so active in monitoring guidelines and updating its genetic testing criteria that other health insurers we’ve talked said they ‘look at their policies’ and ‘have adapted them in some cases’

3) MA Home Care Disrupter: A number of Medicare Advantage plans recently announced a decision to delegate oversight of home health services to myNEXUS, a benefit manager. Blue Georgia’s MA population is one example. It’s interesting that the benefit manager describes itself as ‘a disrupter’ of post acute services, just in case there were questions. PCPs (and hospitals) in states where this company is now overseeing home care coordination need to go through them, and not the plan – anticipate ‘steering’ as well as more hoops to get approvals.

4) Extra Payment For Surgeons, Maybe: Sort of like parents holding out the allowance until they inspect under the bed, Florida Blue is now going to start to give the proverbial extra credit with an enhanced payment to surgical providers if they can prove their procedures take a lot more work to complete successfully, like an unusually lengthy procedure, excessive blood loss complications during a procedure, trauma extensive enough to complicate the work and that which can’t be billed separately, and other so-called ‘pathologies’ that interfere with the surgeons ability to do the procedure, like a tumor or genetic malformation. A modifier (#22) would need to be billed with the correct code and the plan says they’d request documentation, images, and other evidence before agreeing to pay.

5) Home Infusion Policy: An updated policy for home infusion will reduce the per diem reimbursement when multiple codes in the same therapeutic category are used, so reimbursement will fall if multiple codes are used for antibiotics/antifungals/antivirals, chemotherapy, and pain management. The highest valued procedure will be fully reimbursed, but the second procedure will only get 50%. Each procedure after that only gets 25%. The reason for this is that the per diem includes things like “all necessary supplies for delivery of drugs,” which, if you have for the first infusion, you won’t need for the second infusion. This is an attempt to reduce double/overpayment for things that are being duplicated. TPN, Enteral nutrition and hydration are not impacted by this policy since only 1 per diem code is allowed per day. Details here

6) Pharmacy Ramblings: We sat down with a few clinical pharmacy directors recently and 3 of the 4 said the shift to outcomes-based contracting for drugs is a great idea, but is facing roadblocks as payers and pharma companies can’t get to agree on the measures of success and, when they do, there’s considerable argument over the savings split. For now, their attention remains squarely on specialty drugs. The annual trend net of rebates in pharmacy costs is about 15-20% on specialty (e.g. the PMPM on total drug costs), whereas for traditional (non-specialty drugs) the trend is in some cases negative. The annual specialty trend a few years ago, like 2012, was probably around 9-11% net of rebate. A lot of the drug cost is ‘rebatable’ and the size of rebates has escalated. Rebates used to be 8-15% but that’s changed dramatically with Eli Lilly, for example, just paying out 40%+ for Invokana to treat diabetes. There are therapeutic classes for which you get high rebates and some you don’t (HIV might be one area for example, although with generic Atripla that may change). Medicaid, in some cases, has highest drug cost trend due to lower generic options and the population, which includes a higher prevalence of asthma, ADHD, mental health and substance abuse), conditions where drugs are less often generic. Comparably, the Medicare bucket has a 89-92% generic fill rate. Health plans benefit from ongoing rebates for chronic care treatments, like for Remicade; 92% in a poll we did require Remicade first, but as time goes on pharmacy directors anticipate that Biosimilars will become ‘more price sensitive’ and impact the overall trend. Inflectra, the biosimilar for Remicade was 10% less in the fourth quarter of 2017, helping payers, but of course hurting providers who relied on the markup although a biosimilar approved under the BPCIA pathway is reimbursed at ASP plus 6%,

7) No Pain, No Gain: A new health plan policy in the peach state may impact current and former Georgia Bulldog football players, not to mention anyone needing pain management. A trainer for the school said ‘injections’ have been a way to get ‘certain players’ ready to play, without resorting to medication. But in July, the state’s top payer, BCBS, will begin to more aggressively monitor pain management, restricting aspects of interventional procedures, but loosening others, all through a new arrangement with AIM, the benefit manager. There will be more limits to the number of diagnostic medial branch blocks allowed both before and in between injections. In contrast, if you’re giving a patient an epidural injection for post-op pain there is no longer a pre-approval requirement, under certain diagnoses.

8) Woman’s Health Pre Pay Reviews: There’s been more interest in obstetric, pediatric and hospital woman’s health services lately, which 43% of 311 hospital c-suite leaders in our poll last week said was emerging a top service line priority. The interest is largely coming from board strategy planning sessions on how to remake the hospital of the future. ‘There’s pressure on all aspects of our business – but woman’s health services is perhaps one we can leverage, and allow us to own the care from pre-birth, to birth then into all aspects of the child’s care’. Payers, for their part, seem to noticing and creating a host of new policies around newborn care, many very routine, but nonetheless a sign they want to make sure payment is appropriate. Blue Georgia in September will start a new facility payment policy around more complex newborn admissions, such as those where the child is in the NICU. Pre-pay evaluations will take place. If documentation is missing and if the hospital never got pre-approval, the payment will resort to a normal delivery level amount.

9) Diabetes Monitoring: Harvard Pilgrim is updating their commercial continuous glucose monitoring system medical review criteria including a name change to diabetes management devices, extensive criteria revisions as well as changes to prior authorization and coverage requirements. Among other criteria required for replacement, the clinician overseeing the member’s diabetic condition must submit documentation in the form of clinical notes or letters supporting the necessity of the device’s replacement and continued use. More specifically, the policy and coverage criteria addresses rules for monitoring, interpreting, physician supervision and multi-day use.

10) Extra Point: So I’m playing mister mom this week following my wife’s bad luck surgery to repair an ankle she shattered walking the dog with flip flops, a dog I wanted. I’m playing part home care aid, therapist, short-order cook, DME advisor, pharmacist and meals on wheels coordinator. Still waiting for my bundled payment for this. The good news is there’s a lot of evidence of good quality care. On Wednesday afternoon when the nerve block was finally wearing off, I managed in a 10-minute span to get Janine her Advil, do a conference call for work, start a laundry load, and make the kidoes supper. Only problem was the supper – ‘dad, why is my milk blue?’ I suppose pouring the Tide into the cereal bowl was my bad, but good news is the laundry has a nice milky scent.

1) 425: Dollars that several surgeons told us they are charging Anthem patients upfront before cataract surgery to cover anesthesia services since the insurer no longer considers anesthesiologists or nurse anesthetists medically necessary for administering and monitoring sedation during the eye procedures. Kids under 18 aren’t impacted but adults are and one practice here in my state told us the policy has changed patient behavior – in some cases the patient flat out refuses and leaves rather than doing the procedure, others ‘have got wind of the charge’ and ‘cancelled’ the procedure, ‘telling us they will find another option.’ One Midwest practice took a different approach, not charging anything—‘we have picked up about 10-15 new patients simply because they didn’t want to pay their ophthalmologist’s fee for this.’ In an odd way, the payer’s policy--or rather the provider and patient reaction to it--are an interesting example of the science behind our behaviors, how in some cases our initial reaction is to react without understanding bigger picture, while in other cases we slow down and see the opportunity amid the chaos. Contact us for full details.

2) The New Bundle: There are some interesting similarities and differences among commercial payers in their approach to bundling payment for maternity, including a new concept that will ultimately reward practices for mental health management before and after birth. Horizon BCBS in New Jersey now has an episodic program with 300 practice sites. The MCO contracts primarily with physicians and uses a retrospective, upside risk-only payment. Participating practices get a per-patient budget determined by 2 years of their historical data. Humana’s model is different—it’s retrospective and will be triggered upon admission to the hospital for labor/delivery. Bundled services include all prenatal visits during a 200-day period prior to the birth, the delivery and then 45 days after discharge.  Quality measures your businesses would think about include uncomplicated C-section rates, preterm birth rates and C-section rates. Other payers are moving into more 2-way risk, and some, like Parkland Health Plan in Dallas, are thinking of quality measures in more unique ways by trying to incent more preventive screenings for depression to reduce the risk pre-term birth and address post partum.

3) In 5 Years: If you own a healthcare provider practice, or serve one with various software or technology solutions, keep in mind that within 5 years – by let’s say 2023 – a larger portion of the commercial payers in the US will own, operate and leverage their own medical groups. That’s at least according to 74 commercial payer strategy officers out of 112 we polled last week who said they are interested in local market models where they could ‘own the medical group’ and ‘steer patients to the group’ using copay incentives or other tactics to incent patients to use these groups, and then ‘gain control over the entire flow of patient care when they need higher level services, like pain management or surgery’. Finding whether you are a winner or loser in this depends a lot on existing market share, affiliations, access and the overall productivity of your groups, says Martin Saunders, MD, who is leading a strategy by a regional payer to ‘pick 2-3’ target groups per market to explore for acquisition and alignment. ‘I think our focus,’ Saunders said, ‘will be similar to the way a self-insured plan would do it – pick a place for certain orthopedic procedures and have the local physician groups and the PTs all aligned so that the cost is clear and predictable, ‘and so too is the outcome’. I asked Saunders about ankle surgery, given my wife needs this next week, and he said the goal there would be to ‘identify the sub-specialists’ and make sure the ‘hospital ERs who triage the cases and reset the ankles’ are incented to refer to the best doctors, rather than just those in their system. ‘This is probably not possible to control but we are thinking through ways to do it’

4) ADHD Combo: Mark Stein, who heads the ADHD and Related Disorder Clinic at Seattle Children’s Hospital, said that the combination therapy could be a “promising approach to make the effects of methylphenidate more specific and personalized to adults with ADHD,” which he described as a population in which there are concerns of stimulant-related euphoria developing into abuse. The combination, however, would not be useful for children, since this age group more commonly reports dysphoria when taking ADHD-related amphetamines. The next step, according to Stein, would be identifying how effective the combination therapy is in groups who are at risk of SUD. Story here

5) Scrubs: The number of new psychiatry residents grew more than 5% from 2010 to 2015, a somewhat encouraging trend given access issues to mental health professionals in places like Alabama, where there’s really only 1 mental health professional for every 1,260 people, according to the Suicide Prevention Center. Center. In our poll of health plan ‘strategy’ officers this month, 38% named mental health as their #1 emerging priority but only 4% said they had a good solution and would look to providers to create programs and models. ‘I think we can encourage screening and tinker with payment and networks, but at the end of the day the provider community has to figure this out’ said Nicole Wiley, a strategic advisor for Blue plan in the Midwest.

6) Extra Point: In one of my first jobs as a reporter in the late 90s I wrote an investigative piece about a retail store in Swampscott Massachusetts selling fake Kate Spade hand-bags. A quote from the FCC about the illegal practice was the key to my piece and eventually got the store in trouble. I felt bad. Here I was a 23-year-old using words to hurt a long-time mom and pop shop. What did I know about the struggles of running a retail shop? Months later, after several not-so-nice letters to the paper about my story, I got a nice letter from the Kate Spade company to make up for it. Mental illness took Spade’s life this week. It took CNN personality Anthony Boardain’s last night. Boardain, who admitted to years struggling with substance abuse, is a success story. My wife and I enjoyed his ‘Parts Unknown’ voyages. He had this endearing penchant for curiosity. There are tens of thousands likely not as famous as these two icons who struggle right now with mental illness. If I were a healthcare business owner, one question I’d be asking is how curious your physicians and nurses and PAs are about this. How aggressive are they in finding the illness and triaging or treating it before it ends up on TV. Mental health identification and management is an often missing component of bundled/episodic payment models and yet it seems to be a central factor impacting outcomes.

1. 350 Million: The total dollars that five drugs cost Texas managed care plans in the fourth quarter of last year. Abilify (antipsychotic) Vyvanse (stimulant) Nexium (GI), Invega (antipsychotic) and Norditropin (growth hormone) were the five most expensive drugs here. In contrast, through the smaller fee for service program, Ibrance, an antineoplastic systemic enzyme inhibitor, was the most expensive drug at just $2 million, followed by Abilify and three stimulants. In terms of utilization, ibuprofen, amoxicillin (the penicillin) and the bronchial agent Albuterol used to treat Asthma were the most prescribed with 2 to 3 x more encounters than the high cost drugs.

2. On Second Opinion: My youngsters used to go to their grandparents if they didn’t like my answer to ‘can I have $3 for the ice-cream truck,’ a second opinion that would almost always get them a strawberry éclair…hopefully Anthem’s second opinion program has better success than my flawed parenting model. The insurer’s new program gives employees a virtual second opinion from an insurer-selected physician, a program that we think could be a real boost to certain practices who position themselves as quasi centers of excellence in getting the right diagnosis, particularly for hard to evaluate conditions. The insurer says they’ll actually reach out to a certain group of patients who may benefit for this sort of service, such as high utilizers of imaging or surgical procedures. The virtual second opinion service is coordinated by Anthem, who will select the physicians to do the consults. Services available include nervous system diagnoses like MS and Parkinson’s, advanced hip and knee degenerative disease, commonly misdiagnosed conditions like Lupus, Lyme and rheumatoid arthritis, and digestive conditions like Crohn’s. Physician groups ‘selected’ as the preferred second opinion vendors stand to gain new patients and better positioning within Anthem. Reach out for a full list.

3. Molecular Testing Check: Starting in July, pre approval will be required by United Healthcare for several genetic and molecular tests in the outpatient setting. Link to the codes/tests here

4. Michigan 100: Primary care doctors in Michigan will be paid $100 a pop by the Blue plan networkl for closing gaps in Medicare Advantage patient diagnoses, such as ‘confirming’ a diagnosis or based on a face-to-face visit determining that the patient no longer has the condition previously reported.

5. Home Pharmacy Limit: Optum, as of this summer, will limit opioid prescriptions via its home delivery pharmacy service to 30 day supplies. The policy only applies to commercial patients. Cigna, for its part, is equally aggressive. It does quarterly ‘reassessments’ of the benefits of opioid therapy and starting in July requires pre-approval for patients prescribed a total daily dose of 120+ MME.

6. Partners: Harvard Pilgrim Health Care is exploring a collaboration with Partners HealthCare that could take the form of a financial integration or other arrangement. Harvard Pilgrim already has partnerships with area hospital systems via its Benevera Health value-based care entity.

7. Vape Movement Sequel: We reported last week that 891 of 1,216 high school students said they know of someone who has vaped or have themselves tried to vape in the last year. The consumer poll was shared with a guidance counselor at one of the schools who was at first ‘floored by the numbers’ but after investigating has set up a Vape Debate, asking students to debate on stage the pros and cons ‘without punishment’. ‘We want to open this up rather than it be a secretive thing – we’re talking about kids’ health and behaviors, but it goes much deeper and I don’t think we should just dismiss those who’ve tried this and suspend them. Clearly, this is a problem that may benefit from managing out in the open,’ says Sharlene Forlough, who is a counselor at a large high school in New England. We will cover the debate and report back. Students polled said the vaping ‘is everywhere – in the locker-room, parking lot, bathrooms, and quietly in the woods after dusk.’ Of the 320 students who’ve tried it at least once (so about 25%), 196 said their mom or dad works in the healthcare field and, except for only a few dozen, they ‘have no idea’ what I’m doing. This poll is conducted anonymously with student athletes in New England.

8. Hackers Meet Doctors: In case you missed it, last week’s report from a meeting of physicians and software developers highlights the emerging trends in healthcare technology. Highlights here

9. Extra Point: A 78-year-old was back in the hospital this Wednesday to have an additional drain installed but her husband, a man who taught my youngest kids how to fish and took us all on bizarre yet memorable rides to a pretzel factory in Amish country, expects she’ll be home this weekend. The issue is, he is suffering through radiation sickness with acute fatigue and weight loss, so taking care of her is impossible. Their son, 43, has traveled cross-country to help this week; his wife and their kids will muddle through and he will miss work to help his parents. Step one is to set up hospice. The older couple is ‘trying to stay at home for as long as possible,’ and admits to me that ‘starting hospice sooner’ maybe would have been wise given ‘the 20 some trips to the ER and hospital in the past year’. Wendy Abraham, a utilization analyst in Maryland, was kind enough to point out to me this week that very few people have someone to help navigate all of this for them, and that there’s certainly a growing, unmet need for this sort of help. ‘Our healthcare system often forgets about the human nature of our elders and puts more stress on them rather than trying to decrease it.’ I personally haven’t counted the costs for all these ER trips yet but they are staggering, all paid for through TriCare. We may take the trip down later today, pulling our kids from all their weekend sports and music and social commitments, to lend a hand and perhaps say our goodbyes to this couple. This to me is the root of managed care: trying to do the right thing sooner than later, and trying to make the right decision even when it’s hard.

1. 24 to 7: No, this is not my prediction for the next Super Bowl score (Patriots over the Giants), but rather the number of people in millions who suffer from Cataracts in the U.S compared to the 7.7 million with diabetic retinopathy. In contrast, 2.7 million suffer from glaucoma, and 2.1 million from age-related macular degeneration. Eye disease prevalence is a national and global health concern that is higher in risk for chronic health conditions, accidents, social withdrawal, and depression.

2. Drug Testing Limits: Regence BCBS, starting in July will only allow payment for specific codes for presumptive and definitive drug testing when up to 15 units are billed per test type per year. Codes G0482 and G0483 will be denied as not medically necessary.

3. Vape Movement: 891 of 1,216 students we polled in our consumer study this month of 9th through 12th graders said they know of or have tried to vape. ‘It’s everywhere – in the locker-room, parking lot, bathrooms, and quietly in the woods after dusk,’ students reported. Of the 320 students who’ve tried it at least once (so about 25%), 196 said their mom or dad works in the healthcare field and, except for only a few dozen, they ‘have no idea’ what I’m doing. This poll is conducted anonymously with student athletes in New England. They participate as subscribers of a column on losing in sports.

4. Docs and Hackers: We attended a monthly meeting of physicians at a Harvard Medical School event this month where doctors brainstorm new ‘app’ ideas and technology solutions with software developers. Highlights here

5. Out of Network Update: Blue Shield of California is changing coverage for non-participating providers in 2018 that increase patient financial responsibility when receiving services from non-participating providers. Its PPO plans will have separate deductibles and out-of-pocket maximums for participating (in-network) providers and non-participating (out-of-network) providers. The deductible and cost-sharing for participating providers will not accrue to the deductible and out-of-pocket maximum for non-participating providers.

6. More Liberal Vein Treatment Policy: There’s an interesting pattern of payers saying they are relaxing or ‘liberalizing’ criteria for certain procedures after determining that ‘they almost always approve’ or ‘have less concerns given utilization patterns.’ One example is a few western US commercial plans who have ‘liberalized’ criteria for sclerotherapy to treat saphenous veins below the knee.

7. Genetic Testing Can You Hear Me: Regardless of a patient’s risk factors, Arizona Blue says that genetic testing screening or counseling for hereditary hearing loss is ineligible for coverage.

8. Cigna’s Collaborative Care: Cigna’s senior medical director for behavioral health acknowledges that insurers don’t have the tools that the public sector has, like waivers and grants, to implement collaborative care models. Currently, says William Lopez, MD, the only payer truly reimbursing for collaborative care codes at any meaningful level is Anthem and their Blue Cross plans. “But I’m not so sure that they are monitoring the proper elements of the Collaborative Care Model…what we’re trying to do is introduce more of this into the private sector.” Click here for the full story.

9. Extra Point: In an ironic twist, a military base and army college has just decided to require prior approval for urgent care in its community in Tennessee, a move some said is designed to ‘weed out the cases that could wait a few days’ or ‘make sure people see their primary doctor first,’ although others here expect the policy will increase hospital ER visits, particularly for those with chronic conditions. I see both sides though I also see this through the lens of our Uncle John, a retired Colonel in the Army, and his wife Nancy, both of whom are struggling these days to juggle the health system – trips to ERs, battles with difficult to treat cancers, surgeries upon surgeries related to complications from their conditions. It is hard thing this end-of-life care, made harder sometimes by policies that can have a way of forcing us to go a few extra steps, but sometimes only make the problems worse by adding stress. Uncle John and I email about once a week – we talk about the kids, Gonzaga basketball, and politics. I enjoy these conversations. But lately I’ve noticed a new tone, more questions about his treatment, more apologies because he was at the hospital for a few nights, more difficulties navigating what doctors say. As we enter Memorial Day Weekend, I guess the point for any of us with healthcare businesses that deal with veterans is to be thinking about how to take away some of this stress and make end of life care less policy, more personal.

1. 71: Percent of colon cancer cases that appear to be preventable through proper nutrition, 30-minutes of daily exercise, and not smoking or being obese, factors that account for 78% of chronic disease risk.

2. Enter Your Own Clinical Notes: Elaine Benes would have loved this. 15% of physician offices in our poll of 316 groups say they are starting to create a system to allow patients to provide input into their medical records. Elaine was ticked, for you Seinfeld fans, when her doctor fake erased her feedback about her rash. Patients of physicians Georgia and South Carolina, will be able to enter information into a system called OurNotes, which allows both patient and caregiver to enter clinical notes and care plans into the record. It will be interesting to see how this helps the physician practices who are managing MA and Medicaid patients in risk arrangements and how it impacts total cost of care and therapeutic decisions.

3. From Pharmacy To DME: Blue Massachusetts, starting in July, will provide coverage for continuous glucose monitor (CGMs) sensors under the Durable Medical Equipment (DME) benefit. Previously, CGM sensors were covered under pharmacy benefits. The move to DME was made, in part, to ease confusion among members as to coverage requirements for these sensors.

4. Tiered Network: Anthem New Hampshire has updated their tiered hospital network, a trend going on across many states and health plans and eventually, we believe, will move into the outpatient arena). Patients in the Granite State will have a higher out of pocket cost when receiving services at St. Joseph Hospital and Wentworth Douglass Hospital. One takeaway is that investment in hospital services, like technology solutions or clinical staffing, needs to take into account the impact of this tiering on customer volume.

5. Pediatric Partners: Advocate and Northshore health systems have partnered to expand pediatric care in the Chicago area in an effort to increase Northshore’s branding power with parents. The partnership will now include more than 600 pediatricians, pediatric subspecialists and maternal fetal medicine doctors from the two systems. Partnership launches in July.’

6. Tails California, Heads (Up) Carolina: Blue Medicaid in South Carolina is about to undergo post pay reviews of certain procedures or services the physician needs to identify as distinct for payment purposes, such as those billed with modifiers 59, XE, XP, XS and XU)

7. Lab Questions: Questionable lab practices have left 4 hospitals in Blue Arkansas’s out of the network. The hospitals were starting to do lab tests with physicians not affiliated with the hospital. These smaller hospitals get a higher rate than large labs do, basically they don’t perform as many tests; the higher pay helps cover overhead. But when these hospitals started to overbill and do more tests than had been forecasted by the Blue plan, total lab costs whent up. In one facility, lab costs were 50% more than larger labs. A secondary issue is the medical necessity of testing by practitioners. Lab benefit management is a growing area of interest for payers – some, like United, have their own integrated service. The Blues generally don’t.

8. Falling Down: Medication, orthostatic, depression and dehydration issues were to blame for readmissions based on our analysis of 65 patients who fell at home within 2 weeks of discharge from an inpatient rehab stay. Interestingly, 49 of the 65 said they were depressed (based on EMR documented notes with an occupational therapist who had visited the home).

9. Combo Therapy: Avenues to avert misuse of amphetamines have become an area of interest for researchers. One potential option is prescribing a combination of methylphenidate (Ritalin, Concerta) and naltrexone (Vivitrol), a drug commonly used to treat alcohol and opioid abuse. Story here

10. Extra Point: Connor Murphy ‘disappeared’ but he didn’t leave the stage when Janine, me and the girls saw the Broadway show Dear Evan Hansen this weekend. The character’s suicide was the backdrop for a gut-wrenching show about growth and honesty and managing our behaviors. I cried through most of the first act, so much so my peanut M&Ms weren’t as crunchy delicious as usual. I felt more connected as many of us would to the parents than the teens. I thought about my kids. And I suppose I found it interesting that Hansen’s growth actually started when he began to avoid taking his anxiety medications and trusting his instincts for helping others. My younger daughters were confused about Murphy’s death – not just the idea of taking one’s life – but that he never really left the stage. ‘I wasn’t sure,’ Sophie said, ‘because he was in a lot of the scenes talking, singing, dancing – even smiling.’ For a lot of us who operate healthcare businesses or manage the cost of healthcare there’s an underlying message to this musical – that it remains very difficult to see, understand and prevent these tragedies and takes even longer to help those affected by them. ‘There’s a cost I don’t think we think about with suicides,’ says Peggy Flarentine, RN, ‘it’s the families and the close friends who struggle to grieve and don’t get the services they need, and end up with their own challenges, addictions.’ Both payers and providers acknowledge that there is an opportunity to better manage mental health but I do think the underappreciated opportunity doesn’t lie necessarily with the counselors and treatment programs but rather with everyone else – caregivers, families, coaches, schools, primary care, and hospitals. ‘Can you see this coming and have a way to prevent it – that’s the ultimate value based care if you think about it,’ says Flarentine.

1. 1.7 Million: Number of children under the age of 18 with major depressive episodes who did not receive treatment, according to the Suicide Prevention Resource Center. That’s enough to fill every major league baseball stadium on the east coast twice. There is a shortage of providers as well. In Alabama, there’s only one mental health professional per 1,260 people. To meet the need for mental health care, providers in the lowest ranked states would have to treat six times as many people than providers in the highest ranked states

2. MCO Monthly Rate For Rx: Tennessee’s Medicaid program launches a two-year pilot program permitting qualified pharmacists to provide medication therapy management to patients managed under the program’s patient-centered medical home and to enrollees of Tennessee’s Health Link program, which helps those with a lot of behavioral health needs. MCOs here will pay a monthly fee to the pharmacists based on the patient’s risk stratification. The pilot will incorporate a set of defined performance measures.

3. Paying For Adherence: It’s now a thing. You don’t pay a premium, the MCO pays you. Examples are cutting across all types of insured. Boston Medical Center researchers used a patient navigator to help people from low socioeconomic areas get nicotine replacement therapies and, get this, pay them up to $250 for quitting. Smokers who received the incentives and personalized support were the most successful in quitting. Others in managed are contemplating similar tactics to change behavior, like paying people needing infusions in Texas to stop using the hospital or physician office and instead use home services, or a California plan paying people to get colonoscopy if they go to a new single-price center that offers the health plan a deal on the screening ‘at half the cost of the market’

4. Unexpected Diabetes Hurdle: Two physicians weigh in on our story about a diabetic patient struggling with the limitations of her diabetic supplies, insurance coverage and overall challenges of managing diabetes. Read more here

5. Pending: In June, BCBS of TX will request medical records, patient symptoms, and an itemized bill from hospitals to determine inappropriate charges. Claims won’t be denied outright; they will be pending.

6. Working Dogs or Cancer Game Changer? As part of the Center for Public Health Initiatives’ (CPHI) innovation-themed seminar series, working dogs were used in research to detect early stage ovarian cancer at Pennsylvania State and Monell Chemical Senses Center. The dogs are able to detect malignant ovarian cancer using plasma samples from patients. The hope from this research is that it will translate into a device that can be used in clinics, including in creating an electronic nose comprised of nanosensors that mimic the ability of the dog’s nose. The five-year survival rate of stage-IV ovarian cancer is only 17%, but if it can be detected in its earliest stages, survival jumps to over 90%.

7. Teaching Autism: UnitedHealthcare and OptumHealth Education are starting an accredited medical education series on autism spectrum disorder; the six-part webinar series, which began this month, offers free continuing medical education credits.

8. Antipsych Delay: We heard Harold Brandt, MD, at Louisiana’s P&T committee meeting passionately argue in favor of adding the generic antipsychotic aripiprazole to the state’s Medicaid preferred drug list recently, although there was concern that the MCOs here have been taking too long to approve these medications, up to 2 days, whereas the rules are for a one-day turnaround. ‘I’ve seen people who are suicidal and then non-suicidal 4 days later just because of this drug,’ Brandt said. Senator Mills questioned how many PAs are actually denied and the committee suggested that ‘it’s a small number’. The University of Louisiana handles the state’s fee for service prior authorizations usually in less than 24 hours, according to Melwyn Wendth, RpH. In the end, the Committee agreed to add the drug.

9. Inpatient Cost Increase: Cigna has increased the cost share for inpatient hospital stays from $260 to $295 per day for the first week, according to an annual notice from the payer. There was no change in the zero-dollar cost share for days 8-90 although emergency care copayment costs went from $75 to $80 for Medicare-covered visits.

10. Outsourcing Wire: Blue Minnesota now uses SecureCare to handle all the contracting and credentialing for chirorpractors and uses United Concordia for dental and oral surgery contracting and credentialing.

11. Extra Point: My fourth-grade teacher Miss Rosebrooks once said that life doesn’t come with a manual, it comes with a mother. Well an academic center in the Northeast had an idea and searched medical records with the word ‘Mother’ in them, and wouldn’t you know it, found patient/physician readmit rates were lower for these patients due to ‘caregiver involvement’. The analysis, done at Yale, was used to educate physicians and support discharge planners and goes to show you that data analytics can work and that mom maybe deserves TLC and P4P.  See here for a snapshot of the data: click here