Behavioral Health Insights

1. 100: Dollars for helping MA plans with diagnosing patients properly. If your doctors suspect a patient has a condition that hasn’t been formally diagnosed or coded this year, they can get $100 financial incentives as part of a diagnosis rewards program – about two thirds of MA plans in our poll this month say they pay this to PCPs, some pay more or less. ‘It’s for identifying a condition that’s not been diagnosed and coded but should be…but it works both ways – like if you figure out a patient no longer has a condition’

2. Divorce or Separation? A Tennessee couple we are interviewing Monday has been advised to separate and stop living together otherwise they’ll lose their Medicaid benefits. The wife has battled epilepsy and seizures, the husband—who served ironically as a mental health counselor for 47 years until taking early retirement to help with what he thought would be a way to ensure his wife would have coverage for medications, now sees his wife 1x a month. Full story next week.

3. PostPartum: Aetna Behavioral Health is collaborating with its medical management division to assist in identifying depression in pregnant and postpartum women with the ‘Beginning Right Maternity Program” for members and providers. The program uses a clinical case management process including behavioral health and comorbidity assessment, case formulation, care planning and focused follow ups. The program refers members with depression to condition management and a behavioral health specialist enhances engagement. Nurses reach out to members who have lost their babies to offer condolences and behavioral health resources. A hotline is used: 800-CRADLE-1.

4. Oxygen Policy Denial: Portable oxygen for home use will now be denied will now be denied by United Healthcare if the only qualifying blood gas study was performed during sleep.

5. Outcomes Based Pay Program: If Karen Collins, chief of common sense for fictional vice president Serena in television’s VEEP read this, she would surely say this is a great idea if your patients aren’t sick. Otherwise, tread carefully. The concept is the latest payer-program to pay for outcomes: CAC Focus is a new Cigna collaborative accountable care program for provider groups who think they can manage care and succeed in an outcomes-based reimbursement program. Groups qualify if they have at least 1,500 aligned primary care patients. Cigna says it will assist groups in getting the program off the ground.

6. No More Pre Approval: In a new policy, Aetna no longer will require precertification observation stays more than 24 hours and also won’t require pre approval for anti-emetic drugs delivered via an injectable or infusion like Emend IV for nausea.

7. Newborn Blue Policy Change: Blue Michigan change this policy in May so that even if a newborn isn’t added to the insured parent’s health plan contract within required timeframes (which happens more than you think) the MCO will cover both the facility and professional inpatient claims for the newborn during the first 48 hours for vaginal deliveries and 96 hours for c-sections. ‘Going to do this as an extension of the mom’s maternity benefit,’ a source confirmed. The policy is actually going to be retroactive to January 2017 due to the vast number of complaints. The only kicker is that the MCO won’t pay the newborn claim if they find out the mom had other coverage on the birthday.

8. Special Olympics Partner: For those of you looking for social investment with your practice, this one fits the bill: Kaiser Permanente has signed a three-year agreement as the “Official Health Partner” for the Special Olympics Southern California. This means Kaiser is the designated medical group for the games; clinicians from the group will volunteer at competitions throughout the year, including the 2018 Summer Games June 9 at California State University

9. Cardio Deibrillator Medical Necessity Added: Blue Kansas, as of this spring, considers wearable cardioverter-defibrillators to prevent sudden cardiac death medically necessary. ‘They are a bridge to ICD placement’ for patients within 40 days of an MI who the plan says have ‘sustained ventricular tachycardia/ventricular fibrillation that occurs more than 48 hours after index MI.

10. Extra Point: Our two oldest girls got their US Citizenship this week. We celebrated with some sweet frog yogurt and a pop quiz on American History. Being in healthcare, I asked who the first physician was in the US. Our youngest, Tommy, said Dr Phil and my daughter Sophie said Dr. Baker. I generously gave them both partial credit. I was still reeling from the fact both thought the Civil War was fought in 2005. Only Mukue nailed it, sort of, naming Elizabeth Blackwell, who was the country’s first female to get into medical school. She had a leg up on us since the doctor was part of a book report she did in middle school. I personally think all three of the answers are interesting given the trend in healthcare today toward more telemedicine and reliance on what celebrity physicians like  Dr. Oz tell us, as well as the throwback trend of physicians going into the home as Dr. Baker did when poor Laura had a tummy ache on the prairie. And then there’s women in healthcare—the trend is no doubt reversing as we reported a couple months ago with females now for the first time accounting for the majority of medical school students.

1. 70%. Likelihood of acquiring Alzheimer’s disease has been shown to be this much lower in people who eat a vegan diet.

2. Autism’s Cliff: No, we aren’t taking about a fall-off in rates but rather a fall-off in services. Only 36% of autistic young adults attend any postsecondary education. Solutions are needed now for young people on the spectrum who are seeking an independent life. Only about 19% of young autistic adults live independently away from parents and without supervision. Read more on seeking solutions for the transition into adulthood here.

3. Lab Payment Ending: Starting in June, UnitedHealthCare will only reimburse reference laboratories that report lab services appended with modifier 90. Non-reference lab physicians or other health care professionals that report laboratory services with modifier 90 will no longer be reimbursed.

4. Aetna Exclusivity: OneTouch brand test strips are now the only brand that Aetna covers for diabetes supplies.

5. I Alone: The band ‘Live’ performed this song on SNL in 1995, major leaguers started playing baseball again and anesthesiologists at a hospital where I started to work brought in behavioral therapists to do one-hour sessions before authorizing pain treatment. That’s the kind of value that was ahead of its time so go figure that, as of today, cataract procedures will be paid for but not the anesthesiologist or nurse anesthesist services under a policy Anthem has just rolled out after a review of literature deeming the use of these specialists medically unnecessary, unless the patient is under 18 or in severe situations. A friend of mine who works at an eye group in Connecticut, an Anthem market, is planning on charging patients $300-$500 for the services unless the payer reverse course.

6. Walkback: Precedent suggests Anthem may reverse portions of its cataract anesthesia policy. They have recently walked back some policies namely rules around not paying for non-emergent ER trips (where the payer now won’t penalize the patient if they are referred by another practitioner) or their new E&M policy where they will pay 25% of the rate for evaluation and management following minor surgery if done on the same day by the same physician. In the prior policy, Anthem called for a 50% cut. For a story outlining payer perspectives on an urgent care physician’s E&M / emergency decision, click here.

7. Proposal Flurry: More than 82% of health plan directors in our poll this month say the flurry of proposals around intensive care management vendors is picking up, making it harder to differentiate and get attention and for the majority, preference is to ‘let other payers be pioneers’ and test not only the vendor’s ability to bend curve, but to see how the models impact or rather ‘disrupt’ provider networks.

8. Opioid Wire:  Meridian Health of New Jersey announced more addiction treatment and mental health services in a partnership with Carrier Clinic through a signed ‘letter of intent’ to commit to lowering opioid overdoses. “For the 12-month period from July 1, 2016, to June 30, 2017, 2,284 people died of an overdose in New Jersey, a 34.7 percent increase over the previous fiscal year,” according to the CDC. Carrier Clinics have a 281-bed hospital and a 40-bed inpatient and outpatient detox facility. In Rx news, Cigna’s Comprehensive Drug List for April notes that all opioids, both long-acting and short-acting have a quality limit, excluding opiums, hydromorphones and fentanyl citrate.

9. Day In A Life: It’s controlled chaos here in the case management room at St. Francis’s surgical floor where Lynn Veith, a veteran of care coordination, does her best to advise nurses, younger physicians, residents and other clinical staff on the realities of patient crisis.  The room resembles a galley kitchen with 4 EMR stations, allowing the team to read notes, check insurance, and prep for rounds with the medical team. The goal is largely to find the fastest, safest path to discharge. Rounds started 30 minutes early today, and for anyone involved in managing care, running a physician or therapy practice, or making coverage decisions, hear this: hospital-based care coordination is the epi-center of healthcare, probably underappreciated by policymakers, but coveted by hospitals. They take the most complicated cases:. An older woman hit by a bus during a visit from Greece is on day 27 here, the social workers desperately trying to connect her with family, case management feverishly keeping tabs on her neuro tests and update post-acute rehab about her discharge. The hospital won’t get a single penny for its work. A female, 32, hits a pot hole while on her iPhone on her bicycle – she’s set to be discharged, but there’s a scramble to get her into dad’s preferred rehab. Her health plan doesn’t have an LTAC benefit, though, just has acute rehab, so placing her has been difficult. A mid-20s hyperbarics patient may need more debridement, is seeing plastics tomorrow but may need CPAP. Dr. Kahn, the in-house physiatrist, needs to do a PT/OT evaluation today. She has to meet the criteria for rehab to get discharged to Mt. Sinai, but may not, so the care coordinator suggests to the mid-levels to keep all options available. A senior male is about to be discharged to intermediate care, but the team reports that the EMR is wrong, that he is really a ‘readmit’ and should have been flagged as such. He came from assisted living, but was back after 4 days. An adult male is on his 1,367th hour in observation – he has no payer source, has come from Florida but has no family nearby and has severe mental illness and poly-psych issues. The IP psych facility in town won’t take him due to his medical issues, so the hospital is basically his hotel. At one point, there are 6 of us in the room, including the pain pump infusion nurse getting instructions on how to get a woman set up and daughter educated on using the pump before they go home in 4 hours. The PA and nurse coordinator debate next steps on a hyponatremia case for a 66-year-old whose readmit likely score is high, so they are more careful about her plan of care, knowing that her payer, Aetna, is pressing for discharge soon. The team is late for the 10am case manager huddle telecon, an around-the-horn report from each floor on the number of likely discharges ‘in the house’ today – it’s going to be a busy day, 21 planned exits, which is good for flow given the volume coming in, but puts more pressure on medical, social work and case management to get it right. Exacerbating the issue are the weekend gaps, when there is limited case management and, come Monday, no plan and a host of mistakes to fix, like the Aetna patient who got injured at work and should be a worker’s comp case.

10. Extra Point: My mother-in-law, God bless her, still lets me in her Red Sox country house despite being a Yankee fan and always remembers to have a plate of pretzels and dark chocolate on the counter. Last week, after 2 months of visits in and out of doctor’s offices to deal with a respiratory issue, we decided to take another trek north to be with her because she got confused using her nebulizer and ended up taking 7 prednizone on Friday. Her breathing is worsening and so is her cough so the visiting nurse we called to help has, in just one session, fixed a lot of the what the physician’s office couldn’t. The problem could re-emerge, though, as mom deals with dementia, but at least we curtailed a hospitalization or worse. It’s not the doctor’s fault per se, but perhaps underlines the importance of the home visit. When we got to mom’s house the other day it wasn’t 5 seconds from when I stumbled through the broken sliding door I keep failing to fix when she quipped, ‘Bry, what’s going in with your Yankees—already 6 back and it’s not even May?” She may have lost a lot of her mind on things, but she hasn’t lost that.

1. Six Million: Adults in the U.S. who suffer from panic disorder. That’s 2.7% of the population. Women are twice as likely to be affected as men, according to research from the Anxiety and Depression Association of America. Many people don't know that their disorder is real and highly responsive to treatment. People with the disorder experience spontaneous feelings of panic as their brain goes into a fight or flight mode.  The University Health News Daily states that causes of panic attacks in women arise more than men because researchers have identified 3 notable causes: serotonin deficiency, low vitamin B6 levels, and low iron levels. The disorder often occurs with other mental and physical disorders, including other anxiety disorders, depression, asthma, or substance abuse, which more than 84% of our surveyed physicians tell us complicates getting the correct diagnosis.

2. Military Ooopsy Daisy Or Intended Policy? In a bit of an interesting twist on what’s happening nationally, a military base in the south has required pre-approval for urgent care, but not for the ED. Guess what happened? Yes, this increased hospital ED visits. We will follow up this somewhat bizarre story as we learn more, though we have heard some in the health system community broadly questioning ‘overuse’ of urgent care, so perhaps this was the impetus.

3. Network Wins: Although still considered lower tier in the organization, a panel of 104 chief medical leaders and CEOs of health plans in 14 states we polled recently said that they have ‘elevated’ the role, responsibility and compensation of those in ‘network’ positions, tasked to help ensure the plan is ‘meeting regulations around adequacy of networks’ and also ‘supporting the contracting and value-based teams’ in identifying and rewarding the best of the in-network providers. ‘There’s not really a single specialty or service that is more important than the other – we’ve given the team a lot of leeway and the charge to build a better network. They were 3rd or 4th wrung in my book 5 years ago, now I have a standard weekly meeting with our VP’

4. Who’s The Payer Actually? When my youngest Tommy was 5 he said he wanted to be a payer, not the managed care kind like many of you are involved with, but the Harris Teeter grocery store cash register kind. ‘I want be a payer daddy so I can take the money daddy.’ He’s moved on to wanting to be a builder with scotch tape as his reinforcements. Good luck with that Tom. But his coming-of-age dream is interesting if you think what’s happening today. As you look at your mix of payers and think about expanding services to better serve patients and gain better positioning with employers and health plans and referral sources (including consumers), be aware of who the actual ‘payer’ is. A good example is Regence BCBS in the upper northwest. They may be the payer but if you’re in the physical medicine arena, all approvals go through eviCore, which is now part of Express Scripts, which may soon be part of Cigna, while sleep medicine and imaging must get approved by AIM, which is owned by Anthem. As providers integrate services, so too are payers. We would anticipate more integration in the next 2 years in the specialty benefit arena, so stay ahead of how this may impact your contracting and network position. It’s why we often say that the largest specialty benefit managers will be increasingly of interest because they will own a greater portion of the patient data around pharmacy and medical and ultimately behavioral utilization. How providers demonstrate an ability to improve all of these outcomes and costs will help offset pressure on rates.

5. HIV Rx: United Healthcare Oxford now covers the drug Trogarzo for the treatment of the multi-drug resistant human immunodeficiency virus (HIV) in patients who meet the criteria of both the diagnosis and the physician attestation that the patient has the multi-drug resistance. Criteria generally require that patient’s have failed on other treatments. HIV is a unique specialty class that payers have struggled to manage due to the lack of generics. Most have said they were eyeing the generic opportunity this year, such as for the drug Atripla.

6. Lower Cost Solution For MS: An online meditation course is reportedly helping MS patients manage their symptoms and reduce total costs of care according to results from a recent clinical trial. This training in meditation has been shown to ease depression, anxiety and sleep issues. The study recruited 139 MS patients in Italy who were randomly assigned to either an eight-week online mediation course or an online educational course. Participants had either relapsing-remitting or secondary progressive MS; patients with severe co-morbidities, severe neuropsychological impairment, psychosis, dissociative disorders, or who were pregnant were excluded. Those on meditation training were given a telemedicine mindfulness-based stress reduction course, which included music meditations, discussions about symptom acceptance, video conferences with a trainer, and live sessions via video-chat. A specific website was created to encourage the sharing of content among group members. The questionnaires assessed the patient’s quality of life, mental health and fatigue levels.

7. Opioid Rx Down But Not Out: Highmark Health has partnered with AxialHealthcare to assist prescribing physicians and other providers with pain management and safe opioid prescribing in Pennsylvania. This same program was enacted in West Virginia in 2016 and was very successful with patients. More than 250 providers received extensive, targeted clinical consultation on pain management. Patients receiving opioids from multiple prescribers has dropped by more than 28% and patients receiving opioids alongside certain sedatives — a significant risk factor for opioid overdose — fell by more than 25%. Additionally, a report from worker’s comp insurer conversations we’ve had suggests significant improvement in opioid spend year over year – as much as a 15% reduction in one case. These developments raise a question for those who own and operate substance abuse treatment centers – what will your opioid patient volume look like in 5 years?

8. TriCare Network Disruption: Changes to networks have caused a bit of disruption for eye physicians and should be evaluated if you have any Tricare patients in your practice. Tricare now slices the country into two regions, not three, using Humana and HealthNet and dropping United. EyeMed, which administers Humana’s optical network, says it was changing contracts with some physicians in the eastern US region to create what it called its own Tricare network. Some eye doctors who agreed to these EyeMed stipulations told us they were removed from the Humana Tricare network but apparently the American Optometric Association has come in to help advocate for these doctors to still be allowed to treat Tricare ‘Humana’ patients without agreeing to EyeMed’s contract amendments. While unclear where this has all ended up, it’s worth noting if any of your patients – regardless of specialty – are Tricare.

9. Extra Point: Bob Hope once said he’d give up golf if he didn’t have so many sweaters. I used to play a lot but have migrated to tennis and hoops in my quasi middle age. Still, on Masters weekend, golf has a way of bringing you back and for those of us in the healthcare field, it is part therapeutic, part disease. I asked 456 consumers and healthcare workers from our alumni network last fall to weigh in about their sports life. Of the 183 who had picked up a club in the past year, 103 said the sport was more therapeutic than disease while 80 said despite their love of the game, it usually added anxiety, depression, anger and quite often chronic pain. Said Mark Narens, Rph, who works for a hospital pharmacy in Rhode Island: I used to play 9 after shifts during residency and occasionally on weekends with my brothers but I found myself taking too many pills before and after rounds, and I’m a pharmacist! Narens, like many others, says he’s graduated to what I myself have: a few good rounds a year battling windmills on the mini-golf links. It’s no Augusta National, but there’s something about knocking your kid’s pink ball out of the way enroute to a hole in 4.

1. 1948: Average daily price of a typical hospital room according to 15 Ohio hospital prices. That’s at least a dozen urgent care visits.

2. Catholic Systems Move Into Rx Field: Ascension, the world’s largest Catholic health system, is 1 of 4 systems involved in creating a non profit generic drug company. Intermountain Healthcare is spearheading the effort. Trinity System is also involved. The company will be directly manufacturing generics, or subcontract this work, with a goal of improving the supply of medications and getting control over pricing given recent spikes in generic drug costs. So how long now before a specialty pharmaceutical manufacturer partners or starts to build a healthcare provider company focused on their therapeutic concentration?

3. Aging Homes Pass Torch To ALF Campuses: The Jewish Home of San Francisco, founded in the 19th century and California’s largest private nonprofit senior residence and skilled-nursing facility, has started to undergo a facelift this month. Seniors here used to stay for 5 or 10 years, according to CEO Daniel Ruth, but now their length of stay is a matter of months at most, as more of the population gets home or community-based services. The facility will add 115 assisted living apartments and 75 memory care and support suites, expanding on the existing 350 SNF and short-stay suites. The changes, Ruth said, were necessary given over-reliance on Medicaid funding – a 30% reduction a few years ago prompted a new strategy and more privately insured patients. The new campus will be in one of the oldest counties in the country (San Francisco and San Mateo), according to a report by the Jewish News. Ruth believes there is a major resource issue facing the rising number of aging and frail elderly.

4. Veterans Mental Health Top of Mind: Cigna introduced a Mindfulness for Vets program to combat post-traumatic stress disorder, depression and other health conditions. The goal: access substance use treatment, housing, health insurance and more.

5. App For Cancer: 80% of children diagnosed with childhood cancer in the US survive but those that survive often live with co-morbidities that are often a consequence of treatment, ongoing care or remission. GRYT Health and Bristol-Myers Squibb announced a new app, the ‘Stupid Cancer App,’ designed to anonymously connect people affected by cancer, give them a platform for exchange and empower them with important resources and information.

6. Teen Pregnancy & Abortion Trends: A girl in our urban Hartford middle school – a good athlete, singer, and smart-as-whip straight-A student – was offered a full-ride to a private high school in the area, but plans have changed for her due to an unplanned pregnancy. She doesn’t have a mom or dad and is raised by her aunt and a school community. She’s taking a few days to evaluate options. The news was surprising to many of us and it again reminded me anyway of the national debate around abortion. There’s a new report from the National Academies of Sciences on abortion safety and prevalence. It found that an abortion does not increase a woman’s risk of secondary infertility, pregnancy-related hypertensive disorders, pre-term birth, breast cancer or mental health disorders. The vast majority of abortions can be provided safely in office-based settings, the researchers found. On the controversial side, 39% of women of reproductive age resided in a county without an abortion provider and approximately 17% travel more than 50 miles to obtain an abortion. Between 1980-2014, the abortion rate in the U.S. decreased by more than half, from an estimated 29 to 15 per 1,000 women of reproductive age. Increasing use of contraceptives and the decline in the rate of unintended pregnancy are drivers. Health insurers provide coverage in select circumstances related to trauma, violence, injury or abuse.

7. When Travel Ban Policy Impacts Survival: A man with a rare blood cancer needs a bone marrow stem cell transplant to live and his brother, who lives in Iran, is a match. The travel ban complicates this. Click here for the story

8. Extra Point: 79-year-old Ruth was wandering the halls at the Woodland Street medical building near the campus of St. Francis Hospital in Hartford on Monday. I was about to enter the Clinical Lab office for blood work – when I noticed Ruth seemed disoriented. She was trying to find her eye doctor, and thought he was on the third floor. I offered to help and so we walked down to the lobby to look up her doctor’s name. Ruth has a frail figure, walks slow and has some trouble seeing so I give her credit - she made it to her appointment and was only 1 floor away. If I am so lucky at her age. She said she had been in the halls for about 30 minutes. No one was with her so I walked into the office to ‘check her in’ and the office manager greeted with a smile, ‘Hi Ruth – what are you doing here again?’ Turns out Ruth had already been for her appointment the day before. I walked her back to the downstairs elevator and the bench where the senior van stops…she says she lives alone in an apartment in the city. On this Holy weekend for many of us, say a prayer for all the Ruth’s out there.

1. 65 Seconds: Amount of time it takes for someone new in the U.S. to develop Alzheimer’s disease – which by 2050 is expected to shrink to one person every 33 seconds. 5.7 million Americans are living with it now and depending on which state you live in, assisted or senior living can cost approximately $2,525 to $5,745 a month. My grandmother, who spent her childhood in the mountains near Napoli, spent her last 12 years in Fairlawn New Jersey with the disease. I lived with her for part of that time – she was only in a SNF near the end, when pneumonia got her. The pipeline of drugs to address the disease have hit roadblocks recently – Pfizer most recently ending its R&D for neurological conditions. Solutions in the interim seem more focused on care management models, like BCBS of Massachusetts transitions in care model. ‘I’m not sure we have any alternatives – these patients need to be managed at home,’ says Pam O’Hare, a Blue case worker who works with vendors and transition teams. Payment for these services will likely evolve into PMPM and even global capitated arrangements.

2. Dermatology Utilization Boost: Pre approval from United Healthcare is no longer necessary for excisions of malignant lesions, billed using code 11606, starting in April. Most of United’s commercial plans will adopt this policy, but Oxford plans won’t.

3. Wigs after Chemo Coverage: Kaiser Permanente of Oregon added coverage for wigs limited to 1 synthetic-haired wig per year following chemotherapy or radiation therapy. The wigs are considered “outpatient durable medical equipment” as a part of their Senior Advantage plan. Wigs covered by health insurers isn’t a new thing. BreastCancer.org claims that most health insurance companies cover part or all of the cost of the wig if a doctor writes a prescription for an “extra-cranial prosthesis.”

4. Separate Payment No More, Separate Ways Forever: I wore a Separate Ways t-shirt to school for nearly 30 days straight in 6th grade, just so my classmates knew that it was the best Journey song. But being separate isn’t so good for supplies these days. Syringes, catheters, parenteral infusion pumps and other equipment used in various procedures and settings are no longer separately reimbursable by Aetna as of next month, under a new payment policy in which it says items like these are ‘part of the overall episode.’

5. Lab Test Network Rule Change: Molina Healthcare of Ohio updated its laboratory testing payment policy. Providers are now required, as of February this year, to submit specific laboratory specimens to in-network clinical labs. This ensures laboratory services are provided by a credentialed laboratory, and that Molina Healthcare has access to laboratory data needed to measure HEDIS performance quality and outcomes for all network providers.

6. Palliative Partner: Empire Blue in NY will partner with Aspire Health starting this spring to help commercial patients suffering from advanced illnesses. Aspire provides telephonic and home visits, but doesn’t replace the PCP network, although a source with Empire told us, ‘Look, the PCPs are too busy and not managing these patients – so while this doesn’t replace the doctor, at some point I think these companies will just add medical directors’

7. Imaging Heart Update: As evidence that payers usually react within a few months to major guideline changes, specialty benefit manager AIM will incorporate recent literature findings about the use of coronary CT angiography and fraction flow reserve as the first-line test to be used in patients with suspected coronary artery disease. AIM, which serves many health insurers, will update its pre-approval requirements as of May 1st to reflect this.

8. Multiple Procedures Less: Aetna, in March, has started to reduce payments for multiple procedures performed on the same patient on the same day. Therapy services (50% less), diagnostic ophthalmology (20)% and diagnostic cardiology (25%). Both of the diagnostic reduction only apply to technical services, not physician interpretations.

9. Asthma, Growth Hormones Rx: As of March 1st, a number of health plans have begun to require pre-approval on all growth hormone products. Blue Michigan says it has different requirements for pediatric members and adult members. Its Blue Care Network also no longer covers the asthma medication Alvesco starting this month. They are suggesting lower-cost alternatives including Arnulty, Flovent and Ovar.

10. LGBTQ Suicide Prevention: LGBTQ individuals are almost 3 times more likely than others to experience a mental health condition such as major depression or generalized anxiety disorder. For those of you working in the mental health field, or in hospital or primary care settings, there are opportunities to better address these risks to prevent hospitalization or worse. Click here for the story.

11. Extra Point: A dad in Virginia made his 10-year-old run to school in the rain because the kid’s bus driver suspended the boy from riding the bus for bullying kids. The dad drove his truck behind his son en route to school. He says it hopes to teach the child a lesson. A lot of folks found the dad’s online posting of the incident a bit uncomfortable. That aside, the point he makes – healthy punishment and being a parent - makes a lot of sense. Of course I want my kids to run and play because it’s good for them, not as punishment, but I’m not looking to argue with the dad. Like a lot of us, he’s just trying to do his best. In our poll of 452 parents this week, 79% said they drive their kid to school, often less than the 1 mile this boy had to run, and often in silence, if you discount the sweet sounds of texting.

1. $1.6 Trillion: If you had to guess, what you would think is the largest single source of economic burden in the world? If you guess cancer, diabetes, respiratory disease or heart disease you’re wrong. The estimated global cost of mental health problems is higher than all of those.

2. Talk Is Cheap, But Does It Work? A therapist messaging app called ‘Talkspace’ has serviced over one million people and is trying to help solve issues of access, stigma and cost for those suffering from mental health conditions, says app cofounder Roni Frank MD. The new solution has implications for therapy providers who offer residential and outpatient treatment. Don’t hesitate to reach out to discuss. Click here to read the story.

3. PT Milestone: George nearly fell off Jerry’s chair in Seinfeld when he heard there’s health insurance for physical therapy. His angst over getting a male therapist notwithstanding, the episode highlighted what many considered a milestone for PT in the 90s. Flash forward 20 some years and what’s been an at times bumpy road for PT providers has just gotten easier as Humana is the first insurer to remove pre authorization requirements for outpatient PT. Commercial and Medicare Advantage patients benefit from the change. Annual visit limits would still apply for specific ‘plans’ but the announcement is a plus for providers. One source said the rise of opioid addiction is one key factor as is the relative maturity of the authorization process itself – PTs are getting pretty good now at what to request and how to document the need for more visits.

4. Urine Testing Policy Change: BCBS Tennessee has a new outpatient drug testing policy. Urine/serum drug testing will be limited to 20 episodes per annual individual benefit period, effective May 1, 2018. An episode is defined as either a presumptive or confirmatory test (or both for the same date of service per provider billed on the same claim). A presumptive test is also known as a qualitative point-of-care test (POCT) or a drug screen. A confirmatory test is a definitive or combined qualitative/quantitative test. This policy does not apply to BlueCare Tennessee, CoverKids, FEP or the Medicare Advantage members.

5. Eye & Knee Medication Update: Several plans will now require prior authorization across all lines of business for the gene therapy drug Luxturna, designed to help people with vision loss, and for a pair of osteoarthritis treatments, TriVisc and the injectable Durolane. Opthamology and orthopedic practices may want to explore specific use of these products as ancillary solutions.

6. The PAC-12 Misses, But Northwest MCOs Score: While the major players are out of the NCAA men’s hoops tourney, the major ‘payers’ are all in on a strategy to limit hospital costs. Blue Idaho and Regence BCBS are among plans continuing to increase the number of physicians in shared savings arrangements. Idaho’s plan added six more groups this year, raising the number of providers in these arrangements to 25, while Regence Utah’s ‘Total Cost of Care’ program has had good results, as patients who are seeing participating physicians are readmitted to hospitals 28% less than patients who see other doctors.

7. New Heart Procedure Success:  Santa Rosa Memorial Hospital of California completed the first Transcatheter Aortic Valve Replacement (TAVR) procedure, which took place last week. Memorial Hospital is offering a less invasive option to patients with severe aortic stenosis who may otherwise not receive adequate treatment due to their high risk for open heart surgery. Approximately 70% of patients with severe aortic stenosis are at an extreme risk for open heart surgery.

8. Extra Point: New York will become the first state in the nation this June to require schools to incorporate mental health into curriculums. How many states adopt similar policies may not be the major question as much as how quickly they do it and perhaps more importantly which model or companies can figure out a way to help schools. I’m biased as my bride and I have worked at an inner city school that uses these models, some of which are classroom focused, some playground oriented. Health plans are in some ways already showing their hand, some saying they will ‘prefer’ providers who have experience and affiliations with schools, at least as a way to ‘better manage transitions, reduce crisis’ and ‘make it easier for families’. With all the talk about which mega healthcare deal will be next – and there will be 2 or 3 more no doubt – I would not be surprised to see a ‘behavioral’ powerhouse emerge that either focuses on kids and prevention or builds a model.

1. 1,504. The number of children under age 17 admitted into hospitals for opioid overdoses from 2012 and 2015, up from 797 from 2004-07. Researchers at the Comer Children Hospital in Chicago determined these underage overdoses occurred from children getting their parents prescription medication, and particularly children under six years of age who were consuming methadone, a treatment for opioid withdrawal symptoms.

2. Rocky MLR: When meeting quality outcomes targets, 26 physician practices in Colorado earned a share in savings from the Rocky Mountain Health Plan during a recent Medicaid pilot – a 2% adjustment was made to the Medical Loss Ratio for each target the physicians met. Targets largely focused on obesity, diabetes, and depression, including HbA1c poor control greater than 9% (target=28%), adult body mass index assessments (target=82%) and proof of effective acute phase anti-depressant medication management (target=56%). Payments were distributed based on patient volume and risk scores, 60% to primary care physicians, 30% to community mental health practitioners and the rest to the health plan. There was about $5 million saved by 28 practices representing about three quarters of the 35,000 Medicaid population in the program.

3. Pain Response: At Colorado Medicaid’s recent meeting there was some discussion about NSAIDs and whether injectable ketorolac (for pain) has a lot of use in the Medicaid population – a report will be run and discussed at the next meeting. Additionally, the board will allow Narcan nasal spray to be prescribed without prior authorization ‘in the near future’, according to Cathy Traugott, RPh.

4. Network Mix: Just to give you a sense of a health plan’s network size, in New Mexico, there are just 4,222 primary care physicians in the Blue network, though this is about twice the number in the plan’s Medicaid network and nearly 3x the number of PCPs in their Medicare Advantage HMO. In all, BCBS here has 33,568 participating providers, made up of nearly 10,000 allied health practitioners (like PTs, podiatrists, optometrists) and 6,600 behavioral health practitioners in the network.

5. Out of Network, Out of Favor: Several upper Atlantic health plans have essentially halted out of network substance abuse treatment for members who fly to Florida, but in one plan – Horizon – is extending treatment for those who use providers in the area, moving toward ‘full year episodes’ that feature peer recovery and incentives to ‘engage’ the patient through transitions, says Mary Ann Christopher, RN, Horizon’s chief of clinical transformation.

6. Opioid Entrée To Marijuana Program: Opioid withdrawal can soon be considered one of the conditions a patient can claim when applying to be part of Connecticut’s medical marijuana program. Four other conditions were discussed being added including albinism, osteogenesis imperfecta and progressive degenerative disc disease of the spine at a state Board of Physician meeting this past week. At a federal level, marijuana still remains as a controlled substance. There are currently 22 conditions that qualify adults and six for children for the Connecticut state medical marijuana program.

7. Three’s Company? A surprising 61% of physicians in our poll of 274 of them yesterday think the most recent proposed merger (Express, Cigna, and medical benefit manager Evicore) isn’t anti-consumer or anti-provider, but pro-outcomes. ‘Getting approval for a script now comes with a lot more data behind that decision – or it should. We are moving into having to justify everything and get paid for better monitoring of patients and better outcomes but we don’t have the data usually. It’s not just Cigna saying yes or no or the PBM using a step edit or fail first policy or prior authorization, it’s the data from the medical side about prior procedures and history,’ says Gary Rantel, MD, an internist. ‘It’s a more complete picture of the patient before a green light…for me, I lack an understanding of what happens to my patients in between visits. Maybe this helps’

8. Generic Limit:: Alabama Medicaid will create a new process to limit simultaneous use of drugs containing at least one identical generic chemical, initially focused on gabapentin and pregaballin drugs. A review of 2016 claims found 770 patients on at least two strengths of gabapentin. Medical justification will be needed for patients to be on 2 strengths of the same medication at the same time. Other drugs may be added.

9. Cell Transplants: UnitedHealth Group updated their coverage review requirement for commercial, Medicare Advantage and Medicaid plan members to add chimeric antigen receptor T-cell (CAR-T) therapy, including tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™). CAR-T therapy is a form of adoptive cell transfer that’s shown promise in the treatment of certain hematologic malignancies.

10. Hospice, The Cardinal Way: Kindred Healthcare has collaborated with the University of Louisville to create health care technology solutions, including apps, that may improve the lives of the aging population. One app would assess a patient’s eligibility for hospice care. The partnership, called ‘HIVE’, brings Kindred employees together with Cardinal students to develop apps and other elderly-focused projects.

11. Two Hours: There’s a lot I used to be able to accomplish in 2 hours, that before I had children. Health plans, for their part, have their own time constraints given the drain of the pre-approval process. For example, in Alabama, there were 25,881 prior authorization requests this time last year (in January) filed electronically with the state’s Medicaid office, with just 10,505 manual. These numbers stayed relatively flat through the first quarter last year and, on average, manual PA requests were completed usually within 2-4 hours.

12. Boston 150: Sixteen Blue plans have told us that they have already or will move in the direction of changing out of network provider claims reimbursement for PPO plans to reduce exposure to OON charges. Many say they looked at Blue Massachusettts’ policy as a starting point in discussions. Blue MA sets the OON rate at 150% of Medicare, while several other Blues say they may go lower (e.g. to 130%)

13. Extra Point: My daughter Sophia sang her little heart out this week in a rehearsal for her middle school’s performance of Legally Blonde. She is playing this character who jumpropes her way through the song. I can barely drive and text at the same time, so I have to say I’m really impressed with Soph’s ability to multi-task. Of all our kids, she’s my favorite on most days, and she never surprises – at breakfast, while waiting for the waffles to pop the other day, she said she wanted to be a doctor. She’s apparently on the right side of the trend as there are now for the first time more women than men in medical school. “I think it's great that women are now attending medical school in record numbers,” says Laura Erickson-Schroth, MD. “This means that women have access to fulfilling careers and patients are receiving care from a more diverse group of doctors.” The development is small but meaningful for many of you with practices looking carefully about how to find, use, and retain good physicians. They are out there. Perhaps one place to look is on a middle school stage, Act 2. Look for the girl with the pony tail and the sweet voice. Click here to read the full piece.