Behavioral Health Insights

1. 3.6 Million: Number of Americans who miss medical appointments due to a lack of reliable transportation, which evidently lead to the launch yesterday of Uber’s new business called “Uber Health”, according to an Uber general manager. Uber Health will provide a car service platform specifically to drive patients to hospitals and rehab centers, allowing medical facilities to book rides using a web dashboard.

2. Marriage, Is What Brings Us Together…Today: Licensed psychologists and marriage and family therapists are being invited, as of this month, to participate in BCBS of Michigan’s network. What’s sort of interesting is that the health plan doesn’t cover marriage counseling, but it will allow these licensed practitioners to bill for what the plan is calling ‘other behavioral services’ within the scope of their practice, which, as far as I can tell, is marriage counseling. ‘I’m a counselor and while 60% of my practice is family focused and 40% just spouses, the ‘family’ counseling almost always comes back to one core goal – fix the marriage and you fix the family,’ says Steve Olear, who finds policies like these overly complicated. For what it’s worth, the cost of depression is higher among teens and young adults from divorced families than other families, according to study with 151 medical directors.

3. IPM, Sleep Studies Join New Pre Approval List: Blue Illinois, as of last week, will require pre-approval for cardiac services like lipid apheresis, facility-based sleep studies, interventional pain procedures for musculoskeletal pain, ENT and outpatient surgery, such as orthognathic and mastopexy, as well as non-emergency transports.

4. Unicompartmental Knee Replacement: Interest in orthopedic practices with PT capabilities has increased and for those who provide this procedure there’s favorable news from BCBS of Tennessee – the plan updated its medical policy this month, saying it now generally considers UKR ‘standard and conventional practice’. A question for surgeons and practice owners is post-op care and opioid avoidance.

5. ACO Northwest: In January, Regence Blue Cross Blue Shield of Utah and Aledade Inc., a growing national value-based care network, collaborated to expand Aledade’s Accountable Care Organization to provide high-quality coordinated care to 4,000 Regence plan members cared for by its practices in its first commercial contract in Utah. Members will benefit from an innovative physician-led ACO model that rewards doctors for improving quality of care and patient health outcomes, while lowering costs.

6. Opioid Ups & Downs: Independence Blue Cross sends out a letter to physicians who have been over prescribing opioids outside of guidelines, Richard Snyder, chief medical officer, said on Tuesday at the Opioid Management Summit in DC. But the educational effort has worked only to some extent with about 65% of the doctors ‘dropping off the list each quarter,’ but the list isn’t getting any shorter,’ meaning new physicians are continually added. For its part, BCBS of Michigan has collaborated with Value Partnerships and Pharmacy Services to reduce fraud and abuse. This program involves identifying health care providers writing prescriptions for opioids for patients who might be “doctor-shopping;” and recognizing patients who have been prescribed the dangerous drug combination known as the “triple threat;” opioids, benzodiazepines and muscle relaxants. This combination is linked to overdose and death.

7. Disparities Huddle: About 21 MCOs tell us they’ve formed or will form in 2018 healthcare disparities and actions teams, or taskforces. What role healthcare companies can play will evolve – but presumably those with home or community based services, as well as those serving Medicaid populations may find an advantage from getting on the agenda of these teams. From 2007 to 2010, I was an independent member of the disparities, access and restrictions team, or DART, for Pfizer – the goal then was understanding treatment disparities and gaps in care at discharge and post discharge. Seems like things haven’t changed.

8. ASC vs. Hospitals: Today, CBS News reported an investigation claiming that Surgery Centers have led to more accidental deaths because something has gone wrong during a surgery, due to less preparation for a crisis situation. There are now more surgery centers than hospitals in the US. ASC payments and utilization continue to be evaluated at a local level but about 35 out of 50 facility contracting directors we polled earlier in the year said their primary emphasis is on using lower copays and other incentives to drive more commercial patients to use in-network ASCs over alternatives.

9. OB Epidural: Kansas Blue is about to change its guidelines for anesthesiologists doing epidurals to allow for one unit per hour for monitoring women during vaginal deliveries, and 1 unit every 15 minutes for cesarean. Policy relates to regional anesthesia.

10. Prostate Cancer Treatment: Aetna considers transperineal periprostatic placement of biodegradable material (SpaceOAR), a biodegradable hydrogel, medically necessary for reducing rectal toxicity in men undergoing radiotherapy for prostate cancer, but considers it “experimental and investigational for all other indications.”

11. Extra Point: A home health aide on our street who helps an adult with severe mental disability after she comes home from day treatment mentioned to her boss that she often has to wait ~30-45 minutes for the patient to arrive home each day – the van’s arrival, she said, is unpredictable. The state had been paying for that idle time, but not anymore, and the home health company doesn’t want its aide idling unpaid. The day treatment van driver told me he does his best to be on time but bringing 8 to 10 patients home doesn’t always go smoothly – ‘these are very disabled adults.’ The day treatment company won’t take the patient off the van and to the door nor will they stay with her until the aide arrives for what they say are ‘liability’ reasons and told the family that an ‘adult must be present to do this’. The two parents work full-time about 45 minutes from the house. They are using neighbors to help fill the gap for now. They say they may switch home health companies. Seems like a bit of an overly complicated outcome from a reasonable problem. I mention if only to say to those in the home health arena, both skilled and unskilled services, that there are several small but perhaps not unimportant issues to address when forming relationships with other levels of care (day treatment), transport companies, payers and of course parents.

1. 50.7: The percent of women in medical school, up about 3% since 2010. There are about 21,000 enrollees today. Two of my three kids want to be physicians – one boy and one girl. The boy wants to be a dermatologist or doctor of physical therapy, having spent a good part of his freshman year in PT. The girl wants to be an APRN or family doctor back in her home country of Thailand. In either case, neither solve the physician shortage on their own but in a straw poll of 38 medical directors this week, 37 said the girl gets their vole for ‘adding more value’. If you are looking at investing in global healthcare, perhaps that’s a clue; if you’re in PT or dermatology, take the poll with a grain of salt.

2. MA Reimbursement Change: In May, United Healthcare will change Medicare Advantage reimbursement policies for professional and technical services including lab testing to better align with its Medicaid and commercial plans. Details to follow.

3. Autism Therapy Reaction: The first ‘breakthrough therapy’ medication with potential to improve core symptoms of autism has been approved by the FDA. Roche’s Balovaptan improved social behaviors during clinical trials. A question for all autism therapy providers, namely those focused on applied behavioral analysis, is where these medications fit into healthcare delivery and how managed care may position them relative to ABA and PT/OT/ST services. ‘I think it’s all on the table – we’re heavily focused on ABA now and network development but in the next year or two we’re looking at diagnostics in this area as well alternative treatments – would like to see us develop pathways to help the referring providers and schools on what makes sense, so parents are scrambling for 2-3 years to find the right treatment plan,’ says Martin Flanders, MD, who serves on several BCBS behavioral health committees.

4. Genetic Utility New #1: Regence BCBS, this spring, will implement a number of significant utilization management changes for transgender services, chronic pain stimulation and its #1 focus, genetic testing. These will continue to be services the plan monitors closely. For example, genetic testing for Li-Fraumeni syndrome is now considered necessary under certain criteria but when evaluating the utility of genetic panels the plan decided to add 18 new investigational panels and remove 61 others. New genetic technology has led to the ability to examine many genes simultaneously, resulting in a proliferation of genetic panels. The intended use for these panels varies: for the diagnosis of hereditary disorders, a clinical diagnosis may already be established, and genetic testing is performed to determine whether there is a hereditary condition or to determine the specific mutation. In other cases, there is a clinical syndrome (phenotype) with a broad number of potential diagnoses and genetic testing is used to make a specific diagnosis.

5. Obesity Treatment Skepticism: Delaware’s Medicaid program starts covering obesity treatment sessions in 2019 – in our poll of PCPs on the topic, 82% of physicians who see Medicaid beneficiaries are skeptical, saying they regularly discuss nutrition, weight and healthy lifestyle as part of wellness and sick visits and most believe these so-called obesity treatment sessions would be better if ‘out of the office setting’. ‘Getting paid specifically for this may work, but it seems odd to separate it out into its own visit and code,’ says Marsha Heller, APRN. ‘Why not a single case rate that covers all the issues as part of the evaluation or why not pay us or others to do true obesity prevention or intervention with those of any age who need more activity?’ With Medicaid patients, Heller says part of the challenge is at least half of her pediatric population struggle to have enough food in their home, much less healthy food. ‘Had a student in today who is having recurring muscle and pain issues and keeps taking ibuprofen – she just needs bananas.’

6. Izzy Mandelbaum Healthcare: This Seinfeld icon once barked at Jerry that ‘it’s go time’, a plea from the Lloyd Bridges character for the weaker, unhealthier comedian to shed some pounds. Managed care organizations are in a bit of their own go time these days, more willing to entertain contracts with medical groups offering a new site of care. One managed care medical director in Indiana is talking to a medical group here that is turning an old apartment building into a basketball court and gym for patients who need more activity – office visits, check-ups will take place at the facility. The health plan, Welborn, would try to pay the group a PMPY to track BMI, obesity and other measures, including presenteeism in school and work. ‘This is the sort of thing that gets my attention – rather than come in saying you want a 10% increase because you added a clinic, show me how you’ll change the course of life for these patients’

7. Diabetes Glucose Monitoring: Washington State’s Health Technology Clinical Committee reviews evidence and recently found that select use of continuous glucose monitoring was as safe and clinically effective as alternatives for some diabetic conditions. The committee recommended coverage for Type 1 and Type 2 adolescents and children unable to achieve target HbA1C despite adherence to their prescribed glycemic management plan. Other recommendations included coverage for certain pregnant women. Final coverage decisions will be made this year.

8. Prior Authorization Round-Up: Aetna, starting this month, requires pre-approval for dental implants and dialysis visits performed at non-contracted facilities, as well private duty nursing in select situations. Contact us for details.

9. Extra Point: Patriots by 6.

1. 59: The fee in dollars BCBS of Massachusetts will pay for a standard medical tele-health visit, up $10 from last year.

2. OB Pre & Post Term Pay: Changes are likely for OBs both for pre-term and post labor payment. A number of managed care plan case managers, 42% in our poll of 136 of them in January, said they are looking into new depression screening type programs to support moms-to-be, particularly higher-risk pregnancy patients with diabetes or those with prior mental health conditions. The programs may address what one nurse manager called a rise of about 12% in pre-term births due, she said, to undiagnosed depression. OBGYN practices should be able to benefit from these initiatives and work with managed Medicaid and commercial payers across states to conduct the screenings, treat, track and report outcomes. Payment will likely need to be separate though eventually packaged into a bundle. BCBS of Louisiana is looking at post-partem as well, requiring its OBs to submit a claim for post-partem visits using a non-payable code (0503F) so they can track utilization and outcomes. OBs bill maternity care globally, according to the plan.

3. Infusion Pump Policy: Infusion pump criteria is getting a deeper look across health plans in terms of payment policies and medical necessity, in part given rising use of the pumps for a range of needs, including pain, and in the wake of broader discussion about safer ways to address addiction. 71% in our poll of medical and strategic officers at commercial, MA and Medicaid plans noted this.

4. Medicare Advantage Chemo Hurdle: United as of March will require oncology providers to get pre-approval for doing outpatient injectable chemo for Medicare Advantage patients with cancer. The policy impacts providers and patients in Florida and Georgia and then in April rolls out to Wisconsin.

5. Psych In. Babies Out: 58% of rural hospitals in Texas no longer deliver babies. If only telehealth could do the trick, right? Or maybe it could : A maternity nurse in west Texas, Barb Smerson, says she and some former colleagues are thinking of starting a tele, video and dispatch service to avoid situations when families have to drive hours on end to deliver kids. 34% of the hospitals who no longer deliver babies are though pursuing alternative service lines, many looking at adding inpatient psych to make better use of empty wings. Click here for story

6. Conversion: Jerry once accused dentist Tim Whatley of Seinfeld fame of converting to Judaism strictly for the jokes. It did help Whatley with his pre-procedure patient banter so Jerry was probably somewhat right. In healthcare circles, many traditional institutions are facing a conversion of their own but the joke will be on those who miss the bigger picture. A skilled nursing facility in Oklahoma and a hospital in Iowa, both closed due to declining census, will convert to affordable housing, a school, and health clinic for a community in need of all three. These urban-health-social investments are working in a number of communities. United Healthcare is among the organizations making housing investment, enough to help the issue crack the Top 20 managed care priorities. New index here for full analysis.

7. Splitting Medical Necessity: BCBS of New Mexico has new PA requirements for a host of services starting this month, using Evicore some (radiation therapy, advanced imaging, sleep) and managing the rest of the medical necessity evaluations inhouse (dialysis, maternity, neurology, OP surgery, GI, and wound care).

8. Multiple Service Payment Reduction: Anthem and Blue plans are among those now limiting payment on modifier 25 to 50% of the contracted rate when physicians bill it with an evaluation and management service visit. The evaluation is paid at the full contracted rate, but when the same physician does something else for the same patient on the same day billing modifier 25, they will now only get half the rate for this. One contracting manager in Washington on a call this week called this ‘duplication savings’.

9. PBM Play: Regence Blue is using a different PBM this year, changing over to Prime. Home delivery of medications will be managed by AllianceRx Prime, a partnership between the PBM and Walgreens.

10. Extra Point: My mom cheats in scrabble. It’s the closest thing she has to an addiction these days. Like a lot of us, she’s had to deal with a host of behaviors over her 70 some years, not the least of which is my dad. ‘He threw out the social security check again when he was cleaning the kitchen, and now he’s halfway into the outside barrel trying to find them,’ she told me last month. Not sure if she was crying or laughing. Papa can spiral quickly in crisis. He once panicked about not having shaving cream on the eve of a nor’easter, bolted out to the chevy scooter to go to Bill’s general store, and proceeded to back the car right into the lamppost. I still remember helping dad pick up the post and make sure he didn’t electrocute himself trying to fix it. I was 12. I share this story because it illustrates a lot of what we found in our poll of 310 parents (click here), that we love mom and dad, no way do we want them living with us but we do want to help. The fascinating thing is a growing demand among today’s middle age to help the folks get healthcare more easily – like through an app that allows a nurse or physician to come to the home and keep track of those cardiologist visits and medication refills. These apps are now becoming core services of many of the MD-home health businesses cropping up nationwide—those looking to bring us back to Dr. Baker healthcare. In the home. Personal. Low cost. These models, if managed well, and partnered up with Medicare and Medicaid insurers, should thrive. Dad says he likes the home visit at times because he won’t run out of gas on the way to the appointment like last time. He is using ‘the google’ as he calls it for more than looking up basketball drills now. He’s studying up on what he thinks is undiagnosed bipolar (it’s not) and learning about links between nutrition, exercise and mindfulness. Mom says dad spends too much time emailing me. I sort of like it. It’s been a new way to see someone I’ve known my whole life.

1. 7.7 Million: The number of adults who have co-occurring mental health and substance use disorders according to the National Institute on Drug Abuse. New information on comorbidity from a study done across the globe in Australia. The Queensland Brain Institute released a study this month with Aarhus University showing the risk of developing a second mental health disorder. People within the study who were younger than 20 at the onset of their mental disorder were more at risk than others for developing a second disorder in the next 10-15 years. This study is now the largest and most comprehensive look at comorbidity. The next step for this group is to extend the study to identify the risks between mental disorders and the subsequent onset of general medical conditions, such as epilepsy, migraine, heart attacks, and diabetes. If you are looking for how your practice can get a better deal from insurers in the next 5 years it may be in finding a way to prove how your services can help manage or prevent risks related to this mental health spiral.

2. Marriage of 2 Giants: Anthem is taking a bet that Wal-Mart can help them reduce falls in seniors that can cost thousands in avoidable hospital admissions. Its Medicare Advantage members can get a deal on over the counter household safety items like shower grab bars or elevated toilet seats as well as pain medication and other supplies – up to $330 per quarter for many Anthem MA plans starting this year – incenting their members to go to Walmart (or go online) for these purchases through a new partnership rolling out this month. My mother-in-law, an Anthem member, could use a shower bar now that she’s 80 and forgets to eat and drink enough water, but she won’t shop at Wal-Mart because the last time she was there she got so lost in the Tupperware department that she couldn’t find the exit for 2 hours and missed Saturday afternoon Mass.

3. Oncology Pre Approval For Rx: Medicaid managed care plan Sunshine Health has partnered with an oncology company, New Century, to implement a new pre-approval program for cancer treatment for adults. Starting this month, all oncology-related chemo drugs and support agents will require a preauthorization before administration in a doctor’s office, outpatient hospital or ambulatory setting. Optum, meanwhile, will start requiring pre-approval in February for all outpatient injectable chemo, and related therapies.

4. Hip & Knee Oversight Picks Up: Magellan, starting this month, is now doing pre-authorizations and post-service reviews for Florida Blue’s HMO and PPO Medicare Advantage members potentially needing hip and knee procedures.

5. 17.35: Per member per month savings in managing commercially insured members seen by practices doing value based medicine in Kansas, according to Michael Atwood, MD, who heads medical affairs for Blue Kansas. Atwood said the total PMPM in the value models was $6.50. Getting contracts in the future will essentially require providers to come to the table with a value model, according to 80% in our managed care poll last fall, particularly if they are physicians or practitioners treating patients with chronic conditions.

6. If You Build It, Will They Come? 340B hospitals hope so as more of them in 2019 will roll out their own in-house specialty pharmacy. 26%, in a poll we did, say they have one today, up from just 8% two years ago, and an additional 37% say they will or may build one over the next two years to help capture more prescriptions through the discount program. Yes, there’s been some recent angst about the program given more government attention to it, but in some ways this has forced hospitals to ‘go all in while we can’ given the importance of the program in allowing for ‘community programs to exist and service lines to grow.’ Mercy Health System is building a national in-house specialty pharmacy to be available for all of its patients across its integrated delivery network. 6 in 10 say their SPP is part of the preferred network of most national payers. Health plans are getting into the 340B opportunity – at least a third are trying to create arrangements that incent patients to use the 340B health systems and their clinics and specialty pharmacies. Patients ‘pay less’ by using these discount pharmacies and providers within the closed system.

7. Cardiology The Next Target: Several cardiology procedures will now require pre-approval and post-service medical necessity reviews under a new utilization management program that BCBS of Florida, BCBS of Louisiana and several other plans are starting. Procedures performed in an office or outpatient setting will be impacted, including non-emergency procedures like total knee arthroplasty, knee manipulation under anesthesia, knee ligament repair, hip arthroplasty, echocardiography, diagnostic coronary angiography and arterial ultrasound. The UM company AIM will run the program. Both commercial and Medicare plan patients are impacted.

8. School To Home Mental Health Pilot A Gamechanger? Lutheran Social Services of Wisconsin has hired a therapist and a family coach to work with families of students who are receiving mental health services at two Milwaukee area charter schools. The therapist works with children during the school day, and the family coach makes weekly in-home visits. The model, in my opinion, is likely to be a winner over time and be better positioned with managed Medicaid plans seeking more cost effective solutions to mental health. 14 children and their families are participating in the Wisconsin program; the goal is to expand this to 50 by June, and focus on helping those dealing with PTSD, anxiety, depression and other mental health issues. The group hopes to receive state funding to institute 5 other school-centered pilot programs. It has established a committee consisting of state and county representatives, mental health advocacy groups and community organizations to address local and state policy changes needed to sustain the programs. ‘What we’d like to do is achieve policy change for a more comprehensive model of school-based mental health,’ according to the group’s CEO, Hector Colon. ‘That could include higher Medicaid reimbursements for clinical consultations and in-home family coaching. Dr. Judith McMullen, a law professor at Marquette University and committee member, says getting into the home is key but there are challenges in documenting value, proving how the sessions can elevate overall health. Pascual Rodriguez, principal of one of the school’s involved in the pilot, says he is a firm believer in educating children physically, spiritually and emotionally, but acknowledges limitations on what the school guidance team can and cannot offer to some of the kids, so a program like this fills the gap. The future is integration – and therapy that helps not just the kid, but the family. Question is who will convince the policymakers and payers that their model works. See our story on schools and unmet needs here: PE Circa 1983

9. Extra Point: My eighth-grade daughter has the lead in her school play coming up in March and auditions this spring for the lead in an off-Broadway production of Mama Mia, a regional tour that would start in the fall. She has a good chance at the part and, if she gets it, she’d be doing her freshman year of high school on the road juggling algebraic equations, Catcher in the Rye, and learning Sophie’s lines. Her friends don’t understand why she would want to miss the first part of high school, but artists, musicians, they are cut from a different cloth and, to be honest, their healthcare is the stage. Performing, singing in hallways and backseats, and making up songs on the piano rather than studying for a science test – that’s their script. My Sophie asked me if I could tutor her in math on these road trips with the touring show when ‘mom can’t make it’ and I hesitated – not because I don’t want to spend time with her, but because I don’t know what it means when the math question says ‘Solve for X.’ I mean what kind of question is that?!  I will say that if I’ve learned anything from covering healthcare for nearly 25 years now it’s that the secret may be in spending less time doing what is expected and doing more of what just makes us feel good. To heck with high school Soph…break a leg.

1. 80: Percent of non-emergent air ambulance transports, up from 64% last year, that will require pre-approval starting this year, based on a poll of 62 different health plans. There’s a hidden benefit: payers using the authorization process to intercept the next level of care (i.e. hospital or SNF) and diverting to a different option, if lower cost and better quality.

2. No More Reimbursement: Screenings are in and counseling out under a new Aetna policy taking effect this year. The MCO no longer reimburses evaluation and management services billed by some medical specialties, including alcohol and drug counseling, marriage/family therapy, and crisis diversion. Aetna still reimburses structured screenings for alcohol and substance abuse (e.g., AUDIT, DAST), and brief intervention services. Check code 99408-09 if you’re in this field.

3. Top 20: HIV jumped into the top 20 in the latest Managed Care Investment Index, one of eight new entrants since last December to crack the poll of payer priorities. Emergence of generic options is giving managed care an opportunity for savings for the first time in what has historically been an unmanaged class. While it will give payers a chance to save, and likely hurts branded drugs, specialty pharmacies could benefit by making more margin, buying the drug cheaper and getting a larger spread. 6 of the top 20 services or treatments have some connection to behavioral health, the most in the index’s 11-year history. New index here for full analysis.

4. Marriage Is What Brings Us Together, Today: The effort by some PT companies to affiliate or merge with hospitals makes sense given the trend in bundled payment and episodic payments for orthopedic surgery, but there may be a better partner others will consider as a less conventional, but healthier marriage: the worker’s comp insurer. A number of worker’s comp companies—big and small--tell us they are strategizing around acquiring interventional pain and physical therapy providers, as well as a tele-psych service, and identifying exclusive substance abuse treatment partners to gain control of costs and outcomes. In one review, the work comp company said 41 of 100 cases had overuse of both PT and IPM and ‘missed underlying psych’ issues, including PTSD and drug addiction. The strategy is more so in white-board concept stage than formal discussions but is a signal of the growing demand for integration between payer and provider.

5. Live Case Manager, But Not For ABA: Like waiting for your turn to put waffles in the slow-moving toaster when you needed to be on the road to school and work 10 minutes ago, there’s a certain measure of frustration that comes from being in line. Few insurers have figured out the secrets to faster response to managing care but Aetna is trying, by changing its precertification process into a fully queue-based system with a live care manager handling precertification when a patient or provider calls in. ABA services are not evaluated ‘live’, at least not as of yet, in part due to the emerging nature of the service and sheer volume.

6. App Over Entree: A new app that can help someone suffering from depression or anxiety to avoid self-harm could be a new opportunity in the battle to manage care and rising costs in behavioral health. The  ‘Calm Harm’ app, unlike ‘self-assessment’ tools that insurers use to give people a chance to better diagnose themselves before accessing the health system, provides strategies to help a person get past the moment of wanting to self-harm. A few mental health providers are using it as part of discharge planning, what one medical director for a Medicaid plan in Pennsylvania called ‘the kind of value we need more of.’ Whether these apps and assessments bend the cost curve is another story: In a conversation I had with an Aetna manager in between basketball games last week, he said these apps have a bigger impact than you’d think: ‘Still figuring out how to measure impact,’ he said, ‘but we think about 5, maybe 10% of population who use these more than once end up solving their challenges without a medical visit or prescription. Click here  for more on the Calm Harm app.

7. Midwife Win & Loss: A Wisconsin state law changed in 2018 to allow licensed midwives to enroll as ‘providers’ for the state’s Medicaid programs but Anthem has decided for now not to contract with these type of providers, so they won’t cover services midwives perform. The plan will cover nurse practitioner services if the NP is certified with the nurse midwife specialty.

8. Scope of Practice: A reminder that beginning in March Anthem will implement a new policy regarding reimbursement for services or procedures performed outside the scope of a provider’s license. If a provider performs a service or procedure that is outside of the provider’s scope of license, reimbursement may be denied. Details next year on the situations that may impact your practice.

9. Lady Gaga Contracting: Home care companies seeking better managed care contracts ought to send their aides to Gaga concerts for mental health CPR. ‘We just gave a better contract to a home care company because it was the only one in our region whose aides had gone through the training,” says Mary Phelps, a case manager with BCBS in Kansas. The number one goal of the Gaga-led program is suicide prevention. One of our reporters took the training in November – click here for the report.

10. Extra Point: My freshman son went through a bit of big man on campus moment in December, averaging 18 points for his hoops team. He went cold earlier this week, 3 for 15, and found himself sitting more than usual in a loss to a rival. My dad, wife, and just about everyone else felt bad. Jack was down – depressed, over a game. Not sure why, though: being the next Larry Bird or, sorry for the old man reference, Steph Curry, is not the goal here right, nor is it baked in reality. Nor is perfection. He was addicted to the swish, the minutes, the teammates jumping up after a go-ahead 3, but like a lot of addiction, he fell down. He is human. On Thursday, he finally gave me his perspective on the game and he asked for my advice. ‘I don’t have any,’ I said (of course I was a legend in small town, winning all our family games of horse, so I could understand why he came to me). ‘No advise kido. I think what happened in your game was perfect.’ Jack looked at me like I was ET. ‘Wait, what?’ I paused and chuckled, ‘Yeah, perfect. You probably won’t understand it for awhile, maybe not ‘til you’re in your 40s, but someday’