Behavioral Health Insights

740,000: Number of New Yorkers with medical debt on their credit reports as of February 2022 – that's 6% of all residents in the Empire state. A report by the Urban Institute found that NY communities with the highest prevalence of medical debt also faced additional challenges in accessing healthcare – high-debt communities were more rural, had higher rates of disability, and had lower rates of employment. A bill that passed New York State Legislature last month and is awaiting the governor’s review would prevent all medical debt from being included in credit reports.

AI Making Care Decisions: No the great 76ers point guard Allen Iverson is not the new medical director of healthcare but like the hall of famer’s agility navigating to the goal or passing the ball, healthcare’s “AI” is taking on the role of traffic cop under a pilot program from HCSC, the parent company of Blues plans in five states.  The AI pre-authorization tool doesn’t deny any requests - it will kick it over to a clinician if it feels it doesn’t have enough info to approve. During the initial pilot in 2022 for specialty pharmacy and behavioral health, approvals were granted 80% of the time for behavioral health and 66% for pharmacy, and the health plan said it streamlined the process substantially. Now requests for a variety of services will utilize the tool, including inpatient, long-term care, home health, hospice and outpatient services.

Alzheimer’s Cost: The FDA recently decided to grant approval Leqembi, which marks the first time in two decades that a drug for Alzheimer's has received full approval. Clinical trials suggest that Leqembi, administered by IV infusions every two weeks, can slow decline for people with mild symptoms by five to eighteen months. The approval means that Medicare will cover Leqembi for eligible patients at 80% of the total $26,500 cost, leaving patients responsible for the remaining thousands of dollars in co-pays. Medicare Advantage plans will now have to decide if and how they want to cover the drug. Commercial plans will cover the drug with pre-approval and do a review of the site of the infusion, trying to push it to outpatient. The additional cost could lead to increased premiums for all beneficiaries, not just those taking the drug.

Good Drug Combo: CVS Caremark, the PBM, will offer its members access to GoodRx’s prescription program starting next year. The partnership, known as Caremark Cost Saver, will allow members to still use their pharmacy benefit while accessing GoodRx’s often cheaper drugs. The amount members pay will apply against their deductible.

Senior Clinics:  Novant Health, the North Carolina based health system, is partnering with Ochsner health to build “65 Plus” health clinics across the Southeast, providing more access to medical services along with social events and health coaching to seniors. Meanwhile, Virginia Mason Franciscan Health has become the new main acute care referral partner for UnitedHealth’s Optum Washington polyclinic. There’s no financial component according to Virginia Mason’s CEO, but all patients at this Optum clinic will now be referred to Virginia Mason Medical Center and Optum will help manage the health system’s Medicare Advantage patients.

COPD Is Latest To Go Digital: Highmark BCBS recently added virtual COPD treatment provider Wellinks to its network, which will provide 500,000 members in Delaware with access to virtual pulmonary rehab services like exercises, education and personalized coaching.

Bed Less: Health systems are trying to keep up with behavioral health demand by opening new centers. Geisinger opened a new 96-bed unit in Northeast Pennsylvania, in partnership with Acadia, which will begin taking patients August 1. And in Ohio, Akron Children’s Hospital went the outpatient route, hoping to divert pediatric patients from taking up mental health beds in ERs. Patients will have the choice of an all-day program that runs for ten days or an after-school program for three days a week.

Extra Point: Sometimes credit is misplaced, like my bride gave me credit for fixing the toilet leak when it just self-resolved because if I ignore something long enough sometimes I get lucky. Or like in healthcare these days there are a lot of people complaining that they should get the credit for having lowered the patient’s health risk - a social service company tried to persuade a Medicaid plan that their 5 weekly visits to a community of refugees in Minnesota had a much greater impact on the 60% decline in so-called avoidable ER visits than any of the doctors who work inside a building.  “We basically helped these people understand that many times their symptoms could self-resolve or be fixed with changes at home, but we weren’t getting the bonus the doctors were getting,” Paula Kreeger said. A primary care group in the south used its data to convince a Medicare Advantage plan that 261 patients it treated in 2022 should be “attributed” lives, based on a detailed history of when they met the patient, A1C scores for diabetes at the point of care, the treatment plan notes, follow up call log, and follow up visit. “We asked the health plan to show us if these patients had seen another provider that could have indirectly impacted their health too – but they only could come up with that on 18 of them,” Molly Plant, a care coordination director says. Mark Swayne, an attribution specialist, admits that they are encountering attribution issues now with all the bundles and separate contracts with groups managing the same population – “it’s gotten messy assigning who gets credit for cost savings.”  My mom used to say not to worry about getting credit – “you can like it or lump it” she’d say. I didn’t really know what she meant until 6^th grade when Miss Rosebrooks blamed me for killing the goldfish by dumping too much food in the bowl.  I was maybe 25% responsible since I was holding the food, but Lenny pushed Charlie who bumped into me, so her blame was misplaced.  But at 12 years old I had a metal Star Wars lunchbox, could ride my Huffy dirt bike to school and wore blue polyester bell bottoms 4 days a week, so I had it pretty good, obviously.  And so sometimes you just need to take your lumps, keep your chin up and be thankful for just being.

235K: The number of additional ED visits the Center for American Progress projects this summer alone due to increasing temperatures, along with an additional 56,000 hospital admissions.

Social Risk Payout:  BCBS Michigan recently rolled out a new Social Risk Adjustment Initiative, designed to support providers caring for patients with high levels of social needs which often affects overall health. Providers must opt into this program by August 1 and then they will receive funding based on the number of members they have with ADI scores of 8 or above. The Area Deprivation Index numbers are determined neighborhood by neighborhood and the higher the number, the more disadvantaged the area.

R2D2: Dartmouth Hitchcock Medical Center has taken a page from Star Wars and Short Circuit’s Johnny 5 robot and started using 4 foot tall wheeled robots to deliver medications from their pharmacy to patients. Two robots are preprogrammed with regular delivery routes, and a third can be custom programmed by staff members, saving pharmacy technicians and nurses time.

Biosimilar Out of Gate: It isn’t taking long for PBMs to move new biosimilars into the front of the line. Cigna’s PBM Express Scripts announced it will add three biosimilar versions of Humira to its formulary as “preferred” drugs. The biosimilars should be cheaper with manufacturers announcing their versions would be offered anywhere from 5% to 81% cheaper than Humira’s list price. But PBMs negotiate rebates and fees with drugs manufacturers, which means the list price doesn’t always ultimately matter. But the preferred position of these biosimilars should be a positive development for patients looking for a cheaper alternative. SmithRx, a newer PBM, says it now offers the Humira biosimilar Yusimry for $569 plus shipping and dispensing fees through the Mark Cuban Cost Plus Drug Company.

Oral Health Adjustment: Starting in October, kids under 13 get free dental care and adults with certain IDD and mental health diagnoses will get preventive and periodontal services under expanding coverage guidelines from BCBS Massachusetts

Retail Behavioral Health: BCBS Arizona has launched Prosano Health Solutions to blend behavioral health and holistic care. The platform allows members to access primary care teams, behavioral health practitioners, lab services, and more. Prosano will first be available to members of its two PPO plans, but AZ Blue plans to expand to employer groups in 2024 and open four brick-and-mortar locations by the end of 2024.

Urgent Care:  Baylor Scott & White Health will add 41 urgent care locations in Texas through a partnership with NextCare Urgent Care. The health system already owns five urgent care centers, on top of their 51 hospitals, and the joint venture will allow them to increase their footprint outside the Dallas and Austin metro areas.

Extra Point: So I tend to hear a lot of complaining from my family as we approach the table at a restaurant – it’s either too loud for Uncle Roland, too close to the kitchen for cousin Jeff, or too drafty for Aunt Adelline.  “This bacon isn’t burnt enough – send it back,” says Uncle Bobby.  “Dear Lord Uncle B – it’s already black!”  In healthcare, I am hearing a lot of complaining lately from companies about where they sit with insurers - how the payers are too rigid, unwilling to meet much less compromise. Well, there’s some truth to that I suppose but if you really know your history, it’s been 15 some years of many insurers being both flexible and innovative.  I dusted off this interview with Lynn Nishida, the clinical director up at Regence BCBS in Washington. Back in 2008, I called her about an article I was writing on payer-provider marriages in oncology.  Lynn chuckled, then told me how Puget Sound Cancer Center in Seattle had convinced her to lift pre-authorization on erythropoiesis-stimulating agents widely used in managing anemia in cancer patients. Regence spent $70 for each authorization and wanted a better way to limit that cost, address safe use of ESAs, and guide doctors on when to initiate therapy based on blood cell count.  The cancer center had developed a protocol checking iron levels first then starting patients on ESAs with hematocrit under 30 and stopping at 36, according to Richard McGee, the CEO.  “The protocol intrigued us,” she said. “I would have expected some patients to fall out of the thresh­olds but that wasn’t the case, and [PSCC] got 100% of its physicians to follow the orders without any prior authorization.” PSCC’s stand­ing orders did not necessarily align with Regence’s medication policy, but they were a jumping off point. “We were willing to align their orders with our already developed policies,” Lynn said. “We weren’t bypassing the PA—there’s still a standard review through a quarterly retrospective audit,” clarifies Nishida, “but what we’re doing is selecting prescribers who are actually performing well and have a commitment to safety and the right use of medications based on science.”  So for anyone complaining in healthcare, maybe take a page from the past and show the payer you have a better way – you might be surprised. And for anyone in my family - that especially means you Uncle Bobby – yes, the chair is wobbly and the bacon not crispy enough, but doesn’t this beat another TV dinner with Wheel of Fortune reruns?

83: Portion of parents of teenagers who say they are increasing spending out of pocket and through insurance copays on their own care and health related to stress, anxiety, fitness in part due to recent results of lab work or primary care visits showing some combination of problematic indicators of morbidity, like rising cholesterol, rising BP and hypertension, rising A1c and “less productive workdays.”

Predicting Things: In an old episode of Seinfeld George Costanza once asked Kramer about a discoloring on his lip and Kramer, classically, said “Whoa buddy – better get that checked out,” so George did but his doctor said, “Well I don’t know what that is…I haven’t seen that.” Artificial intelligence seems to be helping where TV doctors and others fall short, particularly when the issue is inside the body. AI used at three UPMC hospitals in Pennsylvania performed better than the most common methods for diagnosing certain heart conditions in patients with chest pain, according to a recent published study. And in another study, researchers found that AI helped predict the development of Parkinson’s disease after analyzing data from over 100,000 smartwatch users. Despite the uptick of AI in healthcare, a recent survey found that 80% of patients still are not comfortable with AI and would prefer seeing actual providers for most healthcare services.

No More Double Dip: Effective October 1, 2023, Horizon BCBS will reduce payment for codes representing problem-oriented E&M services by 50% when the services are rendered on the same date of service and by the same provider as routine/preventive E&M services regardless of which procedure codes are appended with Modifier 25. This comes as little surprise as we’ve seen more and more health plans cracking down on E&M coding, making sure they are only paying for what they deem appropriate. In June, Blue Cross NC said it was halting reimbursement for any imaging services – X-ray, CT, or MRI – when billed within 28 days of a principal diagnosis of uncomplicated lower back pain. The health plan is trying to reduce “excessive tests or procedures that result in unnecessary medical expenses.”

Cell Therapy: BCBS Michigan will begin having providers use a portal to track clinical outcomes for members receiving CAR-T cell therapy drugs in July. Audaire Health will provide the portal and when providers request prior authorization for any of six different cell therapies, they will have to confirm they will enter clinical outcome information as their patient progresses on treatment. The portal is meant to ease administrative burden for providers while helping the health plan track how these very high-cost therapies are actually working for their members.

Vascular Control: Aetna is beginning a new Peripheral Vascular Disease program in September for all commercial and Medicare Advantage members. Services like atherectomies, angioplasties, and stenting will begin requiring preapproval through eviCore.

Look On Bright Side: Molina will buy the remainder of Bright Health’s Medicare Advantage business in California for around $500 million. This means Bright Health will no longer operate at all in the health insurance business and will instead focus on consumer care products.

Policy Switch: Highmark announced this week that they would not reinstate their “Stabilize and Transfer” OON protocol for narrow network products, as had been previously announced. So this means the growing eastern US insurer will continue to pay out of network providers directly when they provide emergency care to members at a hospital or freestanding emergency department.

Extra Point (Partially From The Archives): So my folks were late again to supper last night because they were waiting for each other at the library because it had air conditioning that we don’t, sitting on benches maybe 10 feet apart inside the “Fiction” section, pointed in opposite directions…dad having fallen asleep from one too many cinnamon cookies. I dislike summer, but I love fall. There’s the leaf jumping, apple crisp and college football, the pumpkin seeds, bulky sweaters, and gramma’s mashed potatoes. There’s the Fall guy and the Fall of the Empire, Niagra and Tacko Fall, that 7’6” basketball player. There’s Fall Out Boy, falling in love and Fallen, that great Sara McLachlan song. But would you believe it, some people don’t like fall, even though they keep doing it. Some are just clumsy like me, some like Janice fall because their husbands fail to adjust the bike seat. Others have cataracts or glaucoma or live in the icy north, but many are older folks with dementia or weaker bones or malnourishment or fall from the heat of the summer, for whom falls are as common as Uncle Bobby blaming me again for “deleting the internet” because I removed the shortcut to his browser. My dad has fallen a few dozen times – twice hospitalized – while my mother-in-law fell some 15 times after turning 80 that we know about, most of which have landed her in the hospital. What’s underappreciated about falls – the cause isn’t always what you think. We once studied 65 seniors who had fallen and needed inpatient rehab only to learn that some 39 of them had lost a spouse, never really grieved, and became sedentary. They fell into their spouse’s habits and into a health spiral. So, if you are in healthcare and see seniors or are a caregiver on some level for aging relatives, take note not just of what’s happening inside their body but what’s going on inside their home and their heart.

1.7M: The number of Americans who rely on so-called health sharing plans, which are typically arrangements for people who usually share similar religious beliefs and agree to pay one another’s medical bills.  A new report from the Colorado Division of Insurance concluded that even though 1.7 million people is higher than previously realized, the true number is likely still undercounted. These plans do not function as typical commercial health plans, but do not always advertise that appropriately. They do not guarantee payment for health services and are not held to the same standards and consumer protections as commercial plans, such as covering preexisting conditions. The report found that these plans often require people to seek charity care first and many people do not realize that coverage isn’t guaranteed.

Predicting Workflow: OSF Health is utilizing AI to assist with cancer care navigation. The Illinois health system has 15 care navigators at its largest hospital, all of whom focus on specific cancers. The AI model will help predict the upcoming week’s work for existing patients and then factors in which navigators have the bandwidth to take on new patients. The team behind the model hopes this will help even out workloads and prevent burnout.

Heading Off Crisis: Insurer Elevance (formerly Anthem) is using a predictive analytics process to identify teens with risk of suicide, contact their families early, and lower the ~59% of commercial behavioral spend tied to residential and inpatient treatment, according to David Lederman, a product manager at Elevance. This behavioral health initiative is focused on the insurer's ASO business line.  The Blue Cross Blue Shield Association is also trying to head off crisis by partnering with the Boys & Girls Clubs of America. $10 million in funding will go towards a variety of things including professional development to help train 48,000 staff in trauma informed approaches and provide youth with virtual therapy as needed. This investment is expected to reach 3.6 million children nationwide.

A Pickle Of A Problem: Injuries for America's latest phenomenon, pickleball, could cost between $250-500 million this year, according to a recent UBS analysis. Injuries among players 60 and older have risen the most and one study noted that pickleball has become “an increasingly important cause of injury" - even though I'd argue it's a great way to keep people moving. The analysts estimated medical trips and procedures due to injuries will result in approximately $377,000,000 of medical costs, 80% of which likely tie to outpatient care. Many health insurers report outsized outpatient health services utilization in the first half of this year and the pickleball craze could be a part of that. For our part, predicting pickleball injuries is fairly easy - you can see it in people when they walk on the court, or don't stretch, but also in those who try to play like they are Rafael Nadal.

Predicting Weight Loss Drug Impact: Pharmaceutical company Novo Nordisk announced it will seek FDA approval for its oral version of the weight loss drug Ozempic. Predicting whether people will use the medicine and maintain health is to be determined. Clinical trials found the oral alternative to be just as effective as the injectable but there is no timeline for when the semaglutide pill will hit the market. Pharmaceutical competitors Eli Lilly and Pfizer are also in active trials with their own versions of oral weight loss drugs. The estimated cost of the current injectable versions of these medications are around $10,000 per member per year and utilization has skyrocketed, likely forcing payers to react. Oral versions would likely appeal to more people so we expect payers will continue to think through how to control the adoption.

Extra Point: I once called a colleague Radar O'Reilly for her knack of doing things before I even ask for them. "I don't know who that is," she said in response to my email. Realizing my blunder, I quickly called her and tiptoed through my reason saying she, like the short 1970s M.A.S.H. TV character, had a knack of doing things before even being asked, like predicting what I'd need. "Well that makes me feel better," she said. "I was worried because I looked up his picture online." Predicting things to do before being told to do them like Radar is no small feat. There's quite a lot of that innovation these days in predicting disease, like genetic tests and imaging that can mark what's to come even when you have no idea and feel great. You can figure out stuff, predict a condition at its earlier point, and plan your future.  There's a lot of attention to this so-called predictive analytics era, particularly from those who have responsibility for paying for it, like is there utility to the test, will it tell us something we already know, is it necessary even if there's family history? These are fair questions, but maybe a bigger one is will the results actually change behavior? Would the answer give people enough information to adjust how they live?  I mean, these genetic testing and imaging advances are nice until they aren't. We asked a few thousand people and about half of them don't even want to know - "Nah, not interested - no test is going to stop Jack Daniels from visiting every night," said Charlie, a 57-year-old from southern Missouri.  52% do, but half of them say they probably wouldn't change - "if it were predicting cancer, I might stop using the pesticide on my lawn but I do like the lawn really green," said Marge, 49, of eastern Pennsylvania. I'm on the fence personally. I just had a coronary calcium scan using CT imaging that "shocked" my internist. My score was so high that he summoned me to his office, prescribed a statin and referred me to a cardiologist - this all from a doctor who until now described my health profile as "unremarkable," that I'd pass a stress test easily. I guess I'm happy I know, I think, but I'm not sure my behavior is going to change. Perhaps this is precisely why insurers are reluctant to cover these advances at least not without oversight. Parents are in a similar position I suppose. Like on Wednesday, Tommy asked me if he could use my credit card to buy a $77 kit to diagnose ph levels in our soil. "If it's higher than a 7, it's high sodium," Tommy said. "I know, I researched it." Why in the world do we need to diagnose it - "because I'm trying to find the best area to plant a garden so we don't have to keep buying blueberries - and if it's more than 7 it won't work."  I asked him if the soil was chalky and he said, "yeah yeah - so what does that mean?"  It means we just diagnosed the soil kiddo. It's not going to grow us blueberries, and we're not going to spend $77. How 'bout dem apples!

30: If a person’s BMI is above this number, standard guidelines say they are considered obese, but a new report from the AMA states that BMI is an “imperfect measurement” and has caused “historical harm” including racist exclusion. The AMA suggests that if BMI is used, it should be used in combination with looking at other factors such as waist circumference and genetic or metabolic factors.

Screening AC: Effective September 1, eviCore will lower the age needed for coverage of an annual screening of MRI for two genetic mutations ATM and CHEK2 to 30 years of age instead of 40. eviCore is a part of Cigna and also handles benefit and coverage decisions for many other insurers.

Understocked: Less than 60% of US pharmacies stock buprenorphine, used for treating substance use disorder, resulting in treatment deserts across the country. Barriers to prescribe buprenorphine have loosened in recent years, but many patients still struggle to get their prescription filled, which can lead to withdrawal and relapsing. Buprenorphine is even more challenging to find for teenage patients, and despite being the only medication approved for youth, it is only offered at 24% of adolescent residential addiction treatment facilities.

The Digital Formulary: More health insurers are now developing "digital formularies" or digital "networks" to address the avalanche of new companies. "We are setting up a dedicated contracting unit and policies both to vet these providers and oversee them - long time coming," Ken Han told me. A good example might be eLovu, a new digital maternal care platform that works with obstetricians to prevent maternal mortality and head off issues like preeclampsia or postpartum depression. eLovu is currently covered by commercial insurance and Medicaid, and partners with hospitals and health systems, and Han said that with any of these businesses one of the keys to their inhouse contract unit will be to connect with the "provider network team" to understand the implications of adding these businesses.  "It's a positive usually but we need to think about how the doctors are paid and incented and if adding one digital company creates bifurcation, upsets the network, creates duplicate services - and how to control for that."

Nurse On Screen: Providence Health System recently announced it was implementing virtual nursing models at eight hospitals in Texas, as are several other health systems across the country, in part to staff shortages. Virtual nurses can handle admission, taking medical history, assessing symptoms and handling discharge and transfers. Nursing unions have expressed concerns about clinicians providing care remotely but hospitals that have implemented virtual programs have responded strongly ensuring they have put safety precautions in place.

Moving In: As Humana moves out of the commercial insurance space, other health plans are stepping up to cover those members, including Humana’s own employees. Effective July 1, Blue Cross NC will begin providing coverage to Humana workers with employer sponsored coverage.  The same issue is likely starting to unfold as people are disenrolled from Medicaid due to the end of COVID's public health emergency, but as with all these changes there is often a gap in insurance and often access to care. "We saw this in 2008 during the economic downturn - people lost jobs, lost insurance, stopped going to the doctor and then we had a wave of late-stage IV cancer diagnoses," Patti Journs, RN, said.

Extra Point: I once heard legendary baseball announcer Vin Scully tell this story during a game about how he put on a Dodgers uniform and crept into the Cubs dugout just after the Anthem at a Cubs-Dodgers tussle. "I kept my cap down at the brow and arms crossed at the chest, so no one seemed to know who I was for a good half inning," Scully described in that relaxed pace only he could.  That's until the 1st base coach hollered "Vinny" and flipped a ball right at Scully as the players were heading in for the bottom half of the first. Scully caught it and saw written on the ball these words - "if a fight breaks out, I want you," and it was signed by Cubs manager, Don Zimmer. A good friend of my family Stephen Szydlowski reminded me the other day that baseball games in 2023 may be faster but there's no time for these stories, no time to give the audience the inside scoop, the perspective from the trenches. We rush through a lot of stuff these days if you think about it, in a culture where everything has to be instant, faster - rushing through meals, backroads, grocery aisles, and checkout lines, through work meetings, a good page in a good book, an email reply. Schools seem to always be rushing at the bell and in healthcare I'd argue that most of the last 50 years have largely been a rush - in one of our recent consumer polls of 3,135 people some 45% felt rushed out of their appointment in an office or even at home, without a chance to give the nurse or doctor their perspective, their vantage point, the context.  Storytelling is somewhat a lost art and, yeah, maybe it doesn't fit the core curriculum for educators or meet the requirements for doctors to bill insurers - but it means something to people, and I'd argue its vastly underappreciated in its ability to make an impact and change a life.

51: Percent of private practice psychiatrists in this country accept cash only, down slightly since 2017 but still high, and 89% of them in our poll are flat out fully booked.  This is an issue on several levels, one being that many sub-specialists stay cash-only. You can get in with a specialist, but you almost have to be connected personally to them. In one situation, a psychiatrist from the Seattle area known for treating panic disorders couldn’t accept more patients and had a wait list longer than that line I waited in with dad to see Return of the Jedi in ’83. They will bend and take patients either pro bono or as an exception at $275 an hour, but there are only so many hours in the day.

The New PBM: SmithRx, a newer PBM, announced they will offer a Humira biosimilar launching in July to its members at a 90%+ discount to the cost of Humira. The PBM will work with Mark Cuban Cost Plus Drug Company to offer the biosimilar Yusimry for $569 plus shipping and dispensing fees and then members will be able to apply any insurance coverage to further reduce out-of-pocket costs. Click here to register for today's 1PM EST call on PBMs and drug pricing,

Outside The Box: Healthgrades and OutCare Health, a nonprofit focused on LGBTQ+ health equity, have launched a new LGBTQ+ affirming care designation to help LGBTQ+ patients find providers they trust. Providers interested in joining the designation must undergo a review by OutCare and will then be added to OutCare’s “OutList” which is the largest international directory of such providers, helping millions of consumers each month find and schedule appointments. On a sidenote, if needing to call the 988 hotline for mental health crisis, you would press 2 if LGBTQ+.

The Blockade: A Louisiana Medicaid MCO has been requiring pre-authorization for mobile mental health crisis units before they can dispatch to help patients in need, according to Randal Gomez-Simon, the VP for Business Development at Woodlake Addiction Recovery Center. “It’s causing people to end up calling 911 and eventually end up in hospitals,” she told us Thursday during an event in New Orleans.  Sometimes pre-authorization is counterproductive, sometimes it’s necessary as Elevance (Anthem) decided with a new policy requiring precertification this September for wilderness programs and VR-assisted therapy systems.

Room For Shared Savings? Rheumatologists could be the latest to benefit from payment innovation. Starting July 1, 2023, Blue Cross NC is launching an Autoimmune Pathways Program aimed at reducing costs for members with chronic inflammatory disease who need specialty drugs for treatment. As part of what the health plan calls a “shared savings program” rheumatologists will have access to a web-based machine-learning platform that suggests evidence-based care pathways – for members taking high-cost biologics, the pathways may encourage use of lower costs treatments or dose tapering or ceasing medication if the member is in remission.

Virtually 15% Less: Effective as of June 1st, Independence BCBS in Pennsylvania has started to reimburse providers for physical health telemedicine at 85% of the provider allowance. The reduction kicked in this June, only applies to Medicare Advantage members and, like other insurers who have lower rates this year, won’t apply to behavioral purposes.

Driving Spinach & Eggs: Uber Health is getting into the food as medicine movement with a new grocery delivery service for patients recently discharged from hospitals and other post-acute care settings. The new service will allow a provider to select foods that fit a patient's dietary needs and have it delivered to their homes. Like we predicted back in 2014 when we suggested grocery delivery service Peapod ought to add nutritionists and partner with healthcare insurers and hospitals (see video here – starting at the 4:20 minute mark until 5:55), nearly a decade later the grocery delivery service Instacart is moving into healthcare with the launch of Instacart Health. As part of the launch, the company will work with WellCare of Kentucky and digital health company, Good Measures, to make food prescription programs available for Medicaid members. Good Measures’ dietitians will work with members to create a nutrition plan for them, which will be accessible via Instacart. For low-income consumers, Instacart will allow people to use their Temporary Assistance for Needy Families benefits as well as Supplemental Nutrition Assistance Program assistance funds.

At Home Test Kit: Simple HealthKit, a provider of at-home testing kits and digital health tools, has entered a deal with Walmart to offer their products in stores and online. The retailer will now offer at-home diagnostic tests for diabetes, respiratory wellness and sexually transmitted diseases. Simple HealthKit provides physician oversight for users and those who receive abnormal tests are connected to a provider at no additional cost.

Double Trouble: Yet another cross-market merger was announced recently – this time between St. Louis-based BJC Healthcare and Kansas City-based Saint Luke’s Health System. We’ve seen several of these recently, like Advocate-Atrium and Kaiser-Geisinger. These types of mergers likely represent a new challenge for independent companies trying to recruit labor, negotiate for better reimbursement, and if they rely on referrals from doctors “absorbed” into these systems.

Extra Point: A policy quirk in one of Georgia’s 159 counties apparently didn’t allow 6’6” 20-year-old Sam to be taken voluntarily in an ambulance to a mental health crisis center, despite efforts by counselor Wendy Martinez Farmer to set up a bed at the center after driving to Sam’s family home when his mom called asking for help for a kid who had lost control. Turns out due to county law Sam had to first go to the hospital ER where he got tazed, afraid he would be poisoned by a needle. This policy – and the one earlier in our column here about requiring pre-approval for mobile crisis – seems to be remnants of a system in transition, like the typewriter that sits on my desk, next to my laptop. For Wendy, who works with Carelon and has helped set up several call centers for the 988 mental health system including a Spanish-speaking one in New Mexico, the hotline is one way to help people like Sam. She told me that the vast majority using the text and chat 988 service are under 25 and 80% of them confirmed recent suicidal thoughts. Surprising to me, about 80% of these calls/texts and chats are “resolved” but there is not great data on how well referrals are working for those needing it and Wendy admits “resolving” the crisis is often all they can do – “it’s an actual intervention – which is underappreciated” but it’s not a long-term solution for that patient. That’s why the 988 counselors do, in fact, set up appointments ideally for the next day for people who need it, but this is increasingly difficult and there is not great information on whether the individuals get to the appointments, let alone crisis centers same day or inpatient treatment in emergencies. A lot of people still call 911 but only some of those responders are trained and knowledgeable enough to transition the person over to 988. Like any new system, this should improve. In Houston, a 911 and 988 crisis center co-locates responders and is having better results. I suppose these quirks will work themselves so kids like Sam and their families can have a better outcome.

71/100: The portion of cardiologists from our national poll who are in the process of or contemplating whether to enter an affiliation with the local hospital to tap into EMR upgrades, reimbursement increases, and referral volume. 19 are contemplating merging with other groups, staying independent, and finding a way to partner with health plans, and 10 will retire. Of those looking to align with hospitals, the insurer isn’t surprised but wonders about cost – that Duplex ultrasound to test for a leg clot in a 79-year-old 2 weeks after quadruple bypass may be necessary, but at a 3x higher cost when done in the hospital. 

How Urgent Is It?  The next great challenge for the healthcare system may just be figuring out how to get patients into treatment after they end up at an urgent care psych center or call into the 988 suicide hotline. The wave of urgent care psych centers is growing – 5 years ago there were less than a dozen in the US and some filled up so quickly with commercial patients that their intent of serving the uninsured failed, like at the Mental Health Cooperative in Nashville. Efforts by hospital systems to open these with funding from corporate support, including pro sports teams like the Miami Dolphins and insurers like BCBS of Florida, are likely to grow. But as is the MO for US healthcare, we fix one problem and create another – calls to some of the operators at these centers suggest difficulty placing patients into a bed or the right level of care quickly enough and sometimes given their suicidality, they up in the hospital anyways. It will be important for these centers to establish local and regional partners – PHPs, RTCs and outpatient psychiatrists if possible.

Double Trouble: A BCBS of Massachusetts study has found that the insurer’s annual spend on mental health services doubled from $610M in 2019 to $1.3B in 2022. BCBS MA also says to meet demand its mental health provider network has grown by over 50% in the last 5 years and now includes more than 18K clinicians. Other Blues say spend has grown from 1-2% to 6-8% of total medical in recent years.

Lifting The Cloud: Google Cloud and Mayo Clinic have partnered to develop a generative AI-enabled enterprise search capability for the system’s healthcare providers and researchers, with the goal of making it easier for clinicians to access critical medical information at the point of care. Cardon Health announced this week it is introducing an AI-enabled voice-to-text- tool to help clinicians write medical notes in its electronic health record system.

Drug Price Change: In case you missed it, insurer Highmark in September will move from a tiered pricing model for generic and brand drugs or biologicals to a standardized reimbursement method based on the average sales price plus 20%. The change applies to facilities and physicians. ASP, according to some studies, can be up to 30 percent below AWP at the median for brand drugs and 70 percent below AWP for generics.

Extra Point: There is an air of frustration seeping through society lately but I’m hopeful it will fade. A pair of doubles tennis players smacked a ball toward the baseline after losing a game at the French Open last week, only to be disqualified because the yellow ball hit one of the ball girls in the head. A few nurses in London have been suspended for kicking uncooperative patients and a doctor was docked pay reportedly at an Iowa medical center for kicking the monitor because it wasn’t bringing up the patient’s medical history. I can actually relate – as a high school senior in 1990, I kicked a basketball that ended up ricocheting off the wall and landing on poor Heather Duckett’s head, knocking out the cheerleader. This not only hurt my chances of Heather agreeing to go to prom with me, but I was suspended from the next game. In healthcare, there seems to be a bubbling of frustration up and down the health system about the cost of labor, the long hours, and difficulty getting attention of government and commercial payers to help out. There’s no one solution but you’ll kick yourself if you’re not preparing data about how you save these insurers medical, pharmacy and social costs – are you using your influence, data and staff to bend the cost curve – like sending a staffer home to do a follow up visit with seniors who don’t come into appointments with a caregiver. Said a friend who manages contracting for a BCBS plan, “I think there are situations when we should absolutely increase reimbursement if you can show how you help save downstream costs – otherwise, as frustrating as it seems, probably not.”

99:  No not red balloons or that Prince classic but the amount in dollars that it costs people to get a cardiac CT calcium score, a scan that takes less than 10 minutes typically to see the amount of hardened plaque in your heart vessels and likely build-up in arteries. Insurers rarely cover this, but they may start to. “I could see it for healthy and active 50–60-year-olds with significant family history of heart attacks who would easily pass a stress test,” says Marla Calcaveccia, a medical director. Depending on the “score,” primary care doctors may recommend a statin or some other treatment to head off future blockages.

Drug Price Change:  Insurer Highmark in September will move from a tiered pricing model for generic and brand drugs or biologicals to a standardized reimbursement method based on the average sales price plus 20%. The change applies to facilities and physicians.  ASP, according to some studies, can be up to 30 percent below AWP at the median for brand drugs and 70 percent below AWP for generics. It can be complicated to understand how this type of change could impact your drug reimbursement. Reach out anytime.

Filling The Rocky Mountain Bed Gap: Colorado is offering a hiring bonus of $14,000 to nurses to work in mental health facilities in an effort to fill nearly 200 open positions. Facilities located in Pueblo and Fort Logan in Denver can have as many as 100 beds open at a time but are not available to patients because of the lack of staff. Patients often remain in jails while they wait for a bed to open.  Colorado is one of the 5 states most in need of nurses, with an estimated shortage of 10,000 RNs by 2026, according to a Mercer study.

College Gap: Solutions to help college kids with their health tend to still rely on the student to reach out which “rarely happens” if you are suffering from depression, eating disorders or anxiety. College’s ought to use a database that collects input from professors about students who have missed classes.  If a student is missing multiple classes and across multiple courses this could create a flag in the system and prompt student services to reach out. I say this as someone who barely knows how to open an Excel document, much less create a flag in a system, but these kinds of solutions will be important if the country wants to seriously change the narrative around suicide. In a good step, more college health programs are partnering with behavioral health contractors. Companies like Mantra Health and Uwill have partnered with hundreds of college campuses across the country to offer digital mental health services to students. “I like the database idea because you create a more holistic set of information,” says Haley Gregory, an MSW from New Jersey. “Leaving it up to one professor at these big schools, even small ones, is asking a lot – the students will invariably find their person, but the question is when.”

Resuscitate Child Care: Since March 2020 two thirds of childcare centers have closed, according to the National Database of Childcare Closures in the U.S., worsening a childcare crisis that further exacerbates the national nursing shortage. Many experts say providing childcare to retain nurses on staff is the answer. Ballad Health is in the process of expanding to include 11 more childcare sites throughout Northeast Tennessee and Southwest Virginia particularly for recruitment and retention of staff. Wellstar Health, a health system in Georgia, conducted an internal study reporting a low turnover rate of staff members because they used the childcare center – only 1.5%.

ROI, But You Have To Wait For It:  Employers and insurers have a couple challenges ahead figuring out how to pay for people to lose weight – the benefit is obviously lower long-term medical costs but “sometimes we only have a member for 2-3 years, that is the average for us, so time to ROI on a lot of the new services and drugs matters,” benefits manager Paul Lorne told us. Take Noom, the digital weight loss platform that has launched a telemedicine company to include prescriptions for weight loss drugs such as Ozempic and Wegovy, or WeightWatchers who recently acquired Sequence, a digital platform for clinical weight management and prescribing. Are these services and drugs bending the cost curve-and how quickly? If you’re a health system owned plan like Presbyterian Health Plan, you can try simpler tactics like partnering with New Mexico-based TruFit to offer a weight-loss app to enrollees with self-directed benefits. But if you’re a big insurer trying to get primary care doctors incentives for managing care, how do you navigate when employers are carving out services and giving these telemed companies direct access to patients without rules around communicating back to the PCP?

Extra Point: I sometimes like to think I’m Dick Clark on The $100,000 Pyramid when he’d jump in after the contestants fell short because they couldn’t come up with the perfect clue for “Things That Disappear.” If I were channeling my inner Dick Clark, I’d lean in over that cheesy circular gameshow railing and say something like “the other sock…a golf ball sliced into the woods….the eggs in a house of teenage boys….a job in a down market…your car keys when you have to take the kid to work…a loved one.”  For me personally and a lot of folks as they get older, the list of things that disappear or lose seems to be growing - like my poise and energy, my hearing, posture and patience, dad’s discharge instructions, and time with people who matter. But it’s okay. When things disappear, it doesn’t mean they are gone forever. They just found a new home is all and maybe will turn up in some other form when you least expect. Just ask 2-year-old Hayden Wheeler whose red golf ball disappeared (see below) at Castle Creek Mini Golf in Salem, Massachusetts back in 2000. I would think Hayden, now 25, probably came across that ball again – maybe it was the same one or maybe it just had a new look and a fresh perspective.

35: Percent of Americans who said their financial situation was worse in 2022 compared to 2021, which led to a higher number of people skipping medical treatment due to the cost, according to a Federal Reserve study. Only 75% of families with income under $25,000 reported being in good health, compared with 91% for those with income of $100,000 or more. People most often skipped the dentist, followed by seeing medical providers and filling prescriptions.

Oh, The Worried Well: As Archie once said, ‘why do they always give me a shot where the pain ain’t…?’  It was classic Bunker, worried, agitated and usually offensive. I wonder what he’d make of all the changes in healthcare – urgent care clinics, for one, are more often than not staffed by allied health providers. Bunker only wanted ‘regular doctors’ as he called them and, even though he didn’t know it, he had a bit of managed care in him. ‘Do I really need this um needle?’ he would argue. If there’s one delivery model set to face some competitive turbulence and patient cost adjustments between now and 2025 it may be urgent care. HCA is acquiring 41 urgent care clinics in Texas – 19 FastMed and 22 MedPost clinics in Dallas, Austin, San Antonio, Houston and El Paso. In other urgent care news, Zocdoc has added urgent care clinics to its online platform – the company says urgent care is one of their fastest growing categories. Patients now have 200+ locations across 22 states to choose from.

Pay For Equity: BCBS Massachusetts announced that Tufts Medicine is now a part of the health plan’s pay-for-equity financial payment model. The model ties financial incentives to achieving measurable improvements in health equity. Tufts will focus on reducing inequities in colorectal cancer screenings, diabetes care, hypertension and adolescent well-care visits in their network of 2,300 primary care practices.

Rx Tool: Pharmaceutical analytics company HealthPlan Data Solutions is launching its second product, called RevealRx, to offer payer pharmacy teams a tool that targets members though outreach and streamlines care management. The interface automatically enrolls and disenrolls members, and payers can monitor the data being fed to their case managers to reduce time lost from duplicate calls.

Authorize This: The prior authorization process is considered one of the most time-consuming administrative duties by providers and takes longer to do manually (20 minutes on average) compared to electronically (9 minutes), according to a Council for Affordable Quality Healthcare (CAQH) report.  Only about 28% of pre authorizations are processed electronically, though this number has doubled in the past decade and is much higher for things like claims and eligibility and benefit verifications. A bigger question is where the puck moves – for diagnostics, like labs and imaging, there is more authorization for newer generation testing and outpatient diagnostics, but less authorization for certain services considered as cost savers, like the first 3 visits to PT to treat low back pain.

Advanced Care Planning: Cigna is partnering with Koda Health to provide services related to advanced care planning for some Medicare Advantage beneficiaries. Koda’s platform aims to address a gap in coverage around advanced care planning surrounding palliative care, which about only one-third of people make plans for. Cigna plans to expand access to the Koda platform across their MA membership in the future.

Glass Half Full: Cigna is once again delaying their new E&M policy that we mentioned in last week’s edition that would have required providers to submit office notes when submitting E&M claims with modifier 25. The health plan originally tried to put this policy in place last summer but faced significant pushback from providers. Seems like providers have been successful once again.

ER Audit: Starting in September, Highmark will begin auditing emergency claims to determine if the correct codes are billed. The audits, pushed back from their original start date planned for this month, may result in a different reimbursement if the health plan determines the wrong code was billed. We’ve seen several other commercial plans doing pre-pay review of ER coding, particularly level 4 and 5 visits, and it doesn’t look like this trend is going away.

A Richard Kimble Moment: If you are looking to recruit people, link up with local colleges who are expanding their PA and NP programs. About a year ago, a Bay Path College student from Springfield Massachusetts was thrust into helping my dad clean a wound. Dad had pulled a Richard Kimble back home, wrapping a deep shin wound with one hand using amateur tape and gauze like the Fugitive character, driving himself to urgent care in what was a race against time. He had fallen in the garden trying to relocate a hosta only to slip or get dizzy and slam his right shin into a rock. He would later tell me he ‘wanted to get it stitched up before mom found out….’ But the so-called 24-7 urgent care was closed—two of them in fact—so I made my way to dad’s house to pick him up. We averted going to the hospital ER, finding the only urgent care open in the region. The PA, a Bay Path College student, was sharp and a great teacher - cleaning the wound, putting in 8 stiches and allowing dad to feel comfortable.

Extra Point (From The Archives): My kids complain a lot about how I go down the ‘when I grew up’ road way too often and make references to characters like Richard Kimble as though they grew up in the 60s. It’s just so easy sometimes. Helps me make a point, like my latest rant leading into Memorial Day weekend: When I grew up, we ate supper together on Sundays. At 2 o’clock. Not because we were hungry, or it was raining, but because grandma said so. Afterwards, we played kickball ‘til dark. We didn’t have hover boards or Fortnite or Twittergrams or Snapbook. When we fell on the driveway during a game of ‘Red Rover’, mom didn’t rush us to urgent care. There was no urgent care. She layered on three Band Aides and gave you a slice of warmed up apple pie. We didn’t have depression—at least not in the way it’s understood today. Yes, we were sad when the Yankees and Sox were in a rain delay, but dad cheered us up by putting the Polka on the record player and throwing us on his shoulders. We danced. We had a simple life with at most three principles, and I’m pretty sure two of them had something to do with mashed potatoes. We didn’t text or Jabber or FaceTime, we stood by an answering machine hooked up to the rotary dial, replaying Sam’s message because you couldn’t hear the phone number the first dozen times. ‘Download’ was not a word. To hear Survivor’s You Can’t Hold Back, we had to rewind Side B for six seconds, then flip the cassette at least a half dozen times to get to Side A to just the right time. When we were bored, we picked up a shovel and dug a hole, found some worms and put them under my sister’s pillow. Our friends were mostly the seven people we shared the upstairs bathroom with. The same seven we fought with for the Raisin Bran. We wrestled with grandma, played ‘setback’ with papa, and listened to Joe Castiglione call the game on the AM dial. On a good day, I would hold the bunny ears on the RCA, so we could watch the game on TV. What strikes me about then is how if you’re lucky you can get glimpses of this today. Like last weekend, I asked Tommy to lean the phone against the wheelbarrow when we weeded the driveway. We listened to a replay of the inning Fisk waved that homerun fair. We ate spaghetti around two and then played Twister, until the dog peed on the green circle. What’s past is prologue. I would argue that, for some of us lucky enough to be safe and healthy, we aren’t standing still at all as it may seem at times. We are going back, and there’s some good to come from that.

12,000: The number of people who called into the National Maternal Mental Health Hotline in its first 11 months. The hotline, launched on Mother’s Day in 2022, can be called or texted with any type of concern related to maternal health, and about 70% of contacts so far have been phone calls. The US has higher maternal mortality rates compared to other developed countries, and the hotline was launched as part of a broader effort to reduce these rates.

New E&M Requirement: Effective May 25, Cigna will require that providers submit office notes for E&M claims 99212-99215 when using modifier 25 when a minor procedure was billed. The health plan will deny the claim if notes do not support that a “significant and separately identifiable service” was done. In some cases other payers have started to cut E&M reimbursement 50% when combined with office procedures within 3-4 weeks of a separate office visit.

Prison Time: Americans dealing with mental health issues are 10 times more likely to be put in jail than hospitalized, according to a recent National Judicial Task Force report. While a majority of people who are then sent to state prisons report a history of mental health issues, more than 70% have not received treatment. Though there is a shortage of mental health providers overall, the legal system is even less equipped to treat these patients.

At Home DME: Humana is working with DME providers Rotech and AdaptHealth to provide at home services to their Medicare Advantage HMO members through a value-based arrangement. The agreement takes effect July 1, and each vendor will serve a different geographic region.

Foster Works: Blue Cross NC has a new apprenticeship program for adolescents aging out of foster care that will help teens enter community college or find jobs at the health plan’s retail centers. In its first year, there are two apprentices working in the Raleigh Retail Center and the health plan is working with organizations across the state to find future participants.

Obesity Rx Controls: Effective July 1, BCBS Tennessee will add a new prior authorization requirement for any commercial members seeking a prescription for GLP-1 drugs – the new wave of anti-obesity drugs. And they’re not the only payer adding more controls on these drugs. Though they can be very effective for some patients, particularly diabetic patients, an ICER report found that at their current prices, the GLP-1 drugs do not deliver an affordable long-term value for 99% of patients.

Staffing Hurdle:  More acquisition is happening in the health staffing space, which could further complicate staffing shortages. Jackson Healthcare, the parent organization of 16 staffing, search and tech companies, is acquiring LRS Healthcare, which focuses on nurses and allied healthcare professionals. A recent report from McKinsey found that nurse turnover in hospitals increased from 18% to 27% from 2020 to 2021 though that number dropped to 23% in 2022. Hospitals have been trying to encourage nurses to remain in-house rather than joining staffing agencies, but they often cannot compete with payment offered.

PCP-Behavioral Integrate: Emory Healthcare and the Goizueta Institute are partnering with NeuroFlow, a cloud-based behavioral health company, to improve delivery of psychiatric services at Emory’s primary care clinics. They will also pilot a primary care suicide prevention program.

Extra Point: Dad and I once paid $110 to have the repair guy plug in our refrigerator after we thought the fuse box had blown leaving the fridge dark and warm. “The two of you are like the blind leading the blind,” mom said when she came home later that day. “I leave you alone for 2 hours!”  Diagnostics is not everyone’s forte.  George Costanza once asked his Seinfeld crew to diagnose a strange discoloring on his lip. “I’d get that checked out,” Kramer said skittishly, while George wondered if it could be cancer but his doctor said, “I don’t know what it is.” Diagnosing things is particularly difficult these days for parents, schools, pediatricians and indirectly insurers who often lack a true picture of a student’s health to figure out if something is anxiety, pain an auto-immune disease or something else. Here in this Eye on Healthcare, check out results of our poll, a sit down with a family about their teenager’s journey, a day in the life of a school therapist and an example of a solution that helped solve the problem for one teen.