Behavioral Health Insights

$114 Million: The amount L.A. Care Health Plan and Health Net will invest over the next several years to address the homelessness crisis in Los Angeles County. Due to the growing number of seniors and people with disabilities experiencing homelessness, the funding will be used to identify the daily living needs of unhoused people and connect them with caregiver help, along with securing leases on as many as 1,900 housing units and paying for things like vacancy coverage and trash services.   

Buckeye Health Decline: Ohioans have experienced a clear decrease in overall health, according to the Health Policy Institute of Ohio’s annual Health Value Dashboard, where Ohio is compared to the rest of the country based on general health outcomes tied in with social determinants of health. Although there are some improvements, after looking at 10 years of compiling data for the dashboard, the Institute says Ohioans are living less healthy lives compared to most other states. The dashboard shows a clear decrease in mental health treatment for adults as well as a decrease in preventative dental care for children. Tobacco usage is not decreasing as quickly as it is in other states. 33% of smoking in the state was contributed to “adverse childhood experiences.”  

Labor Boost: Kaiser Permanente is trying to increase the number of mental health providers through their Mental Health Scholars Academy, currently offered only to their California employees. The integrated delivery network will pay 75% of tuition at a master’s program and then offer payment and benefits to those graduates as they complete their post-master's supervised clinical training, something that many recent graduates do on an unpaid basis.  

New Nurse News: HCA Healthcare announced during National Nurse’s Week it will provide $90M to open 20 new centers for nurse clinical advancement and IT training over the next three years. HCA will also invest $34.5M to help Kansas City-based Research College of Nursing expand through a new 78,000 square foot HCA Healthcare Center for Clinical Advancement to be completed by 2025. The center will include a patient simulation laboratory, classrooms, and training technologies.  

All Bets Off Kenny Rogers: More payers are covering therapy for gamblers but not in every setting and not as restrictive as you might think. Excellus BCBS allows OP therapy for gamblers without pre-approval. Residential, partial hospitalization and Inpatient services are thought to be investigational. The biological dad for our oldest foster kid has struggled for a number of years with this behavior–using salary to fuel the addiction, putting his family and our oldest in a tough place at times–but what is clear is that social factors have as much to do with the cause of this behavior as anything. How OP therapy addresses these factors will be important for this benefit and treatment to have any success.  One caution when evaluating centers that offer “gambling addiction treatment” is to evaluate whether they have “compulsion specialists.” 

Behavioral Benefit Buildout: Effective July 1, 2023, BCBS Michigan will begin covering Partial Hospitalization Programs (PHP) for SUD treatment and Intensive Outpatient Programs (IOP) for mental health as a standard benefit for all commercial members. Currently, BCBS covers PHP only for mental health and IOP only for substance use disorders.  

Marriage Is What Brings Us Together, Today:  Partnerships are continuing - Humana is partnering with Longevity Health Plan, which specializes in serving individuals in senior living settings, to offer Special Needs Plans for Medicare-eligible members living in skilled nursing and senior living facilities. The plans are launching in South Carolina and Georgia this year and will expand to five more states in 2024. OhioHealth and Intermountain recently announced they are partnering with Surgery Partners, which will help manage and develop ASCs. Option Care, the infusion provider, announced plans to acquire home health company Amedisys last week. The combined company hopes to use this to negotiate case rates and bundled payment with payers.  

Extra Point: So, this one took a while to write folks as on the first attempt to draft it I fumbled the snap and got sacked by a long week, a stressful and frustrating string of Boston sports team losses, and the important job of playing dad to a labradoodle with ADHD. There’s the 19-year-old who swept in from college like Hurricane Gloria leaving his hair, dishes, and laundry all over the house and my favorite 17-year-old daughter who is in the midst of getting ready for her first prom with a kid who strangely reminds me of me.  And our 23-year-old graduates college Sunday and needed my help with tickets and a cover letter for a job as a translator for a population of Burmese and Thai speaking families and discharge support liaison at a hospital because, like a lot of kids, she’s looking to find a job, in healthcare of all places.  “Thanks for helping with the letter,” she said, “but what does ACO, DME, VBC, CMS, BCBS, OCD, PT, AWP, ASD, and PHE mean….do I need to know what these are for the interview you think.”  Good lord! 

1.7 Million:  The number of calls, texts and chats into the national 988 suicide crisis lifeline during the first 5 months of its existence. How the 988 staff deals with these situations and sets up emergency response or makes referrals is still an open question. US Surgeon General Vivek Murthy recently proposed “a national framework to rebuild social connection and community in America” given rising evidence of loneliness and depression in ~60% of young adults and ~50% of mothers with young children according to some studies.

Poor Urgent Care: Several insurers are now eliminating copayments in certain situations, except for urgent care. One source said there has been a quirk in benefit design that charges multiple copayments in situations when patients see the same physician for multiple services on the same day, “so if it’s an office visit, office surgery, an x-ray and lab work, patients were hit with 4 copays at $25 each, or $100,” a source from a national MCO confirmed. Now there will just be one $25 copay for that situation. For urgent care, up to two copays of $30 each or $60 total may apply.

Lyme Aide: In a meeting with an insurer’s utilization analyst this week we both saw an interesting trend in lab orders to test for Lyme disease in teenagers reporting significant fatigue. That makes sense, but what’s interesting is the orders tend to originate from requests by psychiatrists who want to confirm that that the teen’s “chronic tiredness” isn’t really Lyme masked as stress.

Golfers For Cataract: Not all of us have Danny Noonan to carry our bag down the fairway and track our wayward slices. The #1 question that ophthalmologists get from male patients who are about to get cataract surgery is, not surprisingly, ‘how soon after can I play golf….’ What is often not discussed is just how important the surgery is for these golf-obsessed seniors who don’t hit it quite as straight and can’t see the ball off the tee like they used to. A Medicare Advantage plan’s utilization analyst, Mary Kellogg, says the plan is studying cataract utilization trends and related social factors, like surgery by gender, climate and even something as obscure as whether the patient is an avid golfer. ‘Do they need it to see the ball better, or do they need it to drive to the course…two different things.’ While it seems unlikely that denials for cataracts increase drastically, with the increase in MA and medical management of vision, it wouldn’t be surprising to see greater analytics around medical necessity.

Don’t Get Caught Watchin’ Paint Dry: This is arguably the best line from a questionably sober Dennis Hopper in the classic Hoosiers and it is good advice to physician practices and home care agencies who, if they’re not careful, may find themselves stuck if they don’t get ahead of the wave of funding and premium dollars going to companies finding ways to address things like patient loneliness and social risks. Humana once had a pilot program with a company called “Papa” connecting college students with lonely at-risk seniors—one of several initiatives to screen for things like depression, substance abuse and fall risk, and react to them. How information from screenings makes its way into EMRs and back to primary care physicians and caregivers, will be important if this whole social determinant experiment is to work.

Solving The Shortage: How would you like to talk to a chatbot at your next doctor’s appointment? My kids would, but my folks – heck no! “You want me to talk to what?” my dad said. Many of us are probably in papa’s camp, preferring to speak directly to a person, but a recent study published in JAMA shows that AI-based chatbots had better “bedside manner” compared to physicians in about 78% of 585 evaluations. A team of healthcare evaluators said the ChatGPT responses were higher quality, more empathetic and typically longer.

Where To Hang The Infusion Shingle? You might want to put it about 10-25 minutes from the hospital, as it seems that most big insurers now have policies that encourage and in some cases pay cash or gift cards to patients to have their infusions done at independent ambulatory infusion centers or at home, as long as the services are within 30 miles or 30 minutes of the patient’s home. If not available, the patient can go to the hospital.

Match Game: A poll we did of 192 PCPs, OBGYNs and mental health therapists found that about 60% of the time the patient needs to change doctors or therapists. “It can take 2-3 at least to find the right fit, particularly therapists,” Molly Reader said, “but it often takes 3-4 visits to figure this out.” Figuring out how to address this could be a helpful measure of quality and distinguish a practice. Some companies, like Two Chairs, use clinical and patient data to try and match mental health patients to the right therapist from the start. It says that 98% of patients report a strong therapeutic alliance and 90% reach a fourth therapy session, compared to the 36% industry average. One thing to be measuring is patient satisfaction after each visit because reaching 4 sessions may not always indicate effectiveness.

Alzheimer’s Partner: Walgreens has entered into a partnership with Prothena, a late-stage clinical biotechnology company, to boost patient enrollment in the biotech’s ongoing Alzheimer’s clinical trials. Prothena is focused on diversifying the Alzheimer’s clinical trial through accessing clients of the pharmacy’s rural communities.

Extra Point: All you pharmacy fanatics probably will love this as under a new quite controversial Cote family policy effective May 1^st Grub Hub orders are now excluded from the formulary as it were. I love the Grub Hub but with 3 kids in college and one a few years away there’s a budget crisis looming. There will now be a 75% cost share requirement and the loss of any right to complain about me not doing your laundry without public shame. Delivery from Chipotle directly is covered because it’s delicious, but for cost reasons, it is now non-preferred at 50% coinsurance and requires pre-authorization. Getting me to pick up takeout will be on the non-preferred 3rd tier at 50% coinsurance, unless I’m already out driving in the vicinity then it’s covered at 25% coinsurance. Grocery store pizza is 2nd tier with a $5 copay but only if I’m already at the store and if you make your own pizza, there is no cost. In fact, if you give me a slice and I like it, a value-based bonus payment will be provided in the form of doing laundry once. Tommy is appealing the policy, arguing that the Grub Hub ought to be an essential health benefit. But he’s 15, what does he know?

70: Percent of this age group lie to their doctor and parents, particularly about their mental health. Any guesses?

Imaging Cut: Effective Father’s Day, Blue Cross NC will stop reimbursing 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.”

Consumer Behavior: Dr. House once asked on his TV show, “do I get bonus points if I act like I care?” Short answer is heck yeah. Last we broadly studied what drives consumer healthcare decisions, roughly 12,000 women were 3x more likely to lean on Oprah’s advice than their own doctor, “because she cares.”  This was 2014 and times have changed – or have they? Share your experience by completing our consumer health survey about your experience as a patient and caregiver. Linked here. Results to be published in the fall.

Overpaid Transport: And you thought your flight fare was high - earlier this month, BCBS Texas has identified an overpayment error for some ground and air ambulance claims between January 2017 and April 2022. The health plan is now adjusting claims with the last 24 months for ASO and Blue Card members and the last five years for FEP members. Payments for fully insured members are not being pursued.

Weight For It:  Teladoc is expanding services to include prediabetes and weight management, now allowing its telehealth providers to prescribe obesity drugs.

Day In The Life:  A little known law may have big consequences for schools, families and people struggling with their mental health although whether it will help ease the day in a life of school therapists like Peggy remains unclear. Peggy’s day went sideways pretty quickly last week which is more the rule than the exception, so if health insurers are to start paying for in-school therapy sessions, designing the right approach will likely be difficult. Read Peggy’ story here.

Concierge: Elevance Health has expanded its digital concierge care program to members with a range of chronic diseases and according to the plan formerly known as Anthem, they are already seeing results – “39% reduction in ER utilization and 25% improvement in disease symptoms for things like Crohn’s.” Programs last 12-16 weeks and Elevance would like to eventually make them more “disease agnostic,” recognizing many members have comorbid conditions.

Extra Point: So only in my town would parents get in an uproar over high schoolers running through 4-way intersections like Frogger, hiding in bushes, and chasing each other through cul de sacs with water pistols in a seemingly innocent game they call Assassins. Seems harmless, but our town’s helicopter families have gotten so upset over the unfortunately named game that the Police Log had more than 200 calls last week—twice as many as two years ago—and a town forum was held to ‘get to the bottom of this terrible game.’ They have a point, right? I mean kids running after school in the neighborhood, often sprinting to chase down their target, working together in teams, getting wet. Outside. Not inside. This IS terrible…..One kid, Samantha, was hiding in the backyard of my house for so many hours that her phone was ‘losing juice’ so she asked for a charge. ‘Um, Mr. Cote, I know I’m here to get your daughter, but could I come in and charge my phone?’ The Helicopter parents complained about ‘kids wasting time’ and ‘trying to hurt each other’.  I see the opposite – kids who never would interact are playing together, competing. Kids of all shapes, colors, backgrounds, and economic and school status classes are on an even playing field, brought together in a good ole fashion water fight. Many of them sit on the bench on their high school team or spend 7 hours learning algebraic formulas they’ll never use….some are labeled by their schools or the medical community with letters like IEP or ASD, but out here in the neighborhood, there are no labels. They are just kids playing.  A little community camaraderie shouldn’t scare us. In fact, Assassins may be the healthiest thing I’ve seen in this town in years.

1 In 575: The average ratio of psych counselors to students based on our poll of 340 school districts in 19 states.  We learned that the proportion of calls to 911 or 988 related to a suicide situation were about 4-5 times more likely in the schools that had to rely on an extremely high case load for each counselor.   

New PBM Pricing Model: Express Scripts has launched a new pricing model called ClearCareRx to allow employers, health plans, and government employers to pay exactly what Express Scripts pays for drugs. ESI’s new copay assurance plan will cap copays for members – $5 for generics, $25 for preferred brand name, and $45 for preferred specialty drugs. But its formulary exclusion list for 2023 contains more than 600 medications, so it is unclear what prices will be for the substantial number of “non-preferred” drugs.  

Remedy For Waste: A nonprofit that collects unused drugs from patients, hospitals, and providers and redistributes them via mail order pharmacies to other patients in need has partnered with BCBS of North Carolina. RemediChain is primarily focused on limiting waste for chemotherapy drugs but has expanded to include other specialty medications. 

Pre-Surgery Reimbursement Change: If you’re involved in a surgery practice, take note - beginning July 1, Horizon BCBS in New Jersey will no longer reimburse any diagnostic or non-diagnostic outpatient services prior to an admission or same-day surgery when these outpatient services are directly related to the admission or surgery. The only exceptions will be maternity-related services.   

Uber Pilot: A recent pilot between Uber and health behavior research company Surgo Health showed that providing free rides to pregnant patients in DC resulted in increased appointment attendance. Between January 2021 and June 2022, about 450 mostly low-income patients were offered 4,500 free Uber rides, either through a special app for coordinators or by giving patients a voucher to use on their own apps. After the pilot, some managed Medicaid plans agreed to pay for the service, but Uber’s goal is to get more of them to do so outside the scope of the pilot.  

Maternal Outcomes: Breastfeeding relaxation therapy can improve maternal and infant outcomes particularly if the mom is juggling stresses such as a low weight infant, according to a clinical trial published in 2019 in the American Journal of Clinical Nutrition. Several services have emerged to help moms. A lactation services startup is partnering with Nature’s One, for example, to increase access to baby formula. SimpliFed offers virtual support to navigate breast pump selection and insurance benefits and is available to members of TRICARE and Aetna as well as Medicaid members in several states.   

Big Apple Addiction: Reklame Health, a mental health platform that focuses on treating young adults and people of color, is launching a new in-home program for those dealing with alcohol use disorder in the New York City area. Patients will have a telepsych visit with a provider who will assess medication tolerance, then nurses will visit patients’ homes monthly to provide shots of Naltrexone. Depending on how the NYC program goes, it may be rolled out to other locations. 

Staying Independent: Much like the wave of college athletic conference mergers, more health system consolidation may be coming to the Midwest as Froedtert Health and ThedaCare announced plans to merge. According to KaufmanHall’s quarterly M&A report published last week, hospital M&A has increased over the last two quarters, and it doesn’t look like it’s slowing down. The two health systems previously launched a JV in fall 2022 and if the merger goes through, will command a significant presence in Wisconsin with 18 hospitals and 225 outpatient locations.  

Extra Point: My kids got a hold of the 40-minute fireside chat I gave last month on the top 20 payer priorities and stories about how I try to rationalize my poor healthcare decisions (click here) – and perhaps as a bit of payback for all the times I call them out in this column, they let me have it. “Dad, first off, for God’s sake clean your glasses before you go on a zoom! And what’s with the 77 times you touch and fidget with your glasses?” My daughters are my favorite but even they gave it to me. “Nice work almost choking and nice that you made fun of your own doctor visit and not us for a change!” Welp, now that they mention it…I find it interesting that when your middle daughter fails her first driving test you buy her an ice cream cone but when she fails the second you give her a hug and tell her to hang in.  On Wednesday, after Sophie failed the third time, I headed for the shed and dusted off the 10-speed… It’s hard to raise kids amidst all the priorities we have. I’ve heard it said you’re only as happy as your least happy kid and sometimes, even when it isn’t easy, you acknowledge defeat and move on, as I did this week after her driving test.  A primary care clinic had to do that last month.  After a 3-year effort to try and raise its payments from one of the biggest insurers in Rhode Island, it had to go back to the standard rate.  “We tried 3 times to get these incentive payments but we fell short each year,” office manager Roy Sastain says.  He said the payments would have meant about a 20% increase in reimbursement rates per visit all in, paid out in installments, but “we never hit the quality thresholds.”  He blames a range of factors – patients are tough to manage, particularly Medicare and Medicaid, and he blames his own skills at getting the staff to screen and document issues and follow up with patients. “I didn’t appreciate how difficult it would be. We may just have to acknowledge we’re not cut out for this.” Sort of like Sophie, who had to look in the mirror last week and admit that she just isn’t ready to drive.  “I’m going to college in NYC in 4 months – I don’t need a license,” she said.  True sweetie, but pretty sure that’s called rationalization. Welcome to life… 

20: The percent of current prior authorization requirements United announced it will roll back beginning in the third quarter of this year. Beginning in early 2024, the insurer will also implement a Gold Card program for eligible provider groups that would eliminate prior authorization for many procedures.  Keep in mind that for some services, like pain management, even if the health plan doesn’t require pre-approval they likely still have coverage criteria and step therapy rules to follow.

In Prison: Ventura County of California is finally opening a mental health unit at the Todd Road Jail after almost a decade of efforts to treat inmates with serious mental illness and medical conditions. The health unit is a 64-bed locked facility with medical treatment rooms with the capability for x-rays, dental check-ups and dialysis. The presence of people with mental illness in jail is a longstanding issue – the local sheriff’s office reported that 40% of the total jail population takes a medication for a psychiatric disorder.

Latino Resources: Zócalo Health, a virtual healthcare company that provides primary care services and mental health support to Latino patients in Texas and California, is partnering with the Mark Cuban Cost Plus Drug Company to expand its members’ access to lower-cost prescription medication. 1 in 4 Americans taking prescription drugs say it’s difficult to afford their medicines, according to the Kaiser Family Foundation. All users of Zócalo Health will have access to Cost Plus Drugs’ prescriptions through membership packages or urgent care visits.

Smash Stress: If you’re in the mental health field, consider partnering with Hope Means Nevada, a suicide prevention nonprofit that’s now partnering with Anthem to host a “Smash Stress” social media campaign to raise awareness of mental health issues for teens on Facebook, Twitter and Instagram. Teens will be encouraged to log onto social media daily to learn about stress-relieving techniques, as well as how to balance school tasks, have a healthy body image, and find a therapist.

Predicting Outcomes: Advocate Aurora started a 12-month pilot with predictive analytics company KelaHealth aimed at improving surgical care outcomes. The platform uses clinical data and AI to predict patient risk and integrates with the EHR so Advocate providers can see in real time a patient’s risk before and after surgery. KelaHealth’s founder says the company so far has only worked with health systems, but may pursue payers.

Facility Fees: Many hospitals are continuing to charge “facility fees” for things like outpatient procedures and even telehealth visits. Hospitals say they need the fees to cover infrastructure and staffing costs, but at least five states are considering laws to prevent these fees from being charged for certain services. A 2022 RAND report found that facility and related professional fees resulted in employers and private insurers paying 224% more than Medicare would have paid for the same procedures at the same sites.

Let’s Go Mets: The New York baseball team is partnering with NewYork-Presbyterian to “promote health and wellness” in their communities. They plan to hold cancer screenings, blood drives and wellness experiences, some at Citi Field. And beware if you’re an expecting Yankee fan – as part of the partnership, people who deliver their babies at NewYork-Presbyterian hospitals will also be treated to a Mets onesie.

Extra Point: Nebraska Internist Marvin Bittner once told me he ended up buying one of those imaging vouchers through MDSave to cover an MRI his doctor thought was necessary to identify suspicious areas for targeting during a prostate biopsy. And who said doctors weren’t cost conscious? I told Dr. B that using any sort of voucher is usually trouble – I should know, I used one I found in an ATM vestibule to pay for the limo that never showed up on my wedding day. Still haven’t lived that one down! The night before Dr. Bittner’s scheduled MRI Aetna called to deny the scan, arguing his results didn’t meet coverage criteria. Bittner says his doctor was ‘using judgment’ after a series of suspicious PSA results. For what it’s worth, clinicians we talked to in the UK say they routinely do prostate MRIs before these biopsies. But rather than leave Dr. Bittner fledgling in the wind, the hospital where his doctor works told Bittner to buy an MDSave voucher to cover the MRI at a cost of about $150 less than he would have paid for the deductible had he submitted the claim to Aetna. The story ended well. No cancer. But it illustrates some oddities: (1) A US insurance company not covering something that the UK National Health Service does cover, despite its reputation and (2) The MDSave Groupon-like voucher for the entire MRI coming in at a lower cost than a deductible.

3.4%: The average amount ACA health plan premiums increased between 2022 and 2023, likely due to inflation and increased healthcare spending. The increase in premiums reversed several years of declines. Unsurprisingly, markets with a single insurer had premiums that were $128 more than in markets with considerable competition, at least 5 insurers.

Worker’s Comp Alumni: Any guess on one of the most common reasons for worker’s comp claims among teachers? – that’s right, alumni basketball games.

Hole In The White Bag: Regence BCBS will launch a new specialty medication network in January 2024 through their PBM, Prime. The new network, IntegratedRx – Medical, will allow providers to continue to buy and bill specialty medications if they become credentialed and contracted as a dispensing provider with Prime. The health plan said this network is essentially intended to be a compromise between employer groups who have been requesting “white-bagging solutions” and providers who feel they should be part of the dispensing process, keeping the “provider-patient relationship intact.”

Go Blue: BCBS Michigan, one of the more progressive commercial payers in moving away from FFS into value-based care, will be introducing a 1.5% allocation from commercial PPO professional fees to fund Blueprint risk arrangements for their commercial providers, starting July 1, 2023. These risk arrangements will be partially offset by the annual professional fee schedule update that will also take place July 1. The 1.5% allocation will be allotted to the Blueprint reward pool and used to reward eligible risk-bearing contracted entities for improving the quality of patient care and reducing costs.

Unusual Healthcare: People in Pennsylvania will soon be able to learn about their health care options at their weekly trip to the laundromat. UPMC Health Plan’s Medicaid managed care plan is partnering with Fabric Health of Philadelphia to give guidance on applying for coverage assistance programs such as Medicaid, Supplemental Nutrition Assistance and Low Income Energy Assistance. The state of Maine funded a similar program last year to bring telehealth technology to 10 libraries across the state for users to be able to have an opportunity to see a specialist.

Marriage Script: Pharmaceutical company Cosmos Health has acquired ZipDoctor, a subscription-based telemedicine platform that provides 24/7 access to physicians, behavioral health counselors and therapists. Cosmos hopes to target women’s health and weight loss in the future.

18 & Life: Jackie pinned the tale on the donkey and played ring around the rosie at my daughter’s 5-year-old birthday party back in 2010. If memory serves, she was the goose at least three times and she fell off that wobbly chair when the music stopped, laughing like a hyena.  Jackie, a standout athlete, turned 18 last summer but her eyes started to hurt back in September at the beginning of her senior year in high school, the way they do when you’ve been up late typing on the laptop, and this week, when many of us were logging on or checking texts, her parents sadly had to let Jackie go after a painful 7-month struggle with a brain tumor. Why this happened is not something I can answer but sometimes there are sacrifices we can’t explain.  Jackie’s sacrifice may just be to help us see the importance of not ignoring symptoms and to help her classmates see how precious life can be.

Vaccine Cut: Beginning July 2023, Empire BCBS in New York will reduce reimbursement for providers administering COVID-19 vaccines to align with other vaccine administration rates like flu shots.

Post Pay: Perhaps as a precursor to future post-pay audits of facility based care and possibly surgeries and OP care, Blue plans in Illinois and Texas will begin reviewing acute hospital claims for commercial members starting this summer if they are readmitted to the same facility within 30 days of discharge. BCBS may conduct a post-payment audit of the admission and readmission and deny or reduce payment if they determine that the readmission could be “considered a continuation of the initial treatment.”

Extra Point: A black eye is not a great look for me, particularly not on Easter Sunday. “What did you get in a scuffle with the Easter bunny?” my bride quipped. This was 8 years ago this weekend when Paul’s elbow came down on my cheek like a meteor strikes Jupiter, at least it felt that way. I’m 5 foot nothing with a vertical leap no better than an aging cricket and thought I could outrebound a 6 foot something who had boxed me out of the lane. I could not. My cheek swelled quickly and my jaw vibrated and twitched in excruciating, albeit perfect rhythm. On that Sunday, I cupped the left side of my face and slunked off the court but there were no ice bags, so I jammed my face left-side down onto the bubbler, letting the water envelop my burning face. Read more.

25-35: The age group now charting their own path around what their “health plan” will be. For better or worse, younger populations are the likely target of a new wave of virtual-first health insurance plans that package telehealth services to ensure people have a medical home even if it’s not the traditional one. Some Anthem members in Georgia will now have access to their new Virtual-First health plans. Other insurers also offer these and use them almost as traffic cops for healthcare, steering patients to services as needed. These plans provide people access to an AI-driven symptom checker, routine wellness care, chronic condition management, and behavioral health services through a digital platform. Virtual-First plans will become available to some of Anthem’s large group ASO plans first, and then large group fully ensured plans in July 2023.

The New ABA Pay: Fallon Health in Massachusetts is partnering with Autism Care Partners on a value-based care model that tries to address diagnostic barriers. This is the second insurer in Massachusetts to develop a model like this, Point 32 being the other. Case rates tied to acuity and potential bonuses for reducing “events” like hospitalizations or total costs are the typical components of these arrangements. One challenge to consider is how a child’s acuity level can change month to month. Fallon’s partnership will focus on engaging families waiting for a diagnostic evaluation. The idea is to provide continuity of care for the family, whether or not the autism diagnosis is confirmed.

Guess What Situation Drives Cognitive Decline: Sunshine Health, Florida’s largest MCO, has partnered with independent food relief organization Farm Share to open a new food pantry. Opened this month, it has already helped distribute food to 100 families. A new study published in JAMA in March found that food insecurity later in life is associated with “unusually rapid” declines in cognitive impairment.

Diabetes Model To Launch In Fall: Telehealth company Amwell is partnering with DarioHealth, a health management company, to add a cardiometabolic program to their platform to treat chronic conditions like diabetes. 37M adults in the U.S. have diabetes according to the National Institutes of Health. Amwell’s patients with diabetes, high blood pressure and weight management needs will be referred to Dario for health coaching and supplies like glucometers.

Friend Or Foe: 6 years ago, I asked a guidance counselor in my town if he had a suggestion for a therapist for my 8th grader. It is common for this age group to struggle with transitions and anxiety and also to show clearer signs of compulsive behaviors. I’ll never forget his advice – he said that the right fit may not necessarily be a therapist, that sometimes what matters is having someone they can just trust to talk to before anything else – a coach, another adult, a teacher. “Start with the person they already trust – I always ask students to name one adult other than their parents who they look up to or trust,” my friend Steve said. “Doesn’t mean a therapist or more intensive therapy isn’t eventually needed, but sometimes we underweight what the teenager wants and who they feel safe talking with.” New broader research is confirming this. College students are more likely to share their mental health issues with a friend before anyone else, according to a recent survey of roughly 1,000 Americans, half college students, and half parents of college students.

End Stage Renal JV: Oak Street and InterWell are forming a joint venture to integrate primary care for end stage renal disease patients directly in the dialysis clinic. This will begin with InterWell centers in Chicago, Dallas, and Houston. Oak Street providers will also provide behavioral health and renal pharmacy support.

Extra Point: A gold star to the first person to let me know the year when everyone going to a birthday party started getting a goodie bag.  When I grew up, if you went to a birthday party you were lucky if you walked out of there with a dry piece of cake and only a few bruises from the Pinata battle for tootsie rolls. The healthcare system has seemingly followed suit. I got a toothbrush, toothpaste, floss, sugar-free lollipops that limit cavities, and the time and date for an appointment to see an oral surgeon when I left the dentist office last week. After my PCP visit, the doctor gave me a raffle ticket to win a heart healthy gift basket and list of freestanding imaging centers and a cost estimate for my likely uncovered coronary calcium CT scan. And like those parties when all the kids walk out with custom gear, dad’s ophthalmology nurse gave him a T-shirt bearing the practice’s name and a warmed-up homemade blueberry muffin for the road – “and one to take home to your wife” she said, after his cataract surgery this week. I’m not complaining – it’s a nice touch and perhaps the effort helps improve adherence with discharge plans. Now that I say it, it would be interesting to study the effect of the goodie bag on adherence—like does this type of personal touch at discharge reduce the likelihood of post operative complications, limit readmissions, and drug interactions? Maybe. For my family, I would argue yes, with the caveat that this trend is also making me hungry.

13: Percent of Cologuard tests that are reportedly positive, but the colonoscopy ends up negative, a "false positive," and so the anxiety of waiting isn't great for patients and now some payers are wondering exactly how many false positives there are, which might be a bigger issue.

Where's The Surgery? Cigna has launched an education program for their Medicare members to push more procedures to non-hospital affiliated surgery centers, like shoulder arthroscopies and knee cartilage removal procedures at rates $1500 to $1800 less compared to health system owned facilities, a JAMA analysis showed.

UnSelf Insured: The growth of self-insured plans has competition from trends among big payers. Minnesota's HealthPartners is working with health system Avera Health to launch a new health plan option for employers with fewer than 50 employees. The plan is modeled after a similar option for large employers that launched earlier last year. Meanwhile, the company G&A Partners that handles HR for employers will be the first in Florida to offer a Cigna master health plan to their small and mid-size businesses. Cigna traditionally has catered to larger companies with 1,000 or more employees but the G&A plan includes 14 different options, including PPO plans and high-deductible health plans.

Maternal Medicaid: No, not Uma Thurman, but Ouma Health, a maternity telehealth services company now partnering with MedArrive, a mobile integration company, to bring maternal care into homes of women on Medicaid. They focus on high-risk pregnancies and closing gaps in transportation and nutrition assistance.

The New PCP:  Patients in 4 mid-Atlantic states now have access to a new virtual primary care plan from ChristianaCare's Center for Virtual Health via a monthly, quarterly or yearly subscription starting at around $35 per month to get matched with a digital advisor to set up visits and receive tools to monitor things like BP and weight.

It’s a Lifestyle: BCBS of Vermont appears to be one of the first health plans to appoint a program director for Lifestyle Medicine, a medical specialty born 20 years ago but increasing in prevalence. The specialty uses therapeutic lifestyle interventions like whole-food, plant-based diets, exercise, restorative sleep, and stress management to treat chronic conditions. Probably things all of us should be prioritizing on a day-to-day basis.

In Case You Missed It: 68-year-old RN Wendy Abraham has long since hinted that healthcare is not for the faint of heart particularly when you start getting older. Wendy was advised to get a Cologuard test last fall even though she was not scheduled for a colonoscopy until 2024. The test came back positive, but her GI first required a tele consult the day after Christmas and asked her if anything new had happened medically in recent memory. It had. About 3 months earlier, Wendy had a TIA, which is a mini stroke, was put on Clopidrogel for 21 days and a baby aspirin that she now takes daily. The GI decided the colonoscopy couldn’t be scheduled until a neurologist gave clearance to allow her to have anesthesia but getting that appointment has been harder to deal with than the Colonoscopy prep drink. The neuro consult won’t be until the end of April, all the while that positive Cologuard test lingers out there.  All this for an RN who knows how to navigate healthcare. Imagine the 68-year-old who doesn’t?

Suicide: Kids bullying other kids online and sometimes in person is perhaps the chief cause of kids thinking about killing themselves. Not an easy thing to read, for sure, but it's real. A poll of pediatricians who are heavily involved in prescribing medicine to help kids already in therapy reveals their angst over "feeling disconnected" from what might really be happening with the kid. 81% confirmed what one pediatrician explained, "We have limited time and interaction - we're often being asked to prescribe a medication, getting push back about side effects and the stigma around these medicines - it's all fair, but what we're trying to avoid is suicide, and this is sometimes the right step."

Sleepy: 33% of people with anxiety and depression say it keeps them up at night and affects their overall sleep, compared to 29% in 2022 according to a ResMed survey of 20,000 people from 12 countries. About one third with these issues were not seeking help for sleep conditions and say their doctors were not asking questions about sleep quality.

Dewey Decimal Would Be Proud: Mount Sinai health system is teaming up with The New York Public Library to expand access to and education around telehealth.  They plan to offer classes including information on how to find a new doctor, how to schedule a virtual doctor's appointment, and how to access medical records and test results. Participants will also have access to a Chromebook borrowing program so they can actually use telehealth resources.

Extra Point: I grew up in UCONN country but married a Gonzaga alum whose uncle is a Jesuit priest and teaches political science at Gonzaga, so we named our lab Zaggy and every March root for the Zags, and sometimes they play UCLA and hit a game winner. Like they did last night. It's nice to get a win after a long week -- two days earlier I hammered a nail into my finger trying to reattach a shutter. "Are you a dummy?" my bride said at the urgent care. Yes, I would say that's fairly accurate. The shutter repair was incidentally #9 on my bride's list of 13 chores she nicely laid out for me this week. The only one I was able to actually complete involved removing a filter I was supposed to remove in 2016. My stat line was like Gonzaga's free throw shooting. So, it’s fair to say I’m not bringing a whole lot of value to the table, not with household care anyway. I share this to make the point that it’s one thing to delegate a to-do list, quite another to see it knocked out. In healthcare, same thing I suppose. Every year, there are 20 things health insurers tell us they intend to do or ask physicians to do but actually getting them to do it can be painful, maybe not nail in finger painful, but still. I talk about all this amidst a 40-minute monologue you can access here about healthcare payer priorities (enter this code to listen, X1@73cKU). Speaking of priorities, my bride asked me this morning how that wobbly door hinge is doing that I said I'd fix in December. "It’s not rocket science,” she said. Probably true, I said, "but in my defense, I’ve learned that fixing that hinge may, in fact, actually be rocket science."

10,000+: The number of mental health apps circulating on app stores, according to a recent estimate by the American Psychiatric Assocation. While some are filling an important gap in access to mental health treatment, not all apps are equal. An ORCHA review of more than 500 mental health apps found nearly 70% didn't pass basic quality standards, such as having an adequate privacy policy or being able to meet a user's needs. That figure is higher for apps geared toward suicide prevention and addiction, some of the most vulnerable populations. A number of apps are incorporating AI to help diagnose and treat mental health conditions, but there’s limited regulation around this and limited clinical evidence to support its use so far. One company recently used ChatGPT as a “mental health counselor” without notifying users, prompting concerns.

Staffing Solution: CaroMont Health, a health system based in North Carolina, is addressing the nursing shortage by partnering with Gardner-Webb University to offer nursing students $7,500 in tuition assistance as well as the opportunity to complete required practicum hours at the hospital. In turn, the students agree to work as a registered nurse for CaroMont Health for two years.

House Mate: CareOregon is converting a local hotel into housing for its members and providers. The health plan, through its subsidiary Columbia Pacific COO, plans to turn the former hotel into 50-60 individual housing units by next spring, which members with behavioral health issues can then occupy. Two-thirds of the housing units will be reserved for healthcare workers, in part to help attract providers to the rural region.

Worth The Spend?: A medical practice in the northeast is spending $10,000 a month in hopes it can make $250K-$500K in shared savings under a new pay for performance contract for about 150 of its high-risk patients.  “Investment in this value-based work is expensive, but it’s the right thing to do,” practice manager Margaret O’Neill said. Spending covers a better EMR, an ad-hoc on-call social worker for home check-ups, a scribe for office sessions to let the doctor focus on the patient, and a full-time care coordinator to keep track of where patients go for other appointments and help them navigate things like ability to get a cataract procedure after a heart surgery, or whether to eat a certain yogurt if living with heart disease and osteoporosis.

A Beautiful Mind: Blue Shield of CA members now have access to the platform CredibleMind where they can complete assessments on depression, anxiety, sleep, social connections, burnout, PTSD and other mental illnesses and be connected to resources and tools to address their specific needs. CareSource is working with BeMe, a digital behavioral health company, to provide teens enrolled in Indiana’s Hoosier Healthwise coverage access to digital mental health support, education, one-on-one coaching, as well as crisis support. BeMe’s platform serves over 90,000 teens across all 50 states.

End Of PHE, Then What?: Aetna is taking a proactive approach to the ending of the public health emergency and likely disenrollment for many Medicaid beneficiaries by using its CVS stores to put messaging over the sound system, show videos, and provide members with a QR code that connects them with info about what they can do next. The PHE ends April 1 when states can begin redetermining eligibility for Medicaid and disenroll beneficiaries as necessary. This will impact enrollment in Medicaid MCOs including Aetna, Centene, and others.

Postpartum Access: Seeking postpartum care such as a lactation consultation can be difficult for new mothers, especially when seeking options covered by insurance. In response, Zocdoc is partnering with Zaya Care, a company focused on establishing a network of maternity providers, to increase access to pregnancy and postpartum care specialists.

Precisely The Point: BCBS Michigan has launched a personalized medicine program in January this year through an independent company. The service from OneOme offers eligible members pharmacogenomic testing to help providers choose medication based on a member’s genetic makeup. The health plan’s 2022 pilot led to 432 specific medication recommendations for 396 members and early data suggests a reduction in outpatient and ER visits, along with lower spend among the members who received the testing.

Extra Point: So, I’m fairly certain that I’m addicted to cough drops as candy, listening to Broadway songs on a treadmill and eating six or seven of those Smartfood mini bags because, well, it doesn’t feel like quite as much when the bags are so little.  Addiction is a global crisis – 100% of the population has one – but only 4 or 5 addictions seem to get the headlines. They deserve it – they are serious and tragic and need support - but I can think of at least 10 others in my own life that deserve some attention.  Like my sister is addicted to bringing a couple pieces of Wonderbread to Thanksgiving, my neighbor is addicted to mowing the lawn in his boxers at 6am on Sundays, and my PCP is addicted to referring me to “ologists.” The hospital near us seems addicted to sending me flyers inviting me to their Lamaze classes, which is very thoughtful and assumes I have superpowers, and yet it’s awkward. My bride, God love her, is addicted to giving me chores that she knows I’m incapable of completing without her help. My youngest daughter is addicted to telling us she isn’t good enough, when she is – my goodness she is – and my mom and dad like telling the group chat at 8am that they got Wordle by, um, telling us the word. This girl Celeste on my school’s basketball team is addicted to staying late after practice because she wants to make the layup, and because going home means sounds of gunshots and no parents. Her addiction is her reality and also her hope.  So many addictions are and yet we often think of addiction in such negative ways, as flaws, as disappointments, as invisible realities, and yet we’re learning every day that we can survive and recover and live with them.  It just takes someone to care. My mom cares, like she seems to be addicted to sharing funny stories about family funerals.  “So your Aunt Adeline’s funeral was nice, although the cannoli was soggy.” “Wait, what?” I said, “Aunt Adeline died?!”