Behavioral Health Insights

20: The percentage of colorectal cancers diagnosed in younger people, those 50 and below, in 2019, compared to just 11% in 1995, according to research published last week. Worryingly, providers don’t seem to know what’s driving the increase. While health plans have been trying to make it easier for their members to screen for colorectal cancer, such as mailing at-home Cologuard tests and dropping PAs and copays for colonoscopies, these are still typically limited to members who are at least 45-50+ years of age.

Pre-Pay Review: Medical claims are increasing in complexity, according to a Peterson-KFF Health System Tracker report recently released that looked at visits in outpatient settings including physician offices, urgent care centers and emergency departments. The overall number of claims at the highest two levels of complexity – levels 4 and 5 – in outpatient settings grew from 22% in 2004 to 43% in 2021. For the emergency department, it grew from 33% in 2004 to 60% in 2021. It’s not much of a surprise then to see that commercial payers have been pushing back on some of these claims, requesting more documentation to support higher-level claims, and in some cases, down-coding them.

Family Counseling: To help address the cost of diagnosing and referring patients with mental health needs, a few behavioral medical directors tell us they have agreed to pay an additional $10-15 PMPM and potentially an annual $50,000 bonus to PCPs and pediatricians able to reduce hospitalization and re-admission among younger Medicaid and commercial beneficiaries with severe depression and anxiety and eating disorders. One strategy recommended is to leverage telepsych. Evernorth, Cigna’s health services division, is for example adding virtual mental health platform Brightline to its network to allow members insured through employers or marketplace exchange plans to utilize the family mental health counseling service.

Feel The Burnout: In an effort to prevent physician burnout and increase quality of physician notes, the University of Kansas Health System is partnering with Abridge, a company that uses AI to document patient conversations with their doctors in real-time. Abridge’s technology identifies 90% of key points from provider and patient conversations, generates summaries and produces organized drafts with the option to edit. Another tactic aimed at physician burnout is a new platform designed by doctors to address acute and chronic mental health issues of healthcare workers, called Healthbook+. The digital care platform uses predictive analytics and AI to provide guided steps for staff who are experiencing burnout, career fatigue, anxiety or depression.

Same Day HIV: Rent’s Jonathan Larson would be proud of the progress around AIDS. Walgreens, Doordash and Uber are teaming up to provide free, same day prescription delivery of HIV medications to help reduce transportation barriers and stop the HIV epidemic in the United States by 2030. This service is available to patients within a 15-mile radius of thousands of participating Walgreens in the US.

At Home Tech: Best Buy is partnering with several health systems to expand an at-home care technology platform. Atrium Health is working with the retailer to develop a hospital-at-home program and Geisinger Health is creating a pilot program with Geek Squad for in-home delivery and setup.

Extra Point: So my folks were late again to Sunday supper this week because they were waiting for each other at the grocery store, sitting on benches maybe 15 feet apart pointed in opposite directions…dad having dozed off from one too many free cider donuts. Helping the parentals manage aging takes its toll at times -- I'd even argue that caregiver health decline is the next great epidemic -- but it can also be pretty hilarious and instructive. Dad is at it again with a string of ALL CAPS emails outlining his health issues and litany of challenges getting old….BRY!!! I NEED YOUR HELP WITH TV. DOESN’T HAVE TO BE TODAY BUT I CAN’T TURN ON NETFLIX SINCE YOUR MOM PRESSED THE YELLOW BUTTON AND WE CAN’T GET IT BACK TO MAIN SCREEN!!  SO WE JUST PLAYED SCRABBLE. SHE CHEATED AGAIN WITH SOME WORD CALLED GUBBINS.  DEFINITELY NOT A WORD. SORRY I THINK YOU CALLED BUT I COULND’T FIND THE UCONN GAME SO I WENT TO SLEEP AT 730! I CALLED YOU THIS MORNING BUT YOU ARE BUSY. CAN YOU BRING ME AT 845 INSTEAD TOMORROW FOR CATARACT FOLLOW UP. DR TAU CHANGED TIME. ITS $6000 FOR THE TWO LENSES!!!  I WOULD RATHER WEAR GLASSES AND GO TO PEBBLE BEACH BUT YOUR MOTHER SAID NO WAY!! THEY TOLD ME NO EXERCISE FOR 5 DAYS AFTER SURGERY BUT I AM IGNORING THAT. DON’T TELL YOUR MOTHER!!!! I BACKED THE DODGE INTO THE LAMP POST AGAIN SO I NEED YOUR HELP WITH THAT. AND I DROPPED MY HEARING AIDS IN THE TOILET LAST NIGHT AND DIDN’T REALIZE AND FLUSHED. DON’T TELL YOUR MOTHER.  I WENT TO WATCH TOMMYS TENNIS MATCH BUT WATCHED THE WRONG KID.  I DIDN’T REALIZE UNTIL AFTER.  A NICE YOUNG MAN HELPED ME FIND MY CAR. I LOST IT IN THE PARKING LOT. TOOK ME 30 MINUTES…. Sometimes I struggle to understand if dad is grumpy or happy or what the difference is between 1 exclamation point and 4, but it doesn’t matter. He’s communicating and I don’t mind helping him manage his peccadillos and life on the way to 80. I know like many of you I’m lucky for that!!!

930: The number of family medicine and internal medicine residency positions that went unfilled in 2022 despite the significant need for more of these providers. The National Regional Match Program’s data shows that anesthesiology, radiology and surgery residencies tend to only have a few positions unfilled.

Mouth Full: A dental technology company has launched a virtual platform for video visits with dentists and tools to connect patients with care. MouthWatch anticipates this platform will mostly be used for emergencies, prescriptions, second opinions, cosmetic consultations and preventive care. We might see more of this company as they offer services to dental plans, employers, DSOs and health systems.

Run Forrest Run: English neurologist Roger Bannister was the first athlete to run a mile in less than 4 minutes when he did it back in 1954, but a poll of his modern day neurology peers suggests the mental benefits of running so aggressively aren’t as significant as you might think. “It’s a balance,” one neurologist said about a sprint like Bannister’s – it raises cortisol levels which have been linked to mental health issues. A new meta-analysis also shows that more moderate exercise like doubles tennis may be good enough to lower cardiovascular risks and better than fast-paced exercise for mental health.

Fertility Pass: Aetna no longer requires separate prior authorizations for any associated drugs needed for female infertility procedures. Providers can now submit one comprehensive PA for the procedure plus drugs for members of fully insured plans.

Pay For Relapse Avoidance: An addiction treatment provider got a 23% reimbursement rate increase for its outpatient services in a Midwest market after agreeing to keep readmits below 5% for a community devasted by opioid abuse and relapse.

TelePrescribing: A Drug Enforcement Agency proposal changes rules around controlled substance prescribing without an in-person exam or referral from a medical professional who previously examined the patient. Prescribing would be allowed for schedule III, IV, or V non-narcotic controlled medications, and buprenorphine for opioid use disorder, but just for an initial 30 days at which point an in-person visit would be required for an additional prescription.

Homeward Bound: Simon & Garfunkel 1960s hit is a bit of a metaphor for a 2020s movement by healthcare providers to increase home services. In Minnesota, BCBS of Minnesota has entered into a full-risk arrangement with "Homeward" to provide MA members in 24 counties virtual care and in-home and community-based services. The Companies are working together to identify gaps in care where members should receive services they currently aren’t.

Kidney Bean: Healthy.io, the first developer of a smartphone-powered home kidney test, is partnering with Reset Kidney Health, a platform for patients with kidney disease that brings technology into patient hands. Reset will provide patients with the test kit to complete at home to improve early detection and prevent kidney disease progression, which is typically under-tested. This care will provide access to rural and underserved populations, and at-home testing can raise testing adherence rates by 50% Healthy.io says.

Changing Guards: Humana is leaving the commercial health insurance market in order to focus more on its government plans, the payer recently announced. Over the next 24 months, Humana plans to phase out its fully insured and self-funded plans along with any wellness and rewards offering. Less than 10% of Humana’s 17 million members were enrolled in commercial plans but it boasts the second largest Medicare Advantage plan behind UnitedHealth and its MA membership grew ~14% this past year.

Wireless Equity: Equiva Health, a health relationship management company, has partnered with wireless internet service provider Infiniti Mobile under the Affordability Connectivity Program by the Federal Communications Commission to give more members subsidized cellular and data services at $30 discounts in an effort to help end health inequity and disparities.

ExtraPoint: Healthcare’s rankings of the top 20 payer priorities are just out and I wonder if this were a basketball game would #9 CKD/nephrology upset #8 orthopedics, like on a last second kidney disease shot? I mean, the two services sometimes have the same patients – long-term NSAID use for treating knee pain can lead to chronic kidney disease after all – and they do indirectly compete for more of the health insurer’s value based dollars. March madness is definitely a time when we pick upsets like #12 Harvard over #5 Cincinnati because if any student-athlete can figure out the right angle at which to shoot a basketball, it’s gotta be a Harvard kid. But what we lose in common sense we gain in rationalization. We know we should pick #3 Creighton over #14 University of Louisiana at Lafayette, but we change our minds because Creighton’s “Billy the BlueJay” can’t possibly defend Lafayette’s “Ragin’ Cajuns.” I mean, anyone named Billy or any bluebird has no shot against anything that rages. That’s just not a fair fight. Some of us only pick teams if they are a state, like Florida or Arizona, rather than Wofford or Mercer, which sound more like states of depression. “Hi Honey, you seem down today.” “Yeah, I’m feeling very Wofford.” As much as we all have differences in our picks, and tendencies for who we like and why, we’re all connected this year by a common cause. Mental health - improving it, destigmatizing it, trying to see it when it’s not so obvious, and trying to admit we struggle with it. Services designed to address it are ranked 5th in this year’s index of healthcare payer priorities, a ranking not all that different than March Madness rankings given healthcare providers are all competing in one way or another - for talent, for a good seeding in networks, and for our time and copays. Speaking of which – I’m en route to my internist this morning and with any luck will make it back for our conference call to discuss the rankings and, if the spirit moves, to sing the Wofford College fight song.

757: It’s a palindrome as my smarter nieces remind me. It’s also the average cost in dollars for about 1 out of every 10 patients a day who go to some of the urgent care centers in a New England suburb, but then need to be transferred to the hospital via ground ambulance due to things like low heart rate or difficult to diagnose headaches. If you’re pursuing urgent care, keep in mind these centers didn’t really exist before this century, that 1 in 5 patients you see are “more than likely worried well” and could wait 3 days for their symptoms to resolve themselves, but some patients will be too complicated for the center," said retired medical director Mike Halen, “it’s a great site of service for acute issues, but you have to look at the clinical judgement of the staff around testing – there is often overtesting and sometimes referring to hospitals unnecessarily.”

Speaking of Palindromes: Nurses run is also a palindrome, and a good description of what nurses do every day but finding them is getting difficult. My grandmother June was a nurse in the 1930s depression era – she’d run from triage to bedside 40 hours a week, then back home chasing my dad and his brothers, all the while juggling a cup of coffee. I noticed that nurses tend to always be running in and out of coffee shops in the morning with their scrubs. On a hunch, I went to Dunkin for a week in January and Starbucks for a week in February from 6 to 7 each morning. 30 of the 43 who went to Starbucks worked for the local hospital and 11 worked at surgery offices or clinics. In contrast, 23 of the 45 Dunkin cohort are “home nurses” and 6 work at local schools. If you’re looking at how to recruit and retain nurses these days, perhaps your answer lies somewhere between the mobile pick-up lines at the local coffee spot.

Dementia Data: Bruce Willis’ story is reigniting attention to diagnosing dementia and paying for care, but a recent study shows people with dementia receive less home health and hospice care in their final months compared to those without the disease, according to non-profit RTI International. This is despite people with dementia having the same predicted average activities of the daily living score at 17 months before death compared to those without dementia. Findings suggest that people with dementia may receive less home-based care because of the difficulty to determine when they are within six months of death, which is a requirement to receive hospice care. Payers are responding, and Blue Tennessee is partnering with the home health and hospice company Amedisys to offer in-home or virtual palliative care to members at no additional cost. This development is part of a broader trend of payers focusing on home care, which is ranked at #4 for the second year in a row in our 2023 Healthcare Payer Index. Register for our upcoming conference call on 2023 payer priorities here.

Roll With The Changes: REO Speedwagon’s 1970s hit may just be an anthem for insurers and doctors these days trying to figure out how to pay for telehealth. Several insurers have rolled back telehealth reimbursement rates 20-50% for everything except behavioral health, but some like Highmark in the eastern US have decided to reverse their policy. The insurer will continue allowing reimbursement for non-face-to-face consults delivered via telephone, Internet or EHR. The health plan initially decided these codes would revert to their pre-COVID policies, but providers pushed back, saying they found “efficacy in providing these services via telehealth.”

File This Under Paying To Do Something Somewhere Else: A 15% increase in reimbursement to reward doctors just for doing procedures in ASCs is being framed as a value-based payment from several insurers. It is, in effect, a payment for performance simply for doing the same thing but in a different setting, just a lower cost one. “For the right patient without comorbidity, this makes sense – for sicker Medicare patients, not as much,” a clinical director says.

CIN City: Privia Health is partnering with Community Medical Group to launch Privia Quality Network of Connecticut, a clinically integrated network that will cover 180,000 lives, making it the largest CIN in the state. 430 of the roughly 1,100 providers are PCPs. In North Carolina, another CIN is launching, this one backed by the physician enablement platform Alo that focuses on supporting independent providers. Alo has had a presence in the Tar Heel state since its 2021 partnership with Avance Care, a network of independent PCPs.

Extra Point: In my house, we root for the Celtics, and we loved watching coach Joe Mazzulla chew gum at like 30 chomps a minute, but the coach recently stopped chewing, saying he felt like gum was messing up his heart rate and hurting his breathing and focus. That makes sense, but how do we square this with the growing evidence showing that people should chew gum to manage their anxiety? A therapist I know says about half her patients no longer take daily medication and instead chew gum and do talk therapy – at ~$15,000 less a year, but dentists say chewing too much gum causes tooth decay.  I started chewing gum in the 90s after Lloyd Braun chewed it on Seinfeld to impress Elaine Benes but my first editor at The Herald in Boston told me to stop when he saw me chewing Hubba Bubba during an interview with the Swampscott, Massachusetts school committee. “What are you, 5?” he said. “Plus, it’s bad taste.”  I suppose he was right – it did taste bad, and it was immature - so I learned my lesson, but 25 years later I’m honestly more perplexed than ever about gum’s role in health. Maybe I ought to just limit chewing gum to special occasions, like before plane rides the way Pilot Chuck Yeager used to do to settle his stomach, or at Thanksgiving Dinner I could try Willy Wonka’s “Three Course Dinner Chewing Gum," tomato soup, roast beef and baked potatoes. But then my cardiologist may get upset…

58,200: The number of healthcare jobs added in January, with ambulatory healthcare services seeing the biggest increase. Despite this, health systems and independent providers are still struggling with staff shortages. Henry Ford said they’ve hired back only about 25% of their nurses who left during the pandemic and a recent article in NPR highlighted the increased use of mid-level providers in ERs.

But It’s A Match: The number of internal medicine doctor residency training positions has fluctuated over the last three decades but offered 9,380 in 2022, the highest on record with 95% of them filled, including about 1 in 4 who are citizens of countries other than the U.S. and who graduated from medical schools outside the U.S. There were 47,675 applicants overall across all types of doctors, the 2nd highest in history. 3,108 pediatric related positions were offered for 310 programs but 33 of those programs – presumably in more rural areas – were unfilled. By comparison, just 3 of the 288 obstetrics-gynecology programs went unfilled for 1,503 spots and dermatology had just 4 unfilled programs out of 169 available for 544 spots.

Home Acuity: Archie Bunker used to complain about healthcare all the time – like “why do you nurses always have to put the needle where the pain ain’t,” he’d wince. The pain got so bad his doctor once visited him at home and said he’d have to go to the hospital for tests. “But why can’t you just do the tests here,” Edith asked. As we know, the 1970s TV couple was ahead of its time, and now 51% of home health providers say they have plans to pursue higher-acuity care in the home in 2023, a new survey found. Many will pursue a hospital-at-home or SNF-at-home model, both have grown in popularity since 2020. Large health systems like Kaiser Permanente have rolled out hospital-at-home models, and other hospitals have created partnerships with Contessa and other home care companies to provide acute care in the home.

Healthcare’s Runway: Just as New York fashion week wraps up, United rolls out of a new kind of fashion trend that could earn members up to $1,000 a year. Eligible members can use wearable devices, including an Apple Watch, FitBit or Garmin to complete health goals and activities. Logging 5,000 steps a day, tracking sleep for 14 nights, getting a biometric screening or even choosing paperless billing are all examples of activities that earn members rewards. As members complete activities and reach goals, these rewards are put into their HSA or a prepaid debit card.

Neat Feet: Neatsy, an orthopedic and podiatry tech-based company, is partnering with Massachusetts General Hospital to launch a telemedicine platform for orthopedists. Neatsy’s platform uses the patient’s smartphone camera to create a 3D model of the patient’s foot through AI. The model can be used to identify ailments and collect dimensions to accurately size any specific footwear needed. Doctors can then access the 3D model and any risk assessments the scan picked up to confirm a diagnosis remotely.

Caregiver Rollout: Caregiver health is declining in the U.S. – with reports of increased weight, blood pressure and alcoholism, trends driving health plan adoption of services to support families. Superior HealthPlan, a Texas subsidiary of Centene, is expanding its partnership with eFamilyCare, the New York-based telehealth company that helps caregivers find services and collaborate with providers. Originally rolled out in 2022 for certain Superior members, the services are now available to their broader STAR Health Medicaid program.

Top 20 Rankings: Payer priorities for 2023 are ranked in our annual report. You can view it here and register for a call to get the scoop on the rankings by clicking here.

College Psych Screen: Indiana University will soon begin offering around the clock remote mental health services through TimelyMD, a 24/7 virtual mental health care service platform that can diagnose and treat students remotely. The platform allows students to make one-on-one appointments in minutes, compared to a wait time of up to two days for counseling services offered on campus.

Extra Point: 5-year-old Dylan used to hide under a gray wicker chair on our porch until Jack was done with supper, then the pair of kindergarteners would play wiffle ball until dark. Dylan is now a sophomore at Michigan State and Jack at Indiana University—they came of age in a neighborhood without struggle, not real struggle anyway, and now they live on their own in places where they are learning to see and grapple with their own challenges and humanity, and that of their new neighbors. The trauma of last week’s shooting hit home for us. Dylan heard the shots within Berkey Hall, hid under a chair and luckily is safe, but now in the days since he and many others are dealing with the traumatic effects. Colleges – much like secondary schools – are at a crossroads these days as they are having to take on more responsibility for the health of their students, addressing both trauma and suicide. It’s no secret my own son is like many his age trying to manage mental health ups and downs. He reached out to student services many times during his first couple years at IU, missing classes and insulating as many tend to do, but he did not hear from student services, nor did my wife and I. These departments are in all likelihood understaffed and overwhelmed with an increasingly challenging mission. They are doing their best amidst impossible circumstances. IU’s response to add a 24/7 virtual mental health system is a good step many colleges have taken. But these solutions tend to still rely on the student to reach out.  Colleges could use help creating 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. My wife who has taught at the college level tried on her own to help a student but eventually went to administration for guidance, “but I am not sure how they intervened from there,” she said, still worried about the youngster. “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 – maybe it’s a coach, a roommate, a waiter at the diner – but often times they will isolate after trauma or due to depression, so having some data that student services can monitor makes sense.” As I’ve said from experience raising teens, the best idea for any student transitioning into college may just be to have a relationship with “their person” already established – a therapist, a pastor, someone – so when crisis comes – and it will come – they have a lifeline. For Jack, his lifeline has been a mental health therapist who in some ways my wife and I see as an extension of ourselves. We’ve even talked with her, and our son encouraged it. For students at MSU, I wonder who their person is. For Dylan, the kid I can still picture playing wiffle ball in our backyard, his lifeline was Jack.

35 Million: The number of prior authorization requests submitted to Medicare Advantage plans in 2021, about 6% of which were fully or partially denied. But good news for those who take the time to submit appeals - ~82% of the appeals ended up being overturned. Anthem had the highest number of PA requests per MA member in 2021, followed closely by Humana and Centene. But submitting and appealing prior authorizations takes time and energy and is likely contributing to provider burnout. A study from Medscape showed that more than half of physicians report feeling burned out and nearly 25% feel depressed.  

Autism Adjustments: Premera BCBS is making some changes to its ABA policy, effective May 2nd. The Washington insurer is expanding the type of providers who can diagnose autism and provide ABA services, likely in an attempt to expand access to these services. A diagnosis can now be made by any “healthcare professional whose legally permitted scope of licensure includes diagnosis of psychiatric disorders or neurodevelopmental disorders." Premera also updated requirements for where ABA can be delivered, now including community settings and schools.  

Feeling Blue?: North Carolina’s Blue plan will begin insourcing behavioral health referrals in April, replacing the vendor they’ve been using, Quartet Health. This follows the health plan’s trend over the past few years of focusing on behavioral health internally – by bringing the referral process in-house, the plan “will have a stronger, holistic view of member health needs.” They are establishing a team of care navigators within the Behavioral Health Care Management division who will work with members seeking care and the behavioral health specialists providing it.  

La La Land: Payers are getting creative in how they are addressing the growing mental health crisis among children and teens. LA Care and Centene are partnering to offer free mental health services to 1.3 million public school students in California. This program is backed by school-based telehealth company Hazel Health and will be optional for all local school districts, but Los Angeles Unified School District and Compton School District will be the first to use it.   

Oncology Drugs: Mark Cuban’s Cost Plus Drug Company is now partnering with cancer care support company OncoPower to offer oncology drugs via its Medication Savings Suite. The platform will be integrated within OncoPower's Pill Reminder Tool, which alerts patients of cheaper generic options available through Cost Plus Drug when patients log a new medication into the tool.  

Only The Lonely: Social isolation is associated with a 50% increased risk of dementia according to the CDC, so more companies are trying to address loneliness and insurance is showing some willingness to support. A senior-focused virtual reality company is now covered by MA plan AgeWell in New York. My parents said they barely know how to turn the TV on so the idea of operating a headset seems “a bit above our paygrade,” but there is some evidence that these systems can work. The virtual headsets from MyndVR are designed to aid older adults with feelings of isolation, anxiety and depression, and promote memory stimulation and socialization.  

Tier 1: United Healthcare recently expanded access to NexusACO plans, a commercial tiered benefit plan designed to encourage members to seek care for Tier 1 health care providers, including incentives such as lower copays. NexusACO offers two plans, one that requires referrals and one that does not, all members must choose a PCP to manage overall care. 

Extra Point: My daughter left a stack of dirty plates outside her room last night like you might at a hotel. The dog licked them clean and even brought one to the kitchen. “Would you like the turn-down service too?” I quipped. “I have 2 tests and a quiz tomorrow for the second time this week,” Sophie lamented with that bashful face she knows I cave to. Maybe we need one of those tins that lab offices use for specimen pick-up. Like schools, the healthcare system seems to order a lot of tests, and the question is how many are actually necessary? A poll we did a few years ago found that the clinical utility of lab tests varies – that maybe 20-30% of the time physicians are ordering tests they probably don’t need to. Nine out of 10 health plan medical directors argue that the utility of lab testing will likely become clearer and more important as more physicians take risk—noting that with more at stake, physicians will demand more from the test result or report. Asked to weigh how much of the time lab testing is helpful today, cardiologists and endocrinologists we polled say that lab testing helps ‘validate what they're doing or plan to do’ for about 43 out of every 100 patients on average, redirects or actually changes their treatment approach for one-third of patients, and is inconclusive or useless in 15%. For “high-risk patients lab testing doesn’t add much info for me,” one doctor said, and “borderline hormonal tests (like metanephrines, cortisol levels) are more confusing than helpful,” another warned. On the other hand, testing is very helpful to figure out fatigue in undiagnosed hypothyroidism or “when a BNP level redirects appropriate use of a diuretic.” I asked Soph about her tests on the way to school. “You ready?” She shrugged and said, “if by ready you mean do I know the structure of the judicial branch and how to conjugate verbs in French, it’s a 50-50 shot.” 

40: The percent of parents who said they are “extremely or very worried” that their children are experiencing mental health issues like depression or anxiety, according to a new Pew Research Center study. Social media influences have been the #1 driver in research we've done, and the US Surgeon General recently stated that 13-year-olds are too young to join social media platforms. Solutions to help teens manage are increasingly centered around physical education in schools, whereas treatment for crisis continues to evolve. US Acute Care Solutions has partnered with Array Behavioral Care to deliver virtual psychiatric care in hospital EDs. Several hospitals use their own staff, but typically pay an outside team to help with triage and placement.

Staffing Source: CareAcademy, which offers advanced caregiver training and specialized CNA certifications, has acquired NextStep, a digital healthcare training and job placement company for certified nursing assistants. This acquisition will help CareAcademy strengthen its offerings for up-and-coming healthcare workers through online and in-person training to certify new CNAs.

Women First: Women's health clinic company Tia announced a partnership with Cedars-Sinai to expand operations in California, including its seventh clinic in Santa Monica and potentially a holistic offering in the LA market.

BioSimilarity: Earlier this week, Amgen released Amjevita, the first biosimilar version of Humira, an injectable treatment for arthritis and other autoimmune conditions. Whether it will be much of a competitive threat to the 20-year-old blockbuster drug remains to be seen. A couple of the big PBMs have said they will add biosimilars to their formularies, but at least for now, they plan to keep branded Humira on the same tier, likely due to rebates AbbVie is passing along. Look out for our report on drug trends later this quarter, where we’ll dive into biosimilar adoption, with outcomes-based arrangements, specialty pharmacy distribution and more.

The Cancer Lesson: If you're worried about white bagging, there may be an out for those agreeing to clinical-pathway-based reimbursement programs for cancer patients. "There's got to be some give and take between payers and community oncology, particularly if you're moving the needle on addressing toxicity, lowering ER visits," a source told us. For example, dosing can drive up unnecessary costs for patients with liver cancer who receive large doses of chemotherapy via infusion, but if administering magnesium intravenously instead you can help wipe out the chemotherapy side effects and, in effect, reduce other costs, according to Dave Tofanelli, who sat down with us in 2010 when he served as enterprise VP of contracting for Wellpoint. "These patients can end up in an emergency department with bowel constriction, which may lead to exploratory surgery to reopen the valve, so our pathway instructs oncologists to these alternatives."

SDoH In The House: UnitedHealthcare is putting $10M towards SDoH initiatives in Appalachia, which will include support to affordable housing, clean energy, food and agriculture. The funding will cut across six states, including parts of KY, NC, OH, TN, VA and WV.

Pass The Buck: Amazon is launching a new $5 monthly subscription called RxPass, which will allow Prime members to fill as many prescriptions as needed from a list of more than 50 generic medications that can be delivered home. The average Prime member would save about $100 per year, according to the VP of Amazon Pharmacy. Medicaid, Medicare or any form of commercial insurance is not accepted.

Extra Point: Only about 38% say they know what palliative care is according to a consumer poll we did this week of 13,216, a signal that there is a long way to go to educate the nation on end-of-life care.  About a third of those who say they know actually do -- many others saying it's hospice or "companionship," which are directionally close, 5% mentioning "acupuncture" or some other pain relief, 4% saying it must have something to do with being a "food connoisseur" and 2% saying the "study of colors" - or palette - none of which are exactly right, but they at least suggest people are trying to care about the root of words. I'm not sure our healthcare system has really understood palliative care either, at least not until recently. Only 10 new Medicare Advantage plans will offer home-based palliative care as a primarily health-related benefit this year, but more than 150 offer some type of home-based program. The insurer Regence BCBS now has two teams of nurse case managers dedicated to palliative care, one for adults and one for families with severely ill children, and in our 2023 Healthcare Payer Index of Priorities coming out this month, palliative care made the list for the first time ever. Several companies have formed recently getting a monthly ~$300-$400 case rate for palliative care, based usually on at least one RN home visit, one social worker visit, a doctor video visit, a handful of phone calls, one visit from a chaplain and work involved with collecting and reporting data. I have to admit I didn't really know what palliative care was or looked like until the past several weeks when Ellen was getting it. This lifelong Red Sox fan taught for 35 years in Catholic schools in Boston's north shore and told me when I met her in 1998 that I could only spend an hour with her daughter, "because you are a Yankee, that's why," she said. Even now that Ellen has passed, I am still not sure I fully understand. The palliative experience is perhaps different for each family and patient, but I can say with confidence that it may just look a lot like the little stuffed animal cheetah that comforted mom last week. "That's my little guy," she said to the Cheetah. Maybe this image of a furry stuffed animal laying bedside with someone at the end ought to be the new symbol for palliative care. Maybe then people will start to understand.

38: The percentage of Americans who delayed healthcare treatment due to costs in 2022, a 12% increase compared to 2020 and 2021, according to a recent survey by Gallop. More than a quarter of those said the care they skipped was for “very” or “somewhat” serious conditions. Lower-income people, younger adults and women were more likely to delay care. In our own poll, nearly 75% of college age to 28-year-old males tend to skip care, not due to cost but due to fear.

Fertile Ground: About one-third of infertility cases are caused by male reproductive issues, according to a study by the NIH. Employers and fertility benefit managers are responding by expanding their offerings to cover male infertility issues and telehealth companies addressing male reproductive health are gaining increased focus. Posterity Health, a digital male fertility platform, recently announced an oversubscribed funding round of $7.5M. The platform offers technology-enabled male fertility services, including at-home diagnostics, virtual visits and in-person consults. Online pharmacy Ro recently acquired Dadi, a sperm collection and testing startup for $100M.

Kidney Care: If you are living in Idaho and have risk factors for CKD you may just find a kidney damage test kit beside your Amazon package next time you check the front porch. Blue Cross of Idaho members will now have access to at-home kidney damage test kits through a partnership with Healthy.io. Tests include an albumin-to-creatinine ratio urinalysis and results can be shared directly with members’ PCP through their smartphone. A recent study found that 38% of rural Idahoans are between 25 and 100 miles from their PCP, so these test kits aim to reduce barriers to getting tested for kidney damage in hopes of managing it before it reaches CKD.

Dollar Deserts: Dollar General is getting into the primary care business, piloting mobile clinics at three stores in Tennessee. The clinics are being launched through a partnership with DocGo, and represent an expansion of the chain’s DG Wellbeing Initiative, which originally focused on including a wider assortment of medical treatments and supplies in stores. Dollar General execs noted that 65% of its ~19,000 stores are located in healthcare and pharmacy deserts. The clinics will accept Medicaid, Medicare and some commercial insurance plans and will bill those plans at urgent care center rates.

Unisolate: Social isolation is associated with a 50% increased risk of dementia according to the CDC. To address this, Humana launched a program with Wisdo Health targeting seniors with chronic health concerns who may be dealing with loneliness. This one-year pilot program involved 1,400 Medicare Advantage members who were matched with a trained peer using AI analysis and given weekly coaching sessions as well as resources for social determinants of health concerns. The pilot reduced isolation and loneliness and cut down on ER and urgent care visits, along with saving $1,000 a year in medical costs.

Payer Purchase: Elevance, formerly known as Anthem, is buying BCBS Louisiana, adding 1.9M members to Elevance’s overall membership and expanding its footprint to 15 states. The change may create some challenges for Louisiana’s diagnostic providers and pharmacies given the insurer’s efforts to own these services, but independent physician groups or care management models able to scale could benefit.

Extra Point: So, what would you pay for an extra month of quality survival? For an extra week. Without side effects and falls and terrible pain. What’s the threshold? If it’s $50,000 for 2 months, what would you be willing to pay to get it to 3? And how do consumers differ in their answer from doctors, health insurers and policymakers? Does our threshold change for children or our parents, and does it change based on our life experience or socioeconomic situation, or chronic condition? Part of me likes to think it doesn’t, it wouldn’t, that we’re all on the same page regardless of our role in the decision or how much we have available or make or where we live or the credentials after our name. Part of me wonders if cost and price were not an issue — if we took that variable out of the equation— that we’d all just do what’s best in what is an impossible, imperfect and often times painful question. The thing is it’s a question asked of insurers and doctors and of sons and daughters and wives and husbands everywhere every day, perhaps not always in these direct terms, but it’s asked. What incremental gain in months of quality survival would get your attention to keep paying? Is there a cost of therapy threshold at which point you say no, not because you don’t care, but because it stops the pain?  And maybe it’s not so much in dollars but in the cost of the crisis, the toll. I wonder what the answers would tell us about our priorities, our behavior in crisis, and our humanity. In the decade since I first asked this question it seems to me that the country has gotten more comfortable talking about dying and what end-of-life care means. Palliative care was once a two-person job at the community hospital where I worked part-time in 1998. Now it’s done outside the four hospital walls and by dozens of nurses and caregivers. I’m looking to ask the questions again and study what’s changed in our views 10 years later, though if I’m being honest, I’m not sure I nor the rest of us are exactly ready for the answers. Like so many of us, as I go through this in my own family, I admit the hardest thing is just juggling emotions with everyday life. But you just keep swimming. And as Cat Stevens once said, I’m thinking about the good things to come.

28: Amount of market share on average that commercial payers say you probably need to have a fighting chance at leverage in reimbursement rate negotiations. The number varies by sub-sector and service and definitely geography. More recently payers are trying to hold the line on increasing rates, only allowing them if you are performing well, particularly around where you refer and how you treat. For instance, an OBGYN practice in the South has a high postpartum care and colorectal screening rate – 95% better than everyone else – and credentials all of its mid-levels with the payers, a requirement for pay for performance.

Labor Fix: A physician practice in the Midwest has hired health science students from high school and college to call patients and visit them to see if they have questions about their medicine or if they are feeling dizzy. It’s a small fix for a big problem, born largely out of necessity as the health system tries to adapt to a labor crisis. Trinity Health plans to start using virtual nurses at its 88 hospitals, following a successful pilot at the Trinity Health Oakland Hospital in Michigan. The initiative includes a floor nurse, either a certified nursing assistant or licensed practical nurse, and a virtual, on-screen nurse working together to provide patient care.

Closing Time: No, not the title of that 1990s alternative rock song but a positive reimbursement change for dermatology practices who use other physicians to close the wound site after Mohs surgery. A few payers will stop reducing the payment in these situations, in part due to labor dynamics. If the same physician performs the Mohs and closes the site, a 50% MPPR still applies.

What’s Your Combination: It took me nearly an hour to finish the latest wordle, Mucky, which I’m not sure is a word so I asked my son Tommy what it even means, and he said, “You know, yucky, just with mud.” We like to combine things a lot in healthcare too. Putting doctors with data, apple cider vinegar with tummy aches, Amazon with supplies, modifiers with CPT codes. Some combos are gaining traction, like urgent care clinics just for psychiatric situations or Medicaid payers giving allergists spirometers to give to frequently admitted asthma patients in rural areas. What can you combine to solve healthcare?

IDD Root Canal: Partners Health Plan in New York is working with Solvere Health to bring specialized mobile dental clinics to people with intellectual and development disabilities who often wait up to one year for specialized dental services.

Military ER: Any military veteran in an "acute suicidal crisis" will be able to access emergency health care at any facility for free starting next week, the VA announced. Veterans must be enrolled in the VA system to be eligible for most medical benefits, but that requirement won't apply to emergency suicide care. The new policy grants access to care to up to nine million veterans who are not currently enrolled, according to the VA.

Food For Thought: Hospital systems continue to change their business. Memorial Hermann Health System is joining as a founding member of Foodsmarts' Foodscripts Network of dietary assessment, nutrition counseling, and personalized meal planning services, while MetroHealth Health System announced a partnership with Cleveland Heights-University Heights City School District to open a Wellness Center in their local high school to offer services such as physicals, chronic disease management, immunizations, urgent care and mental health screenings.

Caregiver Support: In one of our recent consumer polls, nearly 91% of 45–60-year-olds say their biggest challenge is managing the health of their parents, which has had a negative effect on their own health. Avanlee Care is one company trying to help, teaming with Walmart to bring its digital tool to the 65 million Americans caring for aging family members. Its app integrates appointments, medication reminders and grocery lists in one place, and can also connect to wearable devices, like a smart watch, to provide health info. It will be displayed and promoted in select Walmart supercenter locations in Arizona, Florida, New York and Texas.

Extra Point: So I grew up listening to Crosby Stills & Nash and haven’t until lately really understood what Crosby meant by teaching your children well…but when your teenager asks you what he needs on his mid-term to maintain a B- in his math class, you sort of have two problems – he’s looking to avoid studying or maybe worse, he’s relying on you for help with math.  Tommy asked for my help last night.  “Dad I think I need a 47, but can you check?” “Can I check what,” I said, “if your math is right or if you are indeed redefining what it means to be an underachiever?” “So you’ll check?” Tommy said….Doing the bare minimum is a lifestyle for some of us, like my 19-year-old who texted me from 5 feet away if I could make him an omelette, while he was in the kitchen…next to the stove. Or for one of our girls whose bare minimum is often her struggle, and ours, because it’s usually the best she can do. In matters of health, I like to think men are often experts in bare minimum, skipping dental cleanings like church on a rainy Sunday or telling the doctor “I’m fine” even when they’re not.  Imagine if healthcare workers did the bare minimum? It’s not an option really, at least not anymore, nor is it part of the DNA of doctors and nurses. Parents don’t have much of an option either I suppose. We have to do more to try to understand, not fix the younger generation, even if it sometimes means we struggle. As the late great David Crosby would say, “Teach your children well” – yes, to do more than the bare minimum and to take risks, but also not to be afraid to struggle — to be thankful for being.

1,000: The approximate number of deaths prevented by a naloxone vending machine, according to a recent study published by the University of Cincinnati and Caracole. The vending machines are placed outside a targeted naloxone distribution and syringe service program. Anyone can access the program’s counselors as well as two injectable doses and two nasal spray doses of naloxone, a sharps disposal kit, kits for safe injections, smoking, and sex, as well as a pregnancy test, PPE and a box of bandages every seven days. 637 individuals registered for the program in the first year, 12% of them having never previously used harm reduction services. People access the package by calling a phone number and completing a survey giving them access for up to 90 days.

Full Risk Reward: About 30% of Blue Michigan’s total MA membership will receive services through full-risk reimbursement arrangements, now that six physician organizations in the state have inked new value contracts with BCBS. Full risk can mean a lot of things, but typically it’s limited to professional costs, not inpatient. Idaho Blue is also focusing on value-based arrangements this year, with 15 partnerships across its QHP, MA, and commercial health plans. Idaho Blue developed a payment model for rural providers, rewarding them for improved patient management.

Buy And Bill Beware: Elevance (aka Anthem) and 14 BCBS plans, along with their PBM Prime and their independent pharmacy solutions startup Evio, are all investors in the Synergie Medication Collective, which aims to extract better deals from pharma companies and providers that administer their drugs – namely high-cost specialty drugs. Synergie will not act as a full medical benefit manager because it won’t provide UM services like pre-authorization but will act more as a GPO for specialty drugs and operate under a “transparent, pass-through model” according to the CEO.

Menopause Model: AI-platform Upliv focuses on women’s health, specifically treating menopausal symptoms through video consultations and coaching with menopause experts, alongside prescription treatment. Northwell Health and Aegis Ventures partnered to pilot Upliv’s platform with select nurses, with plans to fully launch in 2024. The platform will be offered as a benefit to employees at $0.

Digital Diabetes: Care manager Omada Health is partnering with Intermountain Health’s subsidiary Castell to identify diabetics who receive primary care through Intermountain. Eligible patients will receive pre-connected cellular scales, continuous glucose monitors and blood glucose meters that allow physicians to track data in real time.

Chronic Rising: A 29% increase in cardiorenal syndrome and a 19% increase in ischemic heart disease are expected this year according to a recent report from Prealize. Care for intellectual and development disorders is expected to increase 13.7% while utilization related to pediatric substance abuse disorders is predicted to jump 24.5%. Care for chronic conditions, including COPD, are expected to increase across all ages by 21%.

MA Landscape: Humana shifted gears over last year and boosted investments into Medicare Advantage products after struggling to hang on to MA lives in 2022. Based on these efforts, Humana reports gaining 500,000 members during the 2023 annual enrollment period, which is expected to boost their overall MA membership to 625,000, which would be a 13.6% increase from 2022.

#18: Asthma is back in the top 20 payer priority rankings thanks to poor education and environmental factors including gas stoves – full report coming out this month. The condition is now considered as a subcomponent of SDoH initiatives this year, but the focus is not on what you might think. Payers are interested in models specifically for inner city populations and rural areas to prevent hospitalization.  “Problem is we don’t have any. It’s vastly underappreciated and poorly managed.”

Extra Point: So I apparently got my AARP card this week but I couldn’t find it since my bride put it on the fridge near our 15-year-old’s B+ English paper, just below a copy of our daughter’s college tuition bill, above a list of chores like “fix the wobbly bathroom door hinge - you know the one, you walk by it every morning,” and next to the bill I owe for the colonoscopy I skipped over the summer. Putting it on the fridge is a big deal but I’m not sure if she thinks I’ve accomplished something turning 50, or if she’s giving me not-so-subtle hints. Probably that. 68-year-old RN Wendy Abraham from Maryland has long since hinted that healthcare is not for the faint of heart, particularly when you start getting older, and her fascinating story about the difficulty getting an appointment after a hard-to-hear diagnosis is a great example. 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 mini-stroke called a TIA and 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 wasn’t going to be until the end of April – not ideal with that positive Cologuard test lingering out there – so using her inside healthcare know-how, Wendy got in at a neurologist who had a cancellation. “The doc asked me why I was there, and I said, ‘I need a colonoscopy’,” Wendy told me this morning. He laughed and said, “You know I don’t do those,” so the meeting started off on a funny note and ended well, since he cleared Wendy for the colonoscopy. All this for an RN who knows how to navigate healthcare. Imagine the 68-year-old who doesn’t? Take it from an old man, it’s already no picnic. Like when I finally found that AARP card, Tommy happened into the kitchen. “So dad – did you see my B+? Not too shabby eh – right next to that thing mom says you got for turning 60.”

20: Percent reduction in telehealth commercial reimbursement rates for medical visits, not behavioral, starting this spring for a few New England area insurers. The trend is accelerating in pockets of the US as we predicted with some insurers lowering rates 20-30%, one as much as 50%, but none changing the policy for behavioral sessions. One New Hampshire plan will keep telehealth rates for “medical sessions” at the same level as in-person.

Empire Strikes Back: Just like Vader’s effort to retaliate against the resistance, nonprofit health plans SCAN Group and CareOregon are merging to create HealthRight Group to "ensure sustainability against the growing threats of provider consolidation and investor-backed and for-profit insurers entering markets and seizing market share with low premiums,” according to SCAN’s CEO. The combined payer will cover almost 800,000 members, both Medicaid and Medicare.

Closing Equity Gap: BCBS Massachusetts has developed risk-sharing contracts with four health systems designed to combat racial and ethnic health disparities. The arrangements feature standalone performance payments based in part on ability to close equity gaps in certain quality measures, like colorectal cancer screening, diabetes care and blood pressure control.

EMT At Home: Superior Health Plan, a subsidiary of Centene, is partnering with mobile home healthcare provider MedArrive to serve 40,000 of Superior’s Medicare beneficiaries. MedArrive will provide in-home preventive care through paramedics, EMTs and others. This partnership follows MedArrive’s recent acquisition of virtual Medicaid mental healthcare provider Brave Health.

Imagine That: BCBS Michigan is the latest payer to partner with Covera Health on a radiology-focused quality improvement program. Participating practices and radiologists are eligible for high-quality or high-value designations, promoted during prior authorization requests.

Concierge: Health systems are getting in on the concierge medicine market, with Tampa General Hospital of Florida most recently launching a concierge primary healthcare practice in Palm Beach County called TGH.  In a poll we did pre-Covid, about 35% of younger doctors were interested in pursuing concierge medicine, compared to just 9% of older doctors. Concierge practices often charge an annual fee to patients in order to receive a higher level of primary care including personalized plans, after-hours and weekend access.

Is Your Practice: Avoiding antibiotic treatment for acute bronchitis, because if so, this is a measure of quality that helped get 10 New England physician groups named into Harvard Pilgrim’s honor roll network.

Extra Point: NFL teams a few years ago were actually required to have a licensed behavioral health clinician on staff and three-quarters of franchises hired psychologists to fill the role, some hired multiple clinicians, and the league even required teams to hire a pain management specialist to work alongside the psych staff. Before Damar Hamlin’s injury, I wondered if the pro and college sports world’s poaching of the best behavioral health practitioners was almost unfair for much of the country where finding access to psychologists can be like trying to find Nemo. But seeing how the players have unified around the role of mental health and watching that moment when one of the Bill’s psych staff embraced a shaken player, maybe I was wrong - perhaps the NFL model embedding these practitioners on teams, in the locker room and partnered with the pain team, is a model to try and replicate.