Behavioral Health Insights

Extra Point: The late Jerry Stiller invited everyone to air their grievances on this day, using a symbolic pole in lieu of a Christmas tree. “You gather your family around, and you tell them all the ways they have disappointed you over the past year,” Stiller’s Frank Costanza said in the classic Seinfeld. In my home, that’s really more of a Thanksgiving tradition, although sometimes if I’m lucky, the grievances come in the afternoon after school when I forget to pick up Sophie or when I’m cooking dinner, and despite all the effort, it tastes a little bit like garbage. My wife, God love her, has a lot of grievances – like when I accidentally weed whacked all the lazy Susans before they bloomed or that time I ran over the kid’s tricycle, on Christmas morning. “You’ve done a lot of dumb things Bry, but this takes the prize,” she said, with that look only a wife can give, the one that says, “I love you, but are you serious?” As normal as grievances are in my home, they are becoming more popular in healthcare. Physician office complaints are highest in our poll of 712 healthcare stakeholders – up 320% this year alone - while hospitals had a 230% increase, home care agencies up 175% and health insurance plans a 150% jump, although insurers have led the ranking 5 of 7 years. Three complaints dominated the grievance line - a lack of follow-up after appointments or ability to talk to a doctor or PA about treatment and lifestyle decisions, like whether to change or taper medications due to a change in symptoms or whether the 70 year old woman with heart disease and osteoporosis can eat a specific kind of yogurt, (2) a lack of staffing when people need it and (3) confusing bills for hundreds or thousands of dollars. The type of complaints run the gamut though, like one person complained to a home care agency that “my nurses aides keep leaving their smelly hazelnut coffee at the house.” It takes a special person to be in charge of handling grievances. In fact many hospitals say they have had to hire more staff to manage the volume in recent years. Being the chief of complaints is not much different than being a mom if you ask me. “I get all the crying and all the crisis,” my wife will say, but she seems to mostly manage to redirect. As we approach the new year, there’s no doubt a lot in healthcare that needs to improve, but perhaps more healthcare providers and payers should just hire moms to manage complaints and if not that, maybe take a cue from Frank Costanza and set up an aluminum pole in your waiting area, allow patients to air their grievances out in the open and then, after one patient wrestles the ER doctor or the chief of surgery in a final feat of strength, all problems will be solved. From all of us here, have a safe and healthy holiday, Merry Christmas and of course happy Festivus for the rest of us.

48: The percent increase in the number of in-network behavioral health providers among commercial health plans over the past 3 years, according to a recent AHIP survey.

Against All Odds: Even Phil Collins could not have predicted this, beginning January 2023 Excellus BCBS will cover gambling disorder treatment services for managed Medicaid members.

New PBM: The Mark Cuban Cost Plus Drug Company is partnering with EmansaRx Plus, a PBM created by the Purchaser Business Group on Health, which represents almost 40 large non-hospital self-insured employers. EmansaRx Plus will start with generic drugs and offer some branded drugs early next year, according to the CEO of Cost Plus Drugs. The PBM will collect a 1.5% flat fee for each claim managed, which means it is passing on all rebates. The goal of the partnership is to provide employers with lower cost drugs through employer plans rather than going through a third party with drug discount cards.

If You Can’t Stand The Heat: Heatstroke and heat exhaustion are becoming far more common among privately insured individuals seeking medical care, according to a FAIR Health analysis. The analysis looked at more than 39 billion healthcare claims and found patients sought treatment for heat exhaustion 52% more in June 2021 compared to June 2016. This is something payers likely haven’t spent much time thinking about given competing priorities the last few years, but this analysis shows heat-related conditions are likely becoming more costly.

Inclusive Rehab: IncludeHealth, a digital musculoskeletal health company, will provide their hardware-free musculoskeletal platform called MSK-OS, developed with Google, to the Yale New Haven Health System. The platform will provide an interactive virtual home exercise program to supplement in-person services. Yale is one of the systems in the US that has an exclusive physical therapy partner.

Modern Day Dispatch: Louie De Palma was the quintessential 1980s dispatcher from the classic TV series Taxi but times have changed, and today’s dispatchers are far more compassionate.  Blue Shield of California is teaming up with DispatchHealth to provide new in-home services for members with chronic illnesses for example. Members will be able to receive daily in-home visits for more than 40 conditions including respiratory infections, pneumonia and COPD.

SDoH Behind The Scenes: Google Cloud has launched three new health care data engine accelerators to help health systems and payers strengthen health-equity programs, streamline patient flow management and better evaluate population health metrics. These tools are being developed to connect patients to community resources. They were developed in a collaboration between the Mayo Clinic, Lifepoint Health, and Hackensack Meridian Health.

HandOff: CalOptima Health has partnered with the National Alliance for Mental Illness (NAMI) Orange County to launch a peer support program for Medi-Cal members recently discharged from a psychiatric inpatient hospital stay or ER visit.  NAMI trained mentors will try to help Medi-Cal members schedule and get to follow-up care. The five-year program starts in 2023.

Extra Point: Great Aunt Mary used to hate this time of year.  “I don’t get what all the gifts are about – I have everything I need right here,” she’d tell me, pointing to her Virginia slim cigarettes and mini powdered donuts. “Mary!” my Uncle Auggie would say, “it’s not about what you have, it’s about giving to others.” She would shrug with a distasteful Ebeneezer look and puff on the cigarette.  But every once in a while Mary would surprise me. “Comere kid – you play Gin right? Let’s play Carmella." She has the dementia so it’s an easy win.  My aunt Adeline once described Mary as a real-life dry heave. To her face. You can’t make this up.  We would see Mary at Sunday suppers throughout the year but never at Christmas Eve or on Christmas Day.  Mary was a nurse, an LPN, over at the Mercy Medical Center in Springfield, Massachusetts. She worked double shifts on those days. “Someone has to,” she’d say. I interned there in the early 90s and I remember visiting the hospital on Christmas Day for a small holiday party for staff. Mary wasn’t there at the party. I was told she was sitting bedside with a patient up on the 8th floor of the 300-bed hospital.  Best I could see, she was holding a full house in her left hand, and holding the patient’s hand with her right.  I’m not sure I miss Mary in the way you miss the fun aunt who gets down on the floor and plays football with you and races matchbox cars, but I bet her patients miss her. She wasn’t exactly the model of compassion we talk about, but she was there. On Christmas. I suppose as I think about it, maybe Mary was the gift.

51: Percent of 6,382 18–22-year-old males in our poll who say they will likely sign up for one of those virtual primary care health insurance plans when they get a job after college and a not so surprising 28% say they may not get any insurance, one junior music theater design major saying he thinks he can just use urgent care if needed. Scrubs TV character John Dorian sort of captures the mindset of today's college age males. "It's funny," Dr. Dorian said, "I guess sometimes when you do nothing at all, things just have a way of fixing themselves.”

No Longer Taboo: Starting January 1, 2023, BCBS Michigan will cover generic and select brand-name male condoms that comply with the ACA’s preventive care benefits requirements. The amount that can be filled will be limited to 12 units per 30 days. Generic condoms will be dispensed where available. The payer notes that members must obtain a prescription from a doctor for preventive care drugs and products, including over-the-counter drugs, for them to be covered at no cost.

Getting Paid For Authorizations: In a new policy, one health plan is paying doctor groups a higher reimbursement rate for letting the payer access their EMR and use the access to help fill out pre authorization requests and build up intel on what a quality outcome really looks like - like are symptoms improved after a certain drug for IBD or a diet change, or both. "It's a step toward redefining how we value treatment and it's also a way to maintain some of the authorization process but allow us to help these small practices do the work," our source said. "We can look back in the record to figure out symptoms, conditions to justify the request."

Mobility Gains: Peach State Health Plan of Georgia is partnering with the National Council on Independent Living to identify and support healthcare providers in need of specialized patient care equipment or structural improvements at their facilities. This includes structural improvements that are compliant with The Americans with Disabilities Act, including handrails, wheelchair ramps and sliding doors. The partnership aims to increase the number of providers in Georgia that meet these standards. 

Predicting The Future:  Like we predicted back in 2014 when we suggested grocery delivery service Peapod ought to add nutritionists and partner with healthcare insurers and hospitals (see video here -- starting at the 4:20 minute mark until 5:55), nearly a decade later the grocery delivery service Instacart is moving into healthcare with the launch of Instacart Health. As part of the launch, the company will work with WellCare of Kentucky and digital health company, Good Measures, to make food prescription programs available for Medicaid members. Good Measures’ dietitians will work with members to create a nutrition plan for them, which will be accessible via Instacart. For low-income consumers, Instacart will allow people to use their Temporary Assistance for Needy Families benefits as well as Supplemental Nutrition Assistance Program assistance funds. 

High-Cost Therapy?: In an effort to better manage the influx of behavioral health cases at urgent care, a growing portion of hospital-owned urgent care operators are partnering with talk therapy services nationally. How much uptake these businesses will see is to be determined but it will be interesting to monitor given the price tag. Hartford Healthcare’s Urgent Care clinics of Connecticut, for example, will now be offering behavioral health talk therapy on a self-pay basis of $95 per session, not covered by insurance - compare that to lower cost and sometimes $0 copay insurance coverage. A patient does have an initial session with a provider that can be covered by insurance, then they are paired with a licensed therapist for a 40-minute virtual talk therapy session. 

Specialist Steerage: Beginning next year, endocrinologists and pulmonologists will now be included in Aetna's Smart Compare program that provides information to patients on the best physicians to use. PCPs, orthopedists, cardiologists, and ob-gyns are already part of these informational reports that score physicians based on two measures, effectiveness and clinical quality. Additionally, the health plan will allow providers to indicate if they are an “LGBTQ Champion” and actively participate in and support provider care to the LGBTQ+ community.

Mom Knows Best: Readmission rates are higher among Medicaid beneficiaries under 25 and over 60 who are in the ER without a caregiver or “mom” present, a small study reveals. The idea for the study first occurred 12 years ago in Connecticut and found that when mom is involved in the discharge planning and education, readmit risk drops significantly. 

Extra Point: 22-year-olds Emma and Emily just graduated with a degree in interior architectural design, paid their way through school as the first in their family to go to college and when I sat next to them on a flight home last night it occurred to me how much I still don’t know. They both said their favorite class in school taught them how to help people living in wheelchairs navigate space and not just to design spaces for them, but to design spaces that "make an impact" that are "welcoming and freeing" so that "our best self can thrive." "We had to simulate it - we tried to get around in wheelchairs – it changed our perspective," Emily said. I suppose I never thought of design in this way, but I like how the young twins from Wisconsin talked about their degree and their hopes. They are wise beyond their years and perhaps they are on to something for those of us in healthcare - think about how you can design a space and a plan and a place for your patients and your families to be their best self too.

27: The number of urgent care centers Providence health system closed in Southern California this month, citing staffing challenges, inflation and increased competition. The health system’s virtual services will still be available to patients, as well as their in-person primary care services. As payers and providers continue to push virtual first options, we wonder if we’ll see more of these closures in other markets.

Stuck In Bed: Hospitals are struggling to discharge patients because of healthcare staffing shortages downstream, leaving many patients stuck in a bed they don’t truly need. For health systems, this is leading to significant costs – one hospital in Washington is on track to spend almost $18 million this year on nursing care for patients who no longer need to be hospitalized but can’t find a post-acute facility with room to accept them. Skilled nursing facilities are rejecting patient referrals from hospitals at higher rates than before the pandemic, data from WellSky shows.

Text Me: A study recently published in JAMA found that using a 30-day automated text messaging support program after hospital discharge led to a significant decrease in the need for post-acute services. The analysis looked at 1,885 patients representing 2,617 hospital discharges and through the text program, there were 41% lower odds that a patient needed additional resources.

Virtual Consolidation – Is It Good For Patients & OP Practices?: Amwell is reportedly in talks to purchase Talkspace, the behavioral health focused virtual company that started as a consumer-focused model but was among the first to get contracts with payers and promoted as a telehealth option for PCPs who had patients in the room with depression. It has 86 million eligible lives, and the potential merging represents a broader theme – payers buying generalist telehealth, and these telehealth companies buying specialty services, like dermatology or PT.  For office-based practices, there are 2 questions—can you get on the shortlist for referrals, and will these companies “replace” your volume? For patients, it’s the same question – will this consolidation make it easier or harder to get good treatment and service, or will there be more “hoops to go through”?

VBC for Dummies: An office practice in Delaware is trying to move into value-based care and is using a service paid for by a Delaware insurer here to help them do work in simple steps to close gaps in care, like what the office manager should do first and say first after the patient with Type II diabetes finishes appointment, or what the medical scribe should do before an exam ends. The workflow support is color coded, and each task is assigned a dollar value that the practice receives each month. Reach out if you have questions about VBC enablement solutions.

Once Upon A Time: Back in 2004, health insurers didn’t cover phone calls from oncologists to patients who were in the early stages of chemo, but eventually pioneers like Blue Michigan paid for the calls and now 18 years later we are in a new world where the follow up call is not just “reimbursable” but “valued.”  In a newer generation example, Cleveland Clinic will begin billing for each message sent through MyChart, whether it’s about new symptoms or general check-in questions. The health system will bill insurance and if the health plan covers these “messages,” patients may have a small copay. If the plan doesn’t cover this communication, patients may owe $33-50. This announcement caused some uproar, but physicians argue they need to be appropriately compensated for all the time they spend talking to patients outside of appointments.

Extra Point: We almost killed Grammy several times last week. It was by no means intentional, though there was some chatter coming from my in-laws on the way to the Thanksgiving table that maybe it was. On Tuesday morning I gave Grammy a potato pancake and by the time I returned she was choking – her third such event of the week. My wife gave it the amateur heimlich to save Grammy, then the labradoodle scarfed up the remains. At 6 pm, my son handed Grammy a cookie, she took her hand off the walker, then timbered like Apollo Creed in Rocky IV, her head bouncing off the kitchen countertop. This was becoming like a real life Throw Momma From The Train situation. The CT scan was negative on Wednesday but the purple eye and forehead are positively stunning – not a great look for an 85-year-old. My wife then hit Grammy in that same spot in the head with the shower door a few hours earlier, and then on Thanksgiving, just when we thought we had things under control, my dad tried to walk up the front yard and nose-dived onto the walkway, saved only by Jack’s reflexes. I realize after this week just how important personal caregivers are – I appreciate the fact that my folks now rely on them and that policy makers are trying to support them, although I can’t imagine how they have such amazing patience and attention to detail, and at such low wages and reimbursement. It’s one thing to prevent falls, quite another to prevent death by knockout.  I should know – I tried. There was a silver lining. On Sunday, I sat down to play Uno with Grammy. I dumbed it down so it basically became a game of pick the higher card. “I appreciate you trying to work my brain,” Grammy said, in a startling but nice moment for someone with vascular dementia who can’t remember what happened 10 seconds earlier. “Well, it’s the least I could do,” I said. After all, I tried to kill you.

544: The number of healthcare stakeholders who weighed in for our multi-year study on the impact of social determinant of health initiatives, a majority of whom note challenges in scaling and achieving a quick ROI but significant longer-term savings and outcomes from sustained programs. Our report delves into ways to invest in social service models to help address gaps via technology, analytics, and infrastructure.  Click to read more. 

Total Cost of Care: Health insurers are entering into these arrangements with selective behavioral health providers, not just primary care groups, so the notion that these arrangements are too difficult for this sector is not true. Both commercial and Medicaid payers are driving this and giving providers a chance to coach patients and essentially take the keys and be the medical home.

Mom Knows Best: Readmission rates are higher among Medicaid beneficiaries under 25 and over 60 who are in the ER without a caregiver or “mom” present, a small study reveals. The idea for the study first occurred 12 years ago in Connecticut and found that when mom is involved in the discharge planning and education, readmit risk drops significantly.

Specialty RX: Independent specialty pharmacies and physicians relying on buying and billing take note as another insurer is adding specialty pharmacy capability. Elevance, formerly Anthem, is acquiring specialty pharmacy BioPlus. The insurer said BioPlus will operate as part of its existing pharmacy benefit manager, IngenioRx, by “providing patients with specialty drugs and a whole-health approach.” BioPlus is one of the largest remaining independent specialty pharmacies, dispensing more than 8 million prescriptions a year.

Only The Lonely: Orbison would be proud as an interesting app called Papa connects college students to older adults to provide senior companionship and general assistance in the home, and studies have shown use of the app results in notable decreases in medical costs.  The study doesn’t get specifically into the benefits for the college students—many who are themselves struggling with the transition—but one study showed that members of health insurer SummaCare had 34% fewer ED visits and an 11% decrease in readmissions after using Papa.

Cataloging Patient Conditions: Clover Health will begin paying its MA members if they visit a provider who uses special software that helps physicians catalog patient conditions. Clover already pays providers $200 for each visit during which they use the Clover Assistant software that acts as a kind of electronic medical record combined with an artificial intelligence tool. The tool prompts physicians for diagnoses, code entries and care protocols.

Pick Your Condition: Despite Amazon choosing to shut down its virtual Amazon Care service at the end of this year, the company isn’t giving up on virtual services entirely. Their newest endeavor, Amazon Clinic, is a telemedicine marketplace where consumers can select their condition, then choose their preferred provider from a list of telehealth vendors. Patients complete an intake questionnaire, then chat with a provider via a message-based portal. There are no video capabilities but afterward the provider will send a personalized treatment plan via the portal, including any necessary prescriptions. Consultations start at $30 and insurance is not accepted.

CrossOver: Aetna is partnering with Crossover Health to provide a hybrid care model of medical service combining tech-enabled in-person primary care and virtual doctor visits in the Seattle area. The new benefit, called Aetna Advanced Primary Health, will be available next year and the pilot program available to self-insured employers will offer care at two Seattle metro Crossover Health Centers. They plan to eventually expand the model to other markets.

Extra Point: Phone chargers disappear in my house like Taylor Swift tickets, Teddy’s peanut butter runs out faster than Usain Bolt on the last leg of the 1600 relay and affordable bedside nurses are becoming harder to find than an open lane at the grocery store at noon before the NFL kicks off on Sundays. And now, just when I thought access to clinical psychologists might be improving, they are being poached by professional and major college sports teams. As we increase coverage and understanding of mental healthcare we are walking into a potential issue — less experienced and less specialized therapy professionals are on the other end of the video as sports teams make a play for the top talent.  If you’re an elite athlete I suppose that’s great, but if you are reading this as an insurer in need of providers for your network or a mental health company trying to recruit, you are at a competitive disadvantage.  These sports teams offer compensation 3-5x what typical psychologists can get, and incentives tied to performance, like touchdowns. As many as 200 of the 350 division 1 NCAA programs have psychologists on staff, and some I’ve talked to have multiple psychologists “dedicated” to each team. “It’s great to see a major university willing to fund mental performance consulting positions,” Brian Lomax, Ed.D., said after seeing the news that Cal Berkeley was hiring sports psychologists. The University of California’s Cameron Institute was looking for 2 full-time certified mental health consultants and it took less than a week to find a candidate.  One of the interesting roles is to meet with each head coach twice a year to establish mental performance goals and to meet with prospective student athletes during campus visits. A doctorate or master’s level degree is required, along with "knowledge of NCAA rules” – sounds a bit like psychologists who need knowledge of Medicaid rules, by comparison. There is a silver lining to all these recruitment issues: a large number of Americorp volunteers are “going back to school” to become psychologists, public schools like the one in Denver are actually becoming training grounds for healthcare, both nursing and psychology, and residency programs for psych are growing in places like underserved Iowa.  In the meantime, the cost to recruit staff and meet demand and get access to the best seems to be getting more difficult. Sort of like trying to find a pair of socks that match in my house.

91: No, not the year the Cold War ended or Dennis Rodman’s jersey number but the percentage of regions across the country that have a single health insurer with at least 30% of the commercial market share, according to the American Medical Association’s new report on health insurance competition. Three quarters of metropolitan areas lacked a competitive commercial health insurance market in 2021, 2% less than the year before. Competition was even weaker in the Medicare Advantage market - nearly 80% of the 380 MSAs surveyed were “highly concentrated.” That’s a slight improvement compared to four years before, when 87% of MA markets were uncompetitive. A single plan enrolled more than half of MA members in 34% of markets last year.

Dental Bridge: A new medical loss ratio system will be put in place in Massachusetts for dental care based on results of a ballot question voted on this week. Dental insurers in the state must now spend at least 83% of premium dollars on dental “services” or refund patients the difference. The vote also authorizes the state’s insurance division to approve insurance rates.

Healthcare’s Bluebook: Since July, Colorado state employees have had access to a book that ranks providers by cost and quality. Providers in the top 25% for quality are designated in green, the bottom 25% in red, and anyone in between in yellow. The same color scale is used for costs so if people go to an all-green provider, they’ll receive a check. The checks can range from under $50 to thousands, depending on the cost of the procedure. In many cases, the money helps offset the employee’s copay or deductible. But for preventive services that have no copay, like colonoscopies, the employee gets to just pocket that cash. The reward program is available to employees in the state’s self-funded health plan, which is administered through Cigna.

School Policy: More schools are putting policies in place to have their guidance counselors trained in mental health first aid and to encourage counselors to help certain high school seniors get a “talk therapist” before they go to college. “It establishes a relationship so that when crisis comes you have a lifeline beyond just mom or dad,” says Ron Youmans, an MSW who told us his son struggled with the transition to school and “would have benefited from having a therapist in place.” In our poll of 1,110 school administrators back in 2018, just 9% had this policy – now it’s up to 28%.

Marriage: That “bwessed event, the dweem within a dweem” that actor Peter Cook made famous in Princess Bride continues to take over healthcare. VillageMD is acquiring Summit Health, the parent company of CityMD, and the marriage will give the company 680+ locations. Walgreens is majority owner and Cigna’s Evernorth joined the deal as a minority owner. Privia and Novant Health are partnering to create a clinically integrated network and One Medical, the primary care platform being acquired by Amazon, recently reported that revenue from capitated Medicare contracts now make up half of their overall revenue, even though at-risk lives only make up 5% of total membership. The provider manages care for only 40,000 at-risk members compared to the 775,000 members who join by paying an annual membership fee or are sponsored by payers or employers.

Skip To The Point Already:  An app called MYIO, short for “My Improved Outcomes,” now allows patients to join telehealth sessions, sign intake forms, complete assessments, and message their behavioral health provider. The app is from Valent’s EHR system and is designed to alleviate administrative burdens for behavioral health providers so they can just get to substance of the session.

Extra Point: Some research suggests that nearly 1 in 5 of all U.S. service members deployed to Afghanistan and Iraq have PTSD and depression, but seeing it firsthand in my own family, I would bet that number is at least 3 in 5. PTSD is a kind of magnet that draws you back and holds you, prevents you from keeping momentum. But there is a program called inTransition from the U.S. Defense Health Agency’s Psychological Health Center of Excellence that’s for all service members and veterans regardless of how long they’ve served. It coaches and coordinates care for active-duty members, National Guard members, reservists, veterans and retirees and we had a chance to sit down with the program’s manager, psychologist Dr. Nicholas Polizzi. “You don’t need a diagnosis to participate – we are come one come all and get a lot of people seeking help for the first time, and many who have tried cognitive therapy, but it hasn’t worked.”  Reach out to us if interested in seeing a transcript of the conversation and learning how your organization can work with the program.

46: The percentage of Americans who have been in debt due to medical bills according to a new survey conducted by Babylon, a digital first primary care service. Another 34% of Americans said they are struggling or will struggle to pay their healthcare maintenance costs, emergency needs and private health insurance. Younger adults between the ages of 25 and 34 were most likely to report struggling with costs, with 56% saying they are struggling or will struggle to pay for health maintenance costs.

Case In Point: Monthly and weekly case rate or value-based agreements tied to acuity level and specific quality metrics, like lowering use of prescriptions, limiting side effects from co-occurring medical issues and preventing readmissions, are growing in popularity. The insurer Point32 in Massachusetts now has one for an autism treatment company, Aetna’s Medicare Advantage plan now has one with Amedisys for home-based care and Cigna reportedly has one with in-home primary care group Heal in Georgia, Illinois, North Carolina, and South Carolina.

Retail Therapy: Walmart Health plans to open 16 new health centers in Florida in 2023, adding to the first 6 Walmart Health locations that opened in the sunshine state in 2022. The new Walmart Health locations will be in the Jacksonville, Orlando, and Tampa metro areas. Florida Blue will begin using Amazon Pharmacy as its exclusive home delivery pharmacy provider next year, giving 2 million members access to the retail giant’s growing healthcare business.

Spinal Tap: Primary care providers, including NPs and PAs, can now earn $200 through Excellus BCBS’ Spine Health Program. Providers must complete a 90-minute online workshop, developed in collaboration with Spine Care Partners, that covers diagnostic, treatment, and communication skills for managing patients who present with spinal issues.

Cancer Coordination: ChristianaCare, the dominant hospital system in DE, won an award from the Association of Community Cancer Centers for their pilot program to embed primary care providers in ChristianaCare’s Helen F. Graham Cancer Center and Research Institute. The program started in January 2021 after Christiana saw increasing numbers of cancer patients without regular PCPs, meaning patients often had no other physician that was helping manage comorbidities or provide care coordination. The embedded PCP manages care while patients are undergoing cancer treatment, connects patients with local PCPs when possible, and manages the timing and handoff, including education on the patient’s case.

Approval First: Home based providers are likely to encounter myNEXUS for visit authorization and clinical support for an increasing number of Medicare Advantage insurers, such as Empire Blue in New York and Elevance (known as Anthem), which owns the company and started using them in 15 states this fall.

Fitness Frenzy: Col. Potter from M.A.S.H. lore once ordered the entire out-of-shape unit to participate in Olympic games, like the “Crutches Race” when Hawkeye lost because Klinger tripped him up. Beginning in 2023, Aetna will deploy its version of Olympics for seniors with a free subscription to Apple Fitness+ to its 3.2 million MA members. Apple recently partnered with fitness solutions provider Tivity to offer subscriptions through its SilverSneaker program. SilverSneakers members will have access to 3000+ fitness programs that can now be integrated into Apple products. Aetna will be the first plan to offer this integrated Tivity-Apple solution to its members.

Breathing Easy: An old episode of Dr. House aired this week – the one when his asthma patient famously used her inhaler like perfume, revealing that people don’t always know how to use devices.  Maybe Google can help. They have acquired a digital health startup called Sound Life Sciences that developed an app that monitors breathing. The app keeps track of respiratory rate and may help to diagnose sleep apnea and other disorders. Google has yet to say how they will utilize the acquisition.

Cultural Therapy: Brightline, a virtual mental health solution designed for families, has partnered with a company that provides cultural competence training for clinicians. Through the partnership, Brightline works with the company Violet to address disparities for BIPOC and LGBTQ+ youth.  Some insurers have hinted to us that these sorts of partnerships may be required to be in network in the future.

Cardio Spotlight: Regence BCBS is launching a cardiology program in the new year to review outpatient cardiovascular tests and procedures, with the goal of better managing costs and quality for the most complex and prevalent cardio services. The program will be managed by AIM and will apply to both fully insured commercial and MA members.

Extra Point: So my bride and I occasionally try to match our snacks to whatever is on the TV.  A Fish Called Wanda? Cod tacos. C.H.I.P.S, the greatest motorcycle cop show of all time, well, a bag of Tostitos. Seinfeld? A big salad, because there’s no soup. I actually think that people should at least have the option to bring a snack instead of a copay when going to the clinic, matched to reflect the specialist of course – like nuts and blueberries for the neurologist, a protein shake for the PT, dark chocolate for the psychologist, a tall glass of milk for the rheumatologist, and a double quarter pounder with cheese for the cardiologist. Talk about a value-based payment. As ridiculous as this is, maybe there’s an underlying lesson in here somewhere – that perhaps what you bring can help you better see and talk about your health, your relationship with food, and how to move forward.

6: The number of states with fewer than 30% of needed physicians available, according to data from the Health Resources and Services Administration. They include Alaska, Washington, Nebraska, Missouri, New Jersey and Delaware. In Delaware, only 16.4% of the primary care physicians needed are available. Rhode Island is the state with the greatest share of need met at 72.1%.

Look What’s On Channel 9: Samsung is bringing primary care to your living room, courtesy of your smart TV. Through a partnership with virtual primary care company HealthTap, Samsung Smart TV users can connect to the company's healthcare platform and see a provider using the built-in camera on their television. People can get access to free texting with their doctor for $15 per month, along with $39 video appointments and $59 visits for 24/7 urgent care with the first available clinic doctor. The platform also includes a network of 90,000 providers across 147 specialties providing free informational answers to health questions.

Picture This: A virtual hospitalist uses digital tools to consult with a paramedic or nurse who’s inside a patient's home. This interaction is the idea behind Ovatient, a new primary care company "built for health systems, by health systems," according to Dr. Patrick J. Cawley, the CEO of the Medical University of South Carolina, who developed the company along with Metro Health System. The company plans to offer the concept to other hospitals in the future.

Pre & Post Surgery: A consumer-facing app focusing on digitizing and automating existing perioperative processes is in the works under a UPMC pilot. The app “Pip Care” provides one-on-one health coaching and education to prepare patients for surgery and recovery and includes appointment reminders, goal trackers and access to certified health coaches. Pip Care will be piloted at all three of UPMC’s Centers for Perioperative Care and is the first company created out of a collaboration between UPMC Enterprises and Redesign Health. How these types of services are paid for and embedded into bundled payment for a surgical episode remains to be seen but one would expect insurers to pay for or “value” aspects of this care, particularly if playing a role in reducing post surgical complications.

Trio HMO: Blue Shield of California is partnering with Aspire Health on a new HMO plan for Monterey County residents. The plan, called Blue Shield Trio HMO, features concierge medicine support from a team of professionals including nurses, social workers and pharmacists. It also features a $0 copay for telehealth appointments and a platform for digital health and wellness apps, as well as meal delivery and non-emergent transportation for members recovering from serious illness. Trio HMO will be available starting January 1, 2023.

Coherent Cardio Decisions: Humana is looking to improve their prior authorization process for cardiovascular and surgical services through a partnership with Cohere Health. The insurer will use Cohere’s digital platform and clinical intelligence starting in January 2023 for its Medicare Advantage members and Humana employees.

New PBM Winner: Beginning in 2024, Express Scripts will administer pharmacy benefits for 20 million Centene members and provide access to its retail pharmacy network.

Imagine That: In what may not be a surprise, a new analysis of data from more than 2,000 hospitals showed that negotiated reimbursement rates for imaging services can vary wildly. The average maximum negotiated price was 3.8 times more than the average minimum price within the same hospital and in the most extreme case, the average maximum price for a brain CT was 17.9 times higher than the minimum price in the same hospital. Researchers blame hospitals’ and physician groups’ size and negotiating leverage and insurers’ negotiating proficiency as reasons for the differences.

Extra Point: Would you believe it, Nebraska is home to the invention of Kool-Aid but now the state’s largest health insurer has invented a policy that could cool the jets, as my Uncle Bobby used to say, on telehealth. A 50% cut in reimbursement for most telehealth services is now apparently in effect and only behavioral health from our sources is excluded. There have not been meaningful cuts in telehealth nationally even though there has been more attention to billing and authorizations.  The reduction itself is not surprising as much as the level. Back in late 2020, we were thinking post-pandemic of the potential for 15% to 30% reductions, and some insurers have said they would lower the rate by 25%.  That behavioral is excluded is not surprising, given growing claims of its popularity and efficacy and importance in expanding access.  For other services, like an encounter between a physician and patient to discuss lab results or side effects from medication, the change suggests that the insurer either sees the value of this as half of what it would be in person, or they are assuming the cost to conduct the same visit in person is twice as much.  We have asked the insurer to clarify, though I’m not certain it matters.  A more important question is how the system responds. We suspect patients just want to have the conversation and, often, a virtual meeting is the most convenient, lower stress and just as effective, even if it loses some of the nuances of being there and the physician can’t do everything it might normally. Will physician practices and other clinics start to change how often they are willing and available for these tele sessions if the revenue is 50% less? In a straw poll of doctors here in my neighborhood, most said they like it when patients come in but there is value to the zoom, at any price. “Once upon a time we didn’t get paid a nickel for that, so beggers can’t be choosers,” says Peg O’Flannery, a pediatrician.  My own son is a good proxy too – I gave him $10 to mow the lawn last weekend, half of what I apparently gave him a few years ago, which is the last time I remember him mowing.  “Alternatively, you could mow the lawn for nothing,” I said. “No no, I’ll get right on it dad.”

400: The percent increase in virtual care utilization since the pandemic started according to United Healthcare’s Kristin Rantala, national VP of sales and client management. Rantala says the level of telehealth “climbed so much throughout the pandemic” and has continued. Based on data from the past two years, BCBS of North Carolina has announced plans to expand telehealth coverage for primary care, behavioral health, and outpatient visits and BCBS of Massachusetts is following suit by rolling out a new virtual primary care option, allowing members to receive comprehensive telehealth through a “team of primary care providers.” The team will aim to address mental health issues and provide health coaching from healthcare providers Carbon Health and Firefly Health.

Heart Partner: Phoenix Heart, a cardiology group in Arizona, has partnered with weight loss app Enara Health to create a service focused on preventing heart disease and diabetes. Patients meet with Phoenix Heart physicians and, if eligible, use Enara’s digital platform for diet consultations, lifestyle evaluations and medication aimed at reducing cardiovascular risks and other health issues associated with obesity. The average Enara patient loses an average of 41 pounds over 18 months using the app.

LGBTQ Payer: The first Medicare Advantage plan specifically for LGBTQ adults is launching in California from SCAN Health Plan. Available to members in only two counties for now, Los Angeles and Riverside, benefits will include virtual behavioral services, legal service reimbursement and companion care services.

The Twilight Zone: Apple is planning to enter the health insurance market in 2024 through a partnership with a “major payer” Forbes reported this week. Apple will likely rely on data collected by Apple Watches, which could give the company an advantage when it comes to developing value-based arrangements, like those that are outcome-based. Feels a little too much like an episode of Black Mirror, or for those of us over 50, The Twilight Zone.

Believe It Or Not: No, not the theme song to the 80s classic TV show Greatest American Hero but a Medicaid managed care plan out west has entered into a 2-part value-based contract with, wait for it, a skilled nursing facility. The goal is to incentivize the SNF to limit weekend admissions to hospitals, particularly for patients who have 101+ fevers, and separately pay a monthly stipend on top of the per diem to help the SNF manage residents with SUD.

Rx Frequency: GoodRx is launching a platform specifically to help providers track prescription frequency and text, email or print a coupon for the patient during a visit. Providers will also be able to reach out to pharma companies directly to ask about new therapies and patient assistance programs and allow providers to compare drug costs based on a patient’s insurance.

Mental Health Access: Only 46% of 12 to 27-year-olds receive follow-up mental health care within a month after a crisis hospitalization or ER visit, according to researchers at the University of Massachusetts, and just 29% received follow-up care within seven days of that crisis. Patients who already have a PCP or mental health provider are more likely to receive follow-up care, even more so if they have both. Follow up rates are much lower for those with SUD.

Extra Point: Maybe it’s me but it seems increasingly difficult to figure out what to do. Like should I rake the leaves so I can jump into a big pile or let them wilt into the lawn. “What are you, like 6?” my wife says. Or now that I am 50, I have to start doing tests I’ve only heard my folks complain about – like that new study suggesting colonoscopy doesn’t lower the risk of mortality from colorectal cancer any more than if you just skip the procedure. I mean, that’s sort of like saying doing your homework doesn’t lower your risk of being dumb any more than if you just skip the assignment. Then there’s eating - dark chocolate can apparently increase caffeine levels in your blood and raise your heart rate, which doesn’t sound so good, but it can lower blood pressure too, which my doctor Jon Wenceslao, MD says he likes since sometimes my BP runs high. If you have kids, youth sports club teams can apparently get your young athlete a shot at playing in college, maybe a scholarship, but can lead to a higher incidence of eating disorders according to a study we have coming out on this issue, so is the old rec team better? None of my kids played on these clubs nor did they get sports scholarships to college, although our oldest Jack says he’s “not on the Indiana hoop team by choice…because I easily would dominate dad if I wanted to.”  At least he doesn’t lack confidence. If you’re a doctor or nurse, figuring out what to do seems tough these days – like do you treat the pain with a drug knowing it will probably cause inflammation in the eye, requiring another drug – a steroid – creating more cost and confusion for your patient? Do you take risk or stay the course, and do you join a multi-specialty practice, hospital system, or sell to an insurer because staying independent is difficult? Maybe it is me, but maybe the easiest way to choose sometimes is just to flip a coin as Joe Dee Messina sings. Heads Carolina, Tails California.

7M: The number of women in the US who live in maternal health care “deserts,” areas with limited or no access to these health services, according to a new report from March of Dimes. The number of counties without any obstetric providers or obstetric care in local hospitals has grown 2% since 2020 and one of the driving factors is hospital closures – since 2005, over 180 rural hospitals have closed. These deserts are also more likely to be found in states that have restricted abortion, creating an even bigger imbalance in healthcare options for women in these areas.

Waiving “Test” Approval: In a positive trend, starting January 1, 2023, prior authorization will be waived for certain biomarker testing for Premera BCBS Washington members living with cancer. The cancer must be stage III or IV, or has come back after treatment, not responded to treatment or spread throughout the body. AIM Specialty may still perform retrospective reviews for these services occasionally.

Move Over Medicine: 21,418 males age 12 to 22 took our sports poll last week – 28% think Kansas City will win the super bowl, 32% don’t have Larry Bird in their top 20 all time – which is ridiculous, but what do the youth know anyway? Actually, maybe a lot more than we give them credit for.  57% have had or would consider using mental health therapy to help them “juggle stress, including the ups and downs of sports pressures”- nearly 1 in 4 who’ve had a therapy session say their friends know and, not surprisingly, for the 21% who say they have had at least one session with a therapist, the number 1 best advice they got and used was, drum roll, “low stress exercise therapy.” Think kickball or pickup volleyball.

Retail Diversity: Walmart is launching a research institute focused on improving clinical trial diversity. The company will leverage its large consumer base and try to expand access to older adults, rural residents, women, and minority populations by serving as a connector between drug researchers and potential trial participants. They plan to start with trials of drugs that most impact underrepresented communities, including treatments for diabetes, cardiovascular disease, COVID-19, and asthma, and are considering areas of research like HIV and dementia. Similarly, CVS is partnering with historically black colleges including Florida A&M, North Carolina A&T and Morehouse College to elevate opportunities in underserved areas. Its pilot program with Morehouse called Accelerating Growth Activators consists of 13 minority-owned businesses that supply services and products to the healthcare industry.

Shark Attack: Capital Blue Cross in Pennsylvania is the first health plan to partner with Mark Cuban’s Cost Plus Drug Company. Beginning in 2023, members will be able to get their prescriptions from Cost Plus Drugs, which sells medications for only 15% more than it pays manufacturers. Because BCBS plans don’t own their own pharmacy benefit manager and specialty pharmacies, we may see more signing up to work with Mr. Cuban.

Homeless Center: The city of Austin has partnered with the public hospital district here in Travis County called Central Health to build a permanent healthcare facility for those experiencing homelessness, a Public Health Committee meeting confirmed last week. The district is contemplating 30 to 40 respite beds to the 10 that are already available through various medical facilities. For providers, do these new housing investments represent opportunity to provide healthcare services?

Who’s Right?: 46-year-old Jane’s pinched nerve became debilitating. After two weeks out of work without improvement, her PCP prescribed Gabapentin to treat the pain but her physical therapist said the drug had significant side effects, including drowsiness, may be difficult to taper from and may make it difficult to know whether the PT exercises and strengthening were working. “Tylenol would seem sufficient, even for a severe pinched nerve,” the PT said. Six weeks since onset, mobility has improved and pain persists, but Jane is at ~75% function – so much better – but still on the drug. Were both practitioners right? Could Jane have recovered more quickly? Is there still risk? These are the kinds of very specific treatment plan decisions that can be improved when PCP and specialists talk. In Jane’s case, she played middleman, advocate and was confused about what to do. The PT and PCP haven’t spoken once.

Extra Point: Well, there seems to be a movement away from having to get pre-approval for everything in healthcare, even if that same trend isn’t happening for husbands. Several laws are in the works – including one moving through Congress that if enacted would require Medicare Advantage plans to publicly share their pre-approval rules and denial rates. That may not move the needle right away, but insurers are at least now more willing to waive pre-approval for providers who meet a certain standard, or for patient situations where requiring pre-approval makes little sense. The cost to pre-approve can be significant – for insurers, it can be hundreds per case, and for practices, it can mean taking clinical staff away from patients. Insurers often kick back requests faster than the Roadrunner.  “It’s fairly automatic - we usually require a couple of weeks of progress notes when it’s a reauthorization – sort of why we exist,” quipped one of my basketball buddies who works as a utilization analyst for a northeast insurer. Lifting pre-approval requirements is probably good for patients on the whole, but candidly I’m not holding my breath that this same trend will sweep through my house.  God love her, but my bride requires me to get pre-approval for many things, likely because I let my 3-year-old run free during a birthday party at the mall in 2006, while I typed on my laptop in the food court. I didn’t pre-verify birthday etiquette. “Did you even know Jack was running naked through Filene’s Basement?” Bridget said during our post-mortem. “Well, no, but in my defense, I managed to get him home with his clothes on. So we got that going for us.”