Behavioral Health Insights

4: Percent increase in suicides in 2021 compared to 2020, according to provisional data released by the National Center for Health Statistics (NCHS).  Experts are worried that after declining rates in 2019 and 2020, rates are increasing again. The report found that males ages 15 to 24 continue to be at higher risk than other groups, but there was a worrying 16% increase among middle-school-aged girls. In a smaller study, CVS Health recently reported a 32% increase in suicides among their members aged 13 to 17 and in response, is partnering with virtual mental health companies targeting adolescents as well as implementing toolkits for parents.

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.

Easier Credentialing: Credentialed primary care nurse practitioners with more than 3,600 hours of experience, as well as psychiatric and women’s health nurse practitioners are no longer required to provide evidence of a collaboration with a physician, a written practice agreement or written practice protocols under a revised Excellus BCBS rule.

Gastro Park: Starting in November, Regence BCBS will require pre-authorization for the site of service for select gastrointestinal procedures including endoscopies and colonoscopies. Providers wishing to perform these procedures at a hospital outpatient surgical site will be required to submit proof the member needs this level of care.  Similarly, Aetna is now beginning to require a precertification for certain procedures like lithotripsy, carpal tunnel surgery, hernia repair and others for members when they are performed in a hospital outpatient setting.

Concierge With Multi Specialty Flare: Gone are the days when the concierge doctor just checked your vitals.  A new concierge care platform from Cigna and its subsidiary Evernorth will focus on MSK conditions, injectable and infusion drugs in a variety of locations including at home and will eventually expand to offer behavioral health and nutrition. The new offering, Pathwell, targets commercial members and integrates Evernorth’s data analytics and digital solutions with Cigna’s medical benefits and networks to provide personalized, comprehensive care for members with high-cost conditions. Pathwell Bone & Joint will connect patients with PT, behavioral health and peer support and if surgery is necessary the members’ benefits will cover the procedure at low to no cost, according to the insurer.

Physical Meet Mental: 24 Hour Fitness is teaming up with Headspace Health, the digital mental health platform, to offer a complimentary three-month Headspace subscriptions to new and existing fitness club members on a first-come-first-served basis. The partnership is set to launch on World Mental Health Day, October 10.  Be aware – these marriages will likely proliferate and partner with health insurers over the next several years.

Extra Point:  Please pray for my 15-year-old Tommy. He has to write 4 whole sentences with adverbs, adjectives and creative verbs by next Thursday on a “health” topic of his choice.  He has to submit it over the google doc, using his iPad. Oh the absurdity, plus this is for his health class. “I don’t know why we have to write at all – it’s not English class!” Tommy said today. I asked him what his topic is.  “I don’t know, I picked the punemo. Sounds like the fish in the movie, right, but no idea what it is.” It sounded like a rare disorder to me, but on a hunch I asked him to show me the spelling. “That’s pneumonia you dummy!” If there’s a lesson here it’s that iphones are creating a generation of misspellers and schools are probably enabling the youth. “Tom when I was your age we didn’t have computers– we had to write book reports, that’s like 30 sentences, all with a #2 pencil on paper and the only spell checker I had was Webster’s dictionary!”  Wait, Tommy said, “what’s a computer?”

18: The percentage of Americans who have skipped a medical appointment or filling prescription drugs in the past six months because of financial strain, according to a new NPR/PBS Newshour/Marist poll. The percentage of respondents answering yes to these questions was higher among those with lower incomes. 30% who make less than $25,000 a year said they had skipped a medical appointment or prescription in the past six months, while 21% of those who made $25,000 to $50,000 a year answered the same. Just 9% reported delaying or skipping paying medical bills or insurance costs in the past six months to save money. 

Back To The Future: The kids like to say I need to join the 21st century, and commercial payers do too, or so it seems. Starting in October, several big payers nationally will update commercially contracted rates that have been based on older years of Medicare such as back to 2007 or 2015, or 1998 in one case. Rates will be adjusted to either the current Medicare year or a more recent year, like 2020, based on CMS’s relative values. We talked to physicians who are in the “procedures” side of healthcare, and they are “definitely impacted,” most were notified earlier this year or this summer. You can challenge the changes but “we were not successful” one urology administrator said, and while providers do not need to sign the contract amendments, most will, given the market size of the payers. “If we don’t sign, we probably lose a lot of patients to other providers.”  Some payers said these changes will be rolled out by the end of the year. Typically, it takes commercial payers between 9 months and 2 years to adopt Medicare changes – usually at a lag and not at the same level but “this one is more impactful” because it adjusts the payment year. Lab providers between 2016 and 2018 had to deal with similar adjustments when many commercial plans adjusted their rates to tie to the current year of Medicare “to make it easier on the ancillary contracting teams.”  

Pre-Approval Waived: Like the dads who do just enough dishes and laundry to get to golf Sunday mornings without mom’s pre-approval, healthcare providers are finding insurers more amenable to allowing services without pre-authorization (PA). The “Texas gold card bill” takes effect October 1, reducing PA requirements for certain in-network physicians and providers. Gold card programs have been utilized by managed care plans for more than two decades, but Texas was one of the first states to implement a program into law. For a provider to receive a gold card, Texas payers will analyze approval rates for at least 5 PA requests and if the provider receives at least a 90% approval rate then they will be exempt from PAs for that service for 6 months until the approval rates are re-analyzed.  

Early Anxiety: A year removed from the U.S. Preventive Services Task Force recommendation for people to get colorectal cancer screening starting at 45, the task force is now recommending providers screen all adult patients under 65 for anxiety. The advisory group said their guidance is intended to help prevent mental disorders from going untreated. Though COVID-19 certainly increased stress and anxiety for many, the group said they had been preparing the recommendation before the pandemic. In a poll of providers, 64% of PTs and 59% of imaging centers say their patients are now more commonly alerting them to their anxiety. “Perhaps stigma changing for good,” said Paulette Connors, a physical therapy from Massachusetts who says it helps to know if patients have anxiety, particularly for treatments like traction or for nerve related conditions. 

Digital Health Benefit: Gravie Partners, a health benefits company, is adding digital health options for all their member plans. These will include digital fitness apps FitOn and Peerfit, digital PT program Sword, as well as telehealth app Teladoc, all at no extra cost. These services were chosen based on members’ claims data which showed mental health and musculoskeletal treatments were most needed. 

Penn Pals: The University of Pennsylvania Health System is investing in Independence Blue Cross’s subsidiary, Tandigm Health, which focuses on preventive primary care. This will be a long-term commitment from Penn Medicine to work with Tandigm for all primary care value-based programs across all payers, set to launch in 2023. Penn will add 275 of its primary care doctors and an additional 100 advanced practitioners to the 400 PCPs in Southeastern Pennsylvania who already have contracts with Tandigm. The practice currently helps manage the care of 110,000 individuals for its doctors and Penn will add about 200,000 patients to that pool. Independence and Penn Medicine have a history of collaborating around value-based care, including the launch of a program in 2017 that reduced hospital readmissions.  

Extra Point: Mike once told Archie in All In The Family, “Hey Arch, would you stand up and cheer if it was me at the door?" “Well that depends Meathead – on whether you were comin’ in or goin’ out?"  Last I checked there’s a monthly premium for the “family” and 5 names are listed on that insurance card, but where in the world is the health plan? We often think about the total cost of care in personal terms, but there’s a family cost. 47-year-old Jenny, a former swimmer, develops alcohol disorder in her early 20s. An assessment by a physician reveals significant childhood trauma and some more recent abuse, but also a larger family health crisis. No longer all that mobile, Jenny has hypertension, fibromyalgia, needs a walker, barely can get to the mailbox, takes Effexor for anxiety, Xanax, and a beta blocker Metoprolol. Her PCP is absent, giving her 90-day refills on these drugs, but doesn’t follow up. She’s now type II diabetic, approaching obesity, and suffers insomnia. But Jenny carries on - she tries to take care of her 80-year-old mom and her younger son Alex who is on the autism spectrum and deals with GERD and sleep issues, but she struggles with it all, obviously, entering him in a full-week ABA program. She cooks for her husband Ben but their health as a couple and as a family is waning. Ben is fatigued, starts drinking himself, and is missing work to help out with Alex and his mother-in-law. Their dog Suzie is no longer walking.  So where's the health plan? Who to prioritize, and how?  A medical at-home model emerges, focusing on the full spat of mom’s conditions, helps Jenny get sober after in-home detox then moves to addressing other issues, reducing doses, treating her childhood trauma, getting mom more mobile. Alex now doesn’t spend all week in ABA and starts to play in a specialized soccer program and helps mom make supper. The medical team works with Alex and Jenny to address their insomnia and mom and dad re-engage in a healthier marriage, walking the dog and cheering for Alex at games. The plan takes 9 months. The estimated $500,000 in annual spend in prior years drops to just checkups. The story may be an extreme one but it’s more common than you may think, and it illustrates what managing care for a family in crisis can look like. When building your model or raising your family, take note. Where’s the doctor? Are they in another state or building or center to the assessment and care—are they comin’ in as Archie said, or checked out as Jenny’s PCP was—and are you capturing and trying to solve just one person’s condition, or have you thought about how you can solve the family’s? 

2,380: The average annual spending in dollars on mental health services by individuals in employer-sponsored health plans in 2020, up 20% compared to 2013. A report from the Employer Benefit Research Institute has tracked mental health spending over time and found that overall spending on mental health care services as a percentage of total spending increased 8.2% in 2020, up from 6.8% in 2013. Though spending rose overall, some services decreased - prescription drug costs actually dropped 15% from 2013 to 2020, while outpatient visit spending rose 37%.

Testing Virtual “Efficacy”: As trendy as it is for payers to provide access to apps as part of their benefit packages, in some cases, little is known about the efficacy of these programs. To that end, Cigna’s health services division Evernorth is launching pilot programs to test efficacy of Jasper, Zerigo, Lid Sync, and Hinge Health for digital musculoskeletal clinics and women’s pelvic health.  Payers have increasingly been providing members access to apps and virtual services, so much so that their lists of approved and vetted apps are now referred to as “digital formularies”. Evernorth recently added access to four new digital health apps to its Digital Health Formulary as a way to further bolster patient benefits. Members will soon receive access to Big Health’s Sleepio and Daylight apps, Quit Genius for addiction, and Health Beacon’s Injectable Care Management System, aimed at assisting people with inflammatory conditions.

You’ve Got A Lot Of Nerve: In case of primary care winning out over specialists, an internist in a women’s health practice complained to us that she’s seen more than 100 patients with pinched nerves over the years but many go straight to chiropractors who offer a Band-Aid and then to PT who can help with exercises but overstate the negative side of effects of medications and tend to fail to understand the patient’s other conditions and the role of drug treatment. “These patients are completely mismanaged,” the doctor said. “Most of the nerve medicines have side effects, but you have to treat the nerve pain, so you start with low dose and take it from there.”  Too many PTs and chirorpractors ignore that or don’t know enough about patients, like if they also have anxiety, or base their input on a small sample. “These situations can be debilitating and if not treated right and you can miss weeks even months of work.”

Burnout: 63% of physicians experienced at least one incident of burnout in 2021, according to an article published by Mayo Clinic Proceedings. This number shows a marked increase from the 2020 survey when only 38% of physicians reported burnout. Other study findings showed increasing scores for emotional exhaustion and decreased satisfaction with work-life balance. 

Fostering Fix: NextGen Healthcare, a provider of cloud-based healthcare technology, announced its new platform Behavioral Health Suite which offers tools that support the delivery of foster care services. The new automated state-reporting capabilities will enable providers to spend more time delivering care and less time on regulatory compliance. Some of these new features will enable clinicians to document initial screenings of prospective foster parents and allow providers to view availability of foster families to assign children to, as well as manage the location of the foster child within the foster care service program. Services will benefit 672,000 foster care youth with complex health concerns.

Pregnant Pause: A new CDC report shows that more than 80% of pregnancy related deaths that occurred between 2017-2019 were preventable. More than half occurred between a week and year after giving birth, highlighting the importance of comprehensive postpartum care for at least a year. Six underlying causes accounted for most of the deaths: mental health conditions, hemorrhaging, heart problems, cardiomyopathy, blood clots, and infections.

Autism VBA: Georgia’s Peach State Health Plan is partnering with The Behavioral Health Center of Excellence to research and improve applied behavioral analysis for those with autism and establish reimbursement incentives for providers who deliver high quality care under the value based care model.

Bonus: So when Dr. House asked on his TV show, “Do I get bonus points if I act like I care?” – the short answer, at least circa 2022, is heck yes.  There are a lot of ways to get bonus points these days in healthcare, like for identifying social risk factors or screening for depression or showing you can get patients to recovery at a lower cost than the average and, yes, even for having a high portion of patients who say they like you.

Extra Point: The truth shall set you free, but it can be awkward and uncomfortable in the healthcare setting, so the youth of America avoid it. Nearly 70% in our poll of 13,262 15-25 year old’s admit they often lie to doctors and nurses. Those are “facts dad,” as my kids would say. The youth say they have lied about a range of things, like family history, taking medicine, blood in their stool, the extent of their pain, whether they are depressed, or whether they drink or smoke. “It’s just not something I will admit or want to talk about–not in person and probably not on a zoom, and not to someone I see once a year,” said one 21-year-old female. Just 9% said they are honest on those depression forms they fill out in the waiting room (unless they are lying about that too!). A 23-year-old said he runs every other day and feels great but his doctor said he had high levels of iron and wanted to run some tests, presumably I would think to account for the possibility of heart or liver disease, but he ignored the doctor. When it comes to divulging their behaviors or engaging with physicians, the Tik Tok generation is reluctant. Sort of confirms what Dr. House used to say on TV, that it is a basic truth of the human condition that everybody lies – the only variable is about what. Nearly half of these young adults say they tend to lie because they don’t see the value in the visit to begin with. “It’s usually just something I’m required to do or all I get is a medicine that makes me tired or more sick, or they tell me I can’t do something,” an 18-year-old male said.  This is probably not earthshattering news – youth going back to the beginning of time have always felt both invincible and smarter. But with the advent of new forms of healthcare and a renewed emphasis on preventive care, it’s noteworthy to consider their resistance, their mindset and their angst, and then find ways to engage and build trust. Keep in mind, as one George Costanza would say, “it’s not a lie, if you believe it."

$43.9b: The amount spent on outpatient drugs through the 340B program in 2021, according to a new government breakdown of spending. Disproportionate share hospitals are the largest purchaser of 340B drugs by far, followed by children’s hospitals, rural referral centers, and Ryan White programs. The difference between list prices for drugs and discounted 340B purchases grew to $49.7b, per Drug Channels.

Mind Games: A collaboration between Highmark Wholecare, the health plan’s Medicaid and Medicare division, and Posit Science aims to utilize brain training software to prevent falls. By identifying members who have a high fall risk, the app uses exercises that target accuracy and visual processing speed. These games aim to help the brain adjust body movement and prevent falls. The program is offered at no extra cost to eligible members, which Highmark reports is close to 7,000.

Hospital At Home Expands: We previously reported that Elevance (known as Anthem) began accepting claims for acute hospital at home services just in Virginia but it appears the insurer is going even further and is accepting hospital at home claims under all of its commercial, Medicare Advantage and Medicare Advantage Special Needs plans across all states. The policy went into effect over the summer and Elevance continues to encourage qualified hospitals or other entities that meet its requirements to reach out to their health plan contractor to get an appropriate participation agreement in place.

Walmart’s New Partner: Walmart Health is partnering with United on a 10-year affiliation in an effort to bring affordable health services to select Walmart locations. The collaboration involves Optum, a United business, and will assist Walmart Health clinicians through analytics to deliver care for seniors and Medicare beneficiaries. The partnership begins in 2023 with 15 locations in Florida and Georgia and likely expands to new states over time.

Shine Bright: Popular behavioral health app Headspace is focusing on more personalized mental health care through the acquisition of an app designed for the unique challenges with the black and indigenous people of color community. The app, called Shine, serves 45,000 paid subscribers and 6 million total users and tailors its content to marginalized communities including women and people of color.

Virtual Benefit ReDesign: HCSC will begin offering virtual primary care in 2023 to limited midsize and large employer groups in IL and TX. The virtual primary care network is supplemented by Teladoc and is intended to help employers with employees scattered across diverse geographies get timely access to care. Members receive a welcome kit with a blood pressure cuff and heart rate monitor so they can provide vital data to their health care team. The offering also includes virtual urgent care, behavioral health, and dermatology.

Scheduling A New Patient: In 2022, it takes 8% longer than it did in 2017 and 24% longer compared to 2004, according to a new survey from AMN Healthcare. The staffing agency tracked appointment wait times in five specialties: obstetrics/gynecology, cardiology, orthopedic surgery, dermatology and family medicine. The average wait for an appointment across 15 large metropolitan markets is now 26 days, up from 24 days in 2017 and 21 days in 2004, when the survey was first conducted.

Extra Point: Next year our two daughters are transitioning – one into college, one out – and, like a lot of healthcare companies, both are facing the obvious questions like are they ready for what’s next, do they have the skills and tools, where should they go, who should they go with, and how much risk should they take. Healthcare companies are facing similar transitional questions—are they ready to make the change to value-based arrangements, do they have the skills, the tools, and the culture? There’s been comfort and familiarity in fee for service, but there’s an unknown ahead. Are their clinical protocols the right ones? Will they need to adjust how often and why they order diagnostics – do they manage patients by testing or clinical judgment? Will they need to spend more to monitor their patients after they leave the clinic and is the cost of this investment worth the bonuses and fewer administrative requirements? And even if transitioning to these arrangements is necessary, which one is best--pay for performance, share of savings, global risk, or something in between? My daughters are facing similar uncertainty – which job or school is right – and like the doctor group who takes care of young and older adults, how much “downside” risk should they take and on what services, with which insurers and patient populations? How quickly will they need to transition and show performance and is there a state or city they should go to that will make the transition the most successful?  It would seem obvious, to most, that you’d pick the biggest insurer in a state like BCBS to partner with, but that’s not always the case. In fact is your partner always the insurer or is there another better, safer, smarter partner to align with? And perhaps most of all are they ready for when things go wrong and every right decision doesn’t go your way and the patient ends up in the hospital 5 times in 5 months? For our girls, I hope they have learned how to be independent and make good decisions and, yes, how to make an egg without burning down the house, but I suppose it’s more important for them to know that when they fail or when things go sideways, that they have a way to get back up.

22.2: Cents of every insurance premium dollar spent in 2020 went to prescription drugs, up from 21.5 cents in 2018, according to a recent analysis of commercial insurance claims from AHIP. Spending on hospital inpatient and outpatient costs held steady compared to 2018, making up a combined 38.9 cents of every dollar, while other medical costs, like physician office visits and ER trips, made up 21 cents on the dollar and the rest went to insurers’ administrative and operating costs and profits.

Isolation: Independence BCBS recently launched a new initiative aimed at addressing loneliness and isolation among seniors. The BlueBench Program creates settings where seniors can meet new people and socialize, the program kicked off by unveiling three new blue benches during a community cleanup in FDR Park in Philadelphia.

Mom vs. Dad: We polled 345 moms and dads a few years ago about a seemingly mundane question – how they decide where to go for healthcare. Moms seem more thoughtful – relying on their OBGYN or their neighbor who’s a pediatrician, or NPR, while Dads, somewhat predictably, rely on it getting better without them doing anything or, increasingly, the nearest urgent care. Moms are more often changing doctors and more thoughtful about where to go and whose advice to use. Unlike Elaine of Seinfeld fame who failed to change doctors because her last one wrote in her medical record that she was too difficult, today’s generation of Elaine’s have more access and control over their records, and more say in where to go. They tend to rely more on what they know, hear and see every day, sometimes for good and sometimes not. In our study of 345 adult consumers, there were some clues as to how people select specialists and how little people rely on insurance to guide them.

Student Insurance Change: Ithaca College of New York now requires each student to have health insurance, whether through the college costing $2,713 a semester, or an alternative like their parent’s commercial plan. Students have until September 15th to waive the student plan or they will be automatically billed. The college recently began using Cayuga Health System’s network to serve students. Before that, students were not charged a fee to visit the on-campus health center, or for any labs, and did not need to provide proof of coverage - they were only charged if using off-campus providers.

Back Pain: Anthem and AIM Specialty are launching a new Back Pain Management Program for fully insured commercial members next month in select Anthem states. The program will use predictive analytics to identify members with back pain, who will then be contacted and provided with customized education and provider options, including behavioral health support if needed. The goal of the program is to reduce risk of chronicity and minimize recurrences and complications.

Psych Gap: Half of U.S. counties do not have a psychiatrist or an addiction specialist as of 2020 and the total volume of prescriptions for mental health medications written by primary care providers far outweighs the total from behavioral health specialists, revealing a widespread dependence on generalists for behavioral healthcare. A newly launched Behavioral Health Workforce Tracker designed by researchers at George Washington University highlights these gaps and exactly where in the country mental health professionals are practicing. The database includes around 1.2 million behavioral health providers - approximately 600,000 psychiatrists, addiction medicine specialists, psychologists, counselors, and therapists, as well as primary care physicians and advanced practice providers who prescribe medication for mental health.

Group Therapy Payment Change: Effective December 7, 2022, Premera Blue Cross is implementing a new reimbursement policy for group psychotherapy services represented by code 90853. All professional services billed by a medical group/clinic, facility or individual will only be reimbursed for one unit per date of service per member, regardless of the length of the therapy session.

Credit Risk: More hospitals are teaming up with banks to offer medical credit cards, which patients can use to pay for bills they may not otherwise be able to afford. These credit cards often have some of the highest interest rates in the industry, as reported by Modern Healthcare. These medical credit cards aren’t new - one company has been offering them since 1987 – but the rise of high deductible health plans means more patients may feel the need to turn to them, especially when hospitals are pitching the cards “at the point of care, at discharge, and when the billing department contacts patients days later.”

Extra Point: So, my folks were late to Sunday supper this week because they were waiting for each other at the apple farm, sitting on benches maybe 15 feet apart pointed in opposite directions…dad having fallen asleep from one too many cider donuts. I love fall. There’s the leaf jumping, apple crisp and college football, the pumpkin seeds, bulky sweaters, and gramma’s mashed potatoes. There’s the Fall guy and the Fall of the Empire, Niagra and Tacko Fall, that 7’6” basketball player. There’s Fall Out Boy, falling in love and Fallen, that great Sara McLachlan song. But would you believe it, some people don’t like fall, even though they keep doing it. Some are just clumsy like me, some like Janice fall because their husbands fail to adjust the bike seat. Others have cataracts or glaucoma or live in the icy north, but many are older folks with dementia or weaker bones or malnourishment, for whom falls are as common as Uncle Bobby blaming me again for “deleting the internet” because I removed the shortcut to his browser. My dad has fallen a few times – once hospitalized – while my mother-in-law has fallen some 5 times since turning 80 that we know about, most of which have landed her in the hospital. What’s underappreciated about falls – the cause isn’t what you think. We once studied 65 seniors who had fallen and needed inpatient rehab only to learn that some 39 of them had lost a spouse, never really grieved and became sedentary. They fell into their spouse’s habits and into a health spiral. So if you are in healthcare and see seniors, take note not just of what’s happening inside their body but what’s going on inside their home and their heart.

56: Percent of 8,806 college students we polled who said they’ve skipped going to the clinic despite sore throats and congestion for fear of being quarantined and “miss the home opener” or frat-sorority “darty” – a daytime party in the quad, which is a term I did not know about until the kids filled me in. This is “the worst kind of mental health for a college kid” one sophomore said.  A far greater portion of freshmen – around 75% - have avoided going to see a doctor or clinic because they live in “on-campus” dorms, so a positive Covid test is like getting grounded by your folks on a spring weekend. Problem is, if that sore throat is strep, it can cause kidney inflammation and eventually heart valve damage.

IDD Help: People with intellectual and developmental disabilities are 1.5 times more likely to go to the ER, compared to people without such disabilities, researchers from St. Michael’s Hospital recently found, and virtual providers are increasingly turning their focus to help prevent these visits. StationMD, a telehealth company that specializes in serving IDD patients, launched a pilot with Partners Health Plan in 2020 with the goal of reducing visits. Over the past two years, the company achieved a 93.1% treat-in-place rate, saving around $5.7 million. StationMD charges the health plan a PMPM. So far, usage has come mostly from patients in residential facilities.

Finding Your Behavioral Lane: In an effort to address increasing demand for behavioral health services, Empire, the New York Blues plan, has added four new providers of virtual services to its network—Alma, Headway, NOCD and Ophelia. These providers all have unique features and address specific behavioral health disorders. NOCD offers obsessive compulsive disorder treatment to individuals as young as 5, Headway offers members price transparency, and Ophelia combines provides medication-assisted treatment. Evernorth, Cigna’s health services division, is also expanding access to virtual providers by bringing virtual SUD treatment clinic Bicycle Health into their network. Bicycle provides MAT services is paid based on patient outcomes.

Old Idea: If you had to guess, you’d say that a majority of Floridians are over 65, driving golf carts to the Harris Teeter, hitting the early bird supper at Del Boca Vista. But just 21% of the Florida population is 65+.

Insomnia’s Marriage:  The sleep condition has a “bilateral relationship with depression,” says Dr. M. Safwan Badr, former president of the American Academy of Sleep Medicine. Having insomnia for up to 3 weeks can often cause depression, ipso facto, can cause a higher risk of sleep disorders, he says. “Anything less than 7 hours increases depression risk.”  We spend about one-third of our lives asleep—well most of us do—and it affects every aspect of our health, yet sleep medicine doesn’t always get the attention it deserves. “There is tremendous value to it - from our brain to our heart and emotional control,” says Badr.

Day In The Life Of A Medical Director: Dr. Kellogg hops to the passenger side of his Blue Saturn and flips me the keys. ‘You drive Cote – I have to take a few calls.’ I push aside a few Zone protein bar wrappers and the Journal Inquirer and sit down. Aerosmith’s Dream On is playing on the radio when I turn the keys and Kellogg, a medical director for a number of health plans in the region quickly taps the power button. He unexpectedly has to respond to requests for coverage in 5 different cases: bariatric surgery, an antidepressant, a series of pain injections, a cancer patient’s continued admission and testing, and a hospital patient who has been bouncing back and forth to a SNF. Kellogg immediately approves the extended stay and MRI for the cancer patient, and then starts reading notes out loud to the case manager for, I presumed, the hospital-SNF patient: ‘Had heart failure and shock with major comorbidity on 5/11, respiratory infection on 4/6, major GI episode on 3/11, esophagitis on 2/14 and kidney infection on 12/27. All discharges to SNF. Don’t let him leave the hospital. We’re looking at a sepsis situation. Have the attending call me. Let’s allow at least 2 more days.’ He puts the case manager on hold. ‘Take a left up here – we should go route 20,’ then proceeds to deny approvals for each of the other three cases. ‘Some of these cases are so black and white – these are lifestyle cases. Happens with the Medicare seniors who get dehydrated and fall because they are depressed and inactive and it happens with dads in their 40s.’ Dr. Kellogg orders a chicken sandwich and a vanilla coke during lunch with a side of fries. Some styles are hard to break.

Rapid Growth of Autism Services: Join BRG experts Misha Segal and Jim Teisl, with guests Mai Pham, Founder and President of Institute for Exceptional Care, and Lorri Unumb, CEO of The Council of Autism Service Providers, on Friday, September 9 at 1 PM ET as they discuss the rapid growth in autism services and the recent debate surrounding types of treatment and standards of practice. Panelists will also touch on lessons learned for other evolving areas, including medication-assisted therapy, outpatient mental health, residential treatment services, and home and community-based services. Pre-Register for the conference call here.

Extra Point: So, Clooney was probably right when he asked us how much our life weighs.  “Imagine for a second that you're carrying a new backpack,” he said in the classic Up In The Air. “Only this time, I want you to fill it with people. Feel the weight of that bag. Make no mistake - your relationships are the heaviest components in your life.” But they are the most important and more businesses are getting the hint that their people and their health matter. Many are now encouraging patients who need surgery or specialized long-term treatment to fly far to do just that, picking a single center thousands of miles away for the diagnosis or treatment. Rush Medical Center and United Airlines partnered 6 years ago, City of Hope and Wellpoint partnered more than a decade ago. After meeting deductibles, employees could get the full treatment and cost of travel and accommodations covered. Dozens of companies are getting on board by broadening or creating these policies, some raising the allowed budget just for travel to $10,000, others more prescriptive identifying specific partners as the airline did. My old friend Dave Tofanelli used to promote the idea back in the late 1990s when he was in charge of contracting nationally for Wellpoint. “It is beyond me,” he said at the time, “why we aren’t paying for travel to get the right diagnosis and treatment, particularly for cancer." Tofanelli was among the first to advocate this at a national level.  Now families can get cancer treatment, organ transplants, gender reassignment surgery, psychiatric treatment and reproductive care at so-called centers of excellence they could never imagine. It is a lifeline for some we sometimes don’t quite appreciate. That extra carry-on bag – well that’ll probably still cost you.

6.5%: The average increase in US employers spend for employee healthcare coverage in 2023 compared to this year, according to an Aon report, bringing the average cost per employee to around $13,800. The year-over-year rise between 2021 and 2022 was only 3.7%, indicating inflation will likely begin to show up in healthcare costs next year. Because healthcare providers are often in years-long contracts with insurers, the impact is not always felt as immediately as in other industries.

Capping PT Pay: A growing number of insurers are capping the amount PTs and OTs can get paid per visit. A strategy first used around 2010 by Aetna in the northeast, the capping is spreading. On September 1, Highmark BCBS starts using a daily dollar maximum for evaluation services and a different daily bundled maximum for therapy services performed by PTs, OTs and chiropractors. Once upon a time there was very little PT coverage, insurers and doctors considered it a commodity and TV shows like Seinfeld mocked the idea that you could actually get insurance to pay for a physical therapist. “You mean I can get a massage for free?” George said. Well, sort of. 20 years later PT is widely covered, and many insurers have even dialed back authorization requirements, but there are adjustments like this to control spend.

Dog On It Ortho: Orthopedic specialists and some health insurers report an uncanny number of ankle breaks and related hospitalizations from dog owners who hang on to the leash while Fido tries to sprint away. More than 23 million Americans bought dogs during Covid and surgeries for ankle repair started to rise, as did calls to adopt a bundled payment for the surgery, like $7,500 for the surgery and a month of PT. Challenge for the patient is rehab is often a year-long struggle including strength and conditioning and pain management and, in many cases, the need for surgery again. Pricing these is challenging. My cousin Mark Cote, a PT doctor and director of outcomes research at UConn’s Musculoskeletal Institute, says the “biggest challenge is the rehab – a lot of non-compliant patients.”

Hospital At Home: More than 6 in 10 parents say they are “intrigued” by the hospital at home model as a way to “limit stress on the family. In recent examples, Resilient Healthcare is partnering with Dallas-based White Rock Medical Center and Pennsylvania’s WellSpan Health recently announced their program freed up more than 1,500 hospital bed days between September 2020 and April 2022. Some consumers are, however, skeptical – citing safety risks and questions about emergencies.

See, I Told You So: If you have a teenager, you have told them that they will be blind by the time they are 25 if they keep looking at their phone, and so it’s not all that surprising to see innovation around vision benefits. UnitedHealthcare now offers its members discounts on blue-light-blocking laptops as part of their vision benefits. UHC partnered with Dell to offer members a 20% discount on Dell XPS laptops with blue-light-blocking screens.

Building Behavioral: At some point, insurers will put requirements in place to measure and score the quality of behavioral health sessions, but until then, insurers continue to be on offense. Anthem in Virginia has partnered with Confidant to offer members access to virtual addiction treatment while Project Healthy Minds is a new nonprofit aiming to be a one-stop shop for finding a crisis line or mental health provider or program. The nonprofit hopes to help build national standards to guide companies’ mental health efforts.

Are You Walkin’ On Sunshine? If there’s a medical specialty that can claim this Katrina and the Waves hit, it’s probably the derms – skin cancer incidence is rising faster than an Olivia Rodrigo song on the charts and there aren’t enough dermatologists. Wait times are sometimes 3-4 months and, increasingly, it’s for the PA or NP, not the dermatologist. The tele-derm experiment is a potential solution as about 90% in our recent consumer poll like the convenience, even though 55% of doctors, down from 70% last year, believe it will add cost, not limit skin cancer. But heading into 2022, these practitioners can evolve to impact health system costs in other ways, like staffing a behavioral therapist and figuring out a way to reduce teen acne that has led to a range of emotional and tragic situations for teens.

Network Growth: The number of in-network behavioral health providers increased by an average of 48% in the last 3 years--the biggest increase from ABA providers, providers eligible to prescribe MAT and psychiatric nurse practitioners, according to an Association of Health Insurance Plans poll. Many insurers now use data about the performance of these providers and share it in hopes to steering care. About ~80% said they have added navigation and support tools and specialized case managers for follow up after emergency or inpatient care.

Extra Point: 63-year-old John Davis could not have foreseen this when he was 11. The tall Pittsburgh sports fan was a good ballplayer then, batted .660 one season in little league, “had great control as a pitcher” and went on to some tryouts for big league clubs. He married Debbie and the pair raised 3 kids in Hartford, Connecticut. Over the last several years John was the crossing guard at a middle school here. “It’s a great day to be alive” he would say. This summer, John’s bone cancer spread, and his doctors say they can’t control it. He entered hospice at home this week and gripped a baseball signed by the kids from the school. “No curve balls in the house John – you don’t want to break a window,” I said. He seemed to smile a hair but didn’t have much strength. He was cuddled up with a Pittsburgh Steelers blanket, peaceful but small, a shell of that big personality we’d see at the bus stop. I wonder if John could have foreseen this, if there would have been a way to extend his survival and control the cancer. I will think of my friend when I cross with the kids for soccer at the corner of Elm and Hudson. “It’s a great day to be alive” I might say. John would like that.

80: Percent of the total cost that Bluebird Bio will return to insurers if their new FDA-approved gene therapy Zynteglo doesn't stop the need for patients to get regular blood transfusions. The gene therapy costs $2.8 million.

Bundle This: We did a poll of 932 parents about what influences their healthcare usage. The amount of time they have to reschedule or miss appointments is going up, and if it were them, they would put pediatrics, dental, orthodontics and physical therapy into one center with a gym. "I'd want the gym for me," quips Molly Rastro, 37, of Connecticut, who says she's canceled 5 appointments already this month for her 3 kids. "Why the health system can't put it together is beyond me.” Physician practices report an alarming trend in missed visits - up to 30% no-shows or reschedules on average, according to one of our polls. The trend varies widely for PTs, therapists and diagnostics, depending on the age of the patient. "For kids needing a lab test or MRI or a specialist for something the PCP can't figure out, parents rarely miss - but the more routine, they do," notes Walter Roe, a practice administrator in the Northeast. The mindset of parents is increasingly important, particularly in an age of HDHPs, HSAs, and FSAs.

Legal Diagnosis: Mount Sinai recently launched a medical-legal program that aims to help patients who may have legal needs that are contributing to healthcare issues. The health system is working with the New York Legal Assistance Group and health insurer Healthfirst to proactively identify patients with unaddressed legal needs by using categories of legal risk, including immigration, housing and personal safety. Once identified, Mount Sinai care managers will screen patients and obtain their consent and then refer them to the legal group for consultations. In a 12-month pilot, the program identified 1,959 patients with potential need, and gave referrals to 165 of those of which 157 consented to assistance.

Therapy Rerun: Amazon is at it again, this time adding behavioral health services to Amazon Care, the medical care service it sells directly to employer health plans. The service will utilize care coordinators to refer patients to in-network behavioral health specialists for acute and moderate concerns. Amazon Care also is partnering with mental healthcare company Ginger. Last year, Ginger merged with Headspace, a meditation and mindfulness app provider, to create Headspace Health. Ginger’s services will be an optional add-on to Amazon Care.

Pharmacist Shortage: In a sign of the times, Walgreens is offering bonuses up to $75,000 to attract pharmacists as ~3,000 stores are understaffed, operating at reduced pharmacy hours, the company reports. Pharmacists must remain in the job for usually at least a year to get the bonus.  A Walgreens spokesman said the bonuses are part of a larger focus on recruitment and retention.

Consolidation Movement: Humana plans to acquire Inclusa, a managed Medicaid organization that provides long-term care services and supports to about 16,000 in Wisconsin. Meanwhile, United is snatching up KS Plan Administrators, a Houston-based Medicare insurer affiliated with the provider group Kelsey-Seybold that United purchased in July.

Diagnostic Speed: Global tech company Becton Dickinson (BD) announced a collaboration with LabCorp to develop flow cytometry-based companion diagnostics to match patients with treatments for cancer and other diseases. Flow cytometry is an emerging technology in companion diagnostics, which is increasingly being used to identify which patients with specific cancer mutations will benefit most from targeted immunotherapies.

Extra Point: I've figured out how to solve the sports gambling problem. It dawned on me about 9 hours into our drive from New England to IU to move Jack back into college. One of his friends Ben had gambled away the $6,200 he earned this summer that was to help cover his tuition. His parents know, but don’t know how to help, Jack said. I say, "Bet on yourself." It’s really my wife’s mantra and, give her credit, it really ought to be the national rallying cry for the growing number of teens and young adults, typically males, losing thousands overnight, finding themselves addicted to the rush of a late-night Ping Pong match on ESPN 8. It's interesting, of all the addictions, sports gambling is unique as many say they see it as a potential career. Heck Jack has polled his 80,000 podcast followers and 3 of 4 say they think they could earn enough money at it, so they don't have to have a real job. I say bet on yourself, otherwise, we’re going to be headed down a long road. The health system is starting to see the effects of this underappreciated epidemic. "We see it as a gateway to other addictions," says ER physician Vu Narayans. It’s a bit perplexing that 20 some states and counting have legalized online sports betting, but these same states and others won’t allow mental health therapists or programs to treat these addictions unless they have a license in the state where the patient is. We’ve made a bet that people can gamble responsibly, the same pact we made to drink responsibly. Kenny Rogers was probably right – we ought to know when to fold ‘em, if we only knew how to walk away and replace the addiction with something different, something healthier. Therein lies one of the least discussed but most important quality measures for behavioral health practitioners, insurers and policymakers to prioritize – don’t just fix, solve. Don’t pay for a session, find a way to pay for “recovery.” For sports gambling, there is a growing continent of sub-specialists who are set up to get patients to recovery There's a specific certification that matters here (the ICOGS or ICCG) but often times people end up in treatment with someone who specializes in treating substance abuse. It's a different addiction and parents, providers and insurers need to understand and communicate the differences. If you’re looking to find your niche in the great big behavioral health market, or just looking to help your kid or friend stop the compulsion, maybe help them place a bet on themselves.