Behavioral Health Insights

70,000: The number of new healthcare jobs added in July, according to the Labor Department’s monthly job report, bringing the industry within 0.5% of its February 2020 employment level. In a sign of the way healthcare is moving, the majority of those jobs were in ambulatory services, ~47,000 compared to just 13,000 in hospitals. 9,000 new jobs were in nursing and residential care facilities.

Drug Cost Sea Change: CivicaScript, part of a nonprofit launched by several health systems and 18 BCBS plans, launched its first drug this month, abiraterone, the generic form of Zytiga. Prostate cancer patients taking this drug will likely pay thousands of dollars less through CivicaScript. A month's supply will be sold to pharmacies for about $160 a bottle, with a maximum retail price of $171 — about $3,000 less than the average cost for someone with Part D coverage, according to the company. The company plans to launch several more generic drugs, with the goal of addressing drug shortages and bringing drug costs down.

Prepay Review: Outpatient claims for more than $100,000 billed as a percent of charges will be reviewed before payment is made under an expanding program from Anthem (now Elevance). This prepay policy has been in effect in NH, NY and VA and now expands to other Anthem states retroactive to July 1. Other Anthem states are expanding these reviews to include ASC claims and claims when a patient is out of the normal network area and a different BCBS plan processes the claim on behalf of the patient’s home plan. Anthem CO, IN and NV are also lowering the dollar threshold to require line-item claims review starting at $50,000.

CVS’s Direct Care Strategy: “We can’t be in … primary care without M&A—we’ve been very clear about that,” CEO Karen Lynch said on a recent earnings call about how the retailer will acquire providers, possibly starting with Signify Health, a home health company, as part of a direct care strategy. “We are expecting to enhance our health services in 3 categories…primary care, provider enablement and home health,” The healthcare conglomerate will also continue to focus on expanding their existing MinuteClinic and HealthHUB offerings and working with Amvell on a new virtual primary care offering.

Post-Acute Hurdle: Beginning November 1, Empire Blue of NY will begin requiring prior authorization for admission to or concurrent stay in a skilled nursing facility, an inpatient acute rehab facility, or a long-term acute care hospital. Reviews will be completed by myNEXUS services for Medicare Advantage individuals, group retiree solutions, and dual-eligible plan members. Clinicians will collaborate with patients, caregivers, and facility care managers/discharge planners to provide transition planning as well as authorizations.

Brain Miss: A new study shows that depression is probably not caused by a depletion of serotonin as once previously believed. Research published in Molecular Psychiatry states that the theory of depression resulting from a chemical imbalance, while still influential, is likely hypothetical. The study showed that serotonin receptors were no different in people with depression and people without depression, and that serotonin activity was actually increased in people with depression.

What’s Your ETA? MedArrive, a home-based technology company launched by a former Lyft and Uber executive in 2020, is partnering with Brave Health, a telebehavioral health company focused on Medicaid and Medicare populations, to integrate virtual mental healthcare services in the homes of Medicaid patients. Through the partnership, if MedArrive identifies an eligible health plan member in need of mental health support, their field providers can immediately refer that member to Brave Health’s behavioral health providers in real-time and schedule care within 72 hours.

Mobile Clinic West: Perhaps not the nostalgia of the covered wagon circa 1850 but a new initiative to provide mobile healthcare services in underserved areas in six Oregon counties and parts of Southwest Washington offers the same concept. The Care & Connect Clinics, part of a new Kaiser Permanente Northwest and Medical Teams International program, will offer emergency dental services, referrals for low-cost specialty services, and screenings for hypertension, diabetes and mental health issues. They’ll also help patients connect with community-based organizations to address SDoH issues like food insecurity and housing needs. Kaiser Permanente says they are offering 14 community-based and culturally specific organizations $20,000 each to help host the clinics and support referral work.

Extra Point: What if healthcare had its own fantasy draft? There’s less than a month to football season and for what seems like most of the U.S. that means draft night, an odd but important tradition of churning out a so-called fantasy roster, then bragging about it.  I’ve never won, but I find the entire industry a fascinating study of human behavior. A fantasy healthcare team is not that unlike a multi-specialty practice if you ask me. I suppose most would draft a strong primary care doctor at QB, perhaps not first, but in an early round, though it’s conceivable many draft a specialist first like a cardiologist or orthopedist, though I’m inclined to say an allergist or behavioral therapist may be worth a flier, particularly in leagues where you get points for “catching” things early. Heck, three-quarters of actual NFL teams employ psychologists. I would be shocked if podiatrists would be selected as kicker any earlier than the final round, and outside of helping treat planter fasciitis and diabetic-related foot issues, their role in helping your team win is likely limited. No offense podiatrists. You could roll the dice on a plastic surgeon in round 4 or 5 as your tight end, obviously, but that might be costly if you’re in a league where physical therapists, aka running backs, gets lots of points per yard. If you could draft a medical trainer, I’d say the most accessible might be Uber, and if you like to shake things up and draft your defense early to annoy everyone, just do what most do, order lots of lab tests and get yourself some beta blockers.

$906: The average out-of-pocket cost for people with employer-sponsored insurance in 2019, compared to just $737 in 2013. A new analysis by the Employee Benefit Research Institute shows that the share of medical expenses paid by people enrolled in employer-sponsored coverage increased from 17.4% in 2013 to 19% in 2019. Out-of-pocket expenses dipped in 2020, probably due to the pandemic, but as these costs continue to rise, more and more insured patients are likely struggling to afford healthcare visits and procedures on top of their monthly premiums. This could lead to deferred care, potentially resulting in costlier health problems.

Warranty For Outcomes: Quit Genius, a digital clinic for treating substance abuse disorders is doubling down on its belief in its clinical model. The company has recently moved to a full risk pricing model, meaning that they only get paid if they meet certain clinical, engagement, satisfaction, and operational performance goals. They previously put up to 50% of their fees at risk, but cite the move to 100% risk as a “natural evolution in our mission to help 100 million people conquer their substance abuse addictions”.

Cardiology’s New Partner: It is astounding that we haven’t seen more partnerships between OBGYNs, women’s health specialists and cardiologists. In our poll of OBGYNs, 65% say they are interested in bringing in a cardiology specialist. This could be helpful particularly around menopause or pregnancy. “We try to refer but there can be long wait times given the hospitals control so many of the cardiologists,” says Val Youmans. There is often underdiagnosis and undertreatment, particularly related to high blood pressure, low-density lipoprotein, diabetes and obesity. Reach out if interested in discussing.

Heat Wave: Cigna is offering MA members rides to community cooling centers and other public areas with air conditioning. Around 354,000 seniors have this benefit through Cigna, but the rides are typically used for trips to physician offices and pharmacies.

Universal VBC Pay Model: Six healthcare organizations in California—Aetna, Blue Shield of California, Health Net, Oscar, UnitedHealthcare and PCP value-based player Aledade have signed a memo of understanding to increase investment in “advanced primary care” that, if successful, could lead to greater transparency into VBC models and quality reporting, adoption of an agreed upon value-based payment model, and technical assistance to primary care practices to implement clinical and business models for success.  This could have sweeping implications for physician groups. The effort, known as the California Advanced Primary Care Initiative, is led by the California Quality Collaborative and the Integrated Healthcare Association.

Lines Unblurred? Humana announced during its recent earnings call that it plans to realign its business into two segments, an insurance segment and its healthcare services segment, CenterWell, by 2023. Humana built out CenterWell extensively over the last few years, with acquisitions like Kindred at Home. The move follows the lead of United/Optum, Cigna/Evernorth, and the newly branded Elevance (aka Anthem) and their healthcare services business, Carelon.

Hospital At Home Claims: On August 1, Elevance in Virginia (formerly Anthem) began recognizing and accepting claims for acute Hospital in Home services for their commercial and Medicare Advantage plans. The plan is encouraging qualified hospitals or other entities that meet the Hospital in Home requirements to reach out to their health plan contractor to get an appropriate participation agreement.

High Success: 86% of eligible contracted PCPs participate in Highmark’s True Performance value-based reimbursement program that the plan says has saved $2.5 billion in avoided costs since 2017, largely from fewer ED and IP admissions.  Highmark recently signed a new 3-year value deal with Bridges Health Partners for Medicare Advantage members in western PA. The agreement creates a joint care management team that will use data to manage care.

Insulin Cost Change: Optum is partnering with Sanofi to offer lower-cost insulin for uninsured people living with diabetes through their online health retailer Optum Store. People with valid insulin prescriptions can access the website to determine whether their insulin is part of the new program, get qualified and download an insulin savings card, and then fill their prescription for $35 at any retail pharmacy. A mail-service option will soon be available for home delivery. Last month, Optum’s parent, UHC, announced plans to make insulin free for fully insured commercial members starting next year.

Extra Point: Cancer treatment cost U.S. families $16 billion out of pocket and nearly $5 billion in patient time costs traveling, waiting for care, and receiving care back in 2021 alone. It is staggering – my neighbor spent so much last year ($35,000+) that she had to tell her son that he had to leave the Ivy League and transfer to community college this fall. Every summer since 2010 my own family has tried to do a small part riding in the Pan Mass Challenge, a 100+ mile bike ride for Dana Farber and The Jimmy Fund. My son Jack and I will ride this weekend, and though we usually get lost each year along the route, the survivors and the moms and dads with a kid in treatment line the streets, cheering, hoping for a cure and a miracle. My 3 days of knee pain and nausea at mile 60 are a small price.

1 in 100,000: Prevalence of Addison’s Disease, which Professor Jiwa Moyez says is a good example of the difficulty physicians can have in diagnosing patient symptoms and over-alerting them without appreciating the stress. Particularly for rare conditions that often require multiple tests before a diagnosis can be confirmed, and that are in all likelihood going to rule out the condition eventually. “The patient has to live with the idea that the test is positive” – or going to be, says Moyez, the associate dean of health innovation at The University of Notre Dame, Australia. The diagnostic process ought to be a partnership between doctor and patient and give the patient ‘context’ and help them understand “why” you need to test.

Infection Caught Early: A new AI tool from Johns Hopkins has helped detect early signs of sepsis in real-time, reducing the likelihood of death by 20%, according to a new study. Sepsis causes the most in-hospital deaths in the country but in-hospital mortality, organ failure and length of hospital stay all declined in sepsis cases confirmed with the tool within 3 hours, especially in patients who were high-risk.

Where Art Thou ABA? Breann Gonzalez, the Clinical Director at Colorado ABA Therapy, says they’ve been adjusting to a Medicaid requirement that impacts their service providers making sure they “clock in and clock out” when providing ABA services in a patient’s home. Providers now have to give their GPS location and timestamp and Gonzalez, a BCBA, says they are having challenges adjusting. But the practice’s 4-hour minimum requirement has helped to control cancellations and staffing better than the more common approach by many Colorado providers who set a 20-hour per week minimum, which is an automatic disqualifier for kids in school. To read the full story, click here.

Understaffed: A recent BRG survey of 25 hospital administrators and 30 nurses reveals persistent staffing challenges being experienced by hospitals across the country and limited overall change in travel nurse rates, despite some isolated reductions and pressures on agencies to lower pay. Even as COVID-19 hospitalizations have decreased, 90% of respondents say their hospital remains understaffed. For the full story, including insights on patient experience, click here.

Another Step Into Healthcare: Sort of like Aunt Theresa and Uncle Bobby moving into your dining room during Thanksgiving week, one of healthcare’s leading disrupters is moving into primary care as Amazon acquires One Medical, which offers patients 24/7 virtual and in-person care at its 200 clinics through a sleek app—think tele-prescriptions and same-day app-scheduled visits. Whether One Medical will actually refer patients with depression to Alexa is to be determined, but the acquisition is noteworthy. The company primarily focuses on direct-to-employer offerings, but also sells membership directly to patients at $200 per year, on top of normal care costs, which can be paid through insurance or out of pocket.

Tier 1 vs. 2: More specialists, therapists, behavioral health providers and diagnostic companies will be placed into tiers in the next 5 years and if you’re not paying attention your group may lose patient volume. A new ACO from UnitedHealthcare is using a tiering system to incentivize the use of certain providers. NexusACO launches in Wisconsin for the 2023 plan year, featuring Advocate Aurora Health, Froedtert Health, the Medical College of Wisconsin and Children’s Wisconsin as the lowest-cost providers in Tier 1. If member patients get care at other network providers, including Ascension Wisconsin and ProHealth Care, they pay more.

Extra Point: So, I learned pretty much everything I need to know about how to muster up enough courage to ask a girl to dance from Celeste, the angel who cut my hair in high school after 15 very sad years of an uncomfortable-looking bowl cut. Celeste lifted my self-esteem, helped me juggle anxiety, depression and fear before they were talked about. She gave me street cred, made me blush and she was my barber I suppose, and so I’m pretty sure the new “Deload” business of mental health-trained barbers from Gymshark is on to something. I’ve long since said physical therapists and little league coaches and physician specialists need this training, so why not the folks who style our hair? And if they’re looking for barbers or trainers, perhaps Eddie Murphy’s Coming to America character Clarence is up for the gig. Can’t you hear it? “Look sonny! This stuff - that’s got ya down - with your family and work – it ain’t nothing to worry about. Do what Joe Louis did. He was the greatest. He took punches—he came out of retirement at 137 years old to fight Rocky Marciano - but he hung in there and kept fighting.”

60: The percent of doctors who said they’d retire if they could, according to one of our polls. The number is both alarming and unsurprising, but there may be hope, according to Paul Rudd’s character in Anchorman. “60% of the time, it works every time,” Rudd said about his potent cologne, which Ron Burgundy sternly replied in a way that only Will Ferrell can, “Well that just doesn’t make sense.” But Rudd’s stat isn’t so illogical if you think about it.  In baseball, 60% gets you in the Hall of Fame, in high school it gets you a diploma and in healthcare it can get you “coverage” for novel treatments if you can show efficacy. 60% is also a kind of target number these days for a new series of commercial contracts – if physicians can follow a treatment regimen for 6 out of 10 patients or get patients to goal 60% of the time, they are eligible for big bonuses. Maybe this will stem the tide of retirement and encourage more people to become doctors.

Help Wanted To End Chemo: Seattle’s Fred Hutchinson Cancer Research Center is looking to recruit 20 participants in a Phase 1 trial with the goal of developing personalized vaccines for breast cancer and melanoma that could eventually replace the need for chemotherapy. The center is partnering with Amazon to develop cancer vaccines as part of the recently launched FDA-approved trial.

Tele Pay Policy Change: Harvard Pilgrim replaced their temporary COVID-19 telehealth payment policy with a permanent policy that will continue to reimburse all telehealth services at parity, effective September 2022. Providers will need to indicate appropriate place of service and use correct modifiers and, under the policy, will not be paid for telephone calls on the same day as an E&M or if an in-person E&M was done in the prior week.

Watch Out: For health insurers who realize they set the target goal too low in value-based contracts and end up “paying out too much”, needing to reset the terms.  This is especially a risk for PCPs and specialists like orthopedists. Our story on this topic first appeared in 2019 and it’s a reminder to practitioners about the challenges in value-based contracting. Read it here.

One Baby, $18,000: Did you know that the average total cost to have a baby in the US is about $18,000, according to a new Kaiser Family Foundation report. $2,854 is the average amount of out-of-pocket costs for those with insurance, though for all you parents out there you know that is a fairly comical estimate given all the diapers, Band-Aids, piano lessons, pizza pies, prom dresses, frantic runs to the ER and, oh right, college tuition!  But, when isolating maternity and delivery by itself, out-of-pocket costs are $3,214 for C-sections and $2,655 for vaginal deliveries. Out of pocket includes more than just the delivery – it includes psychiatric care, prenatal visits and other medical services that stem from being pregnant and carrying the pregnancy to term.

Time To Visit Down: Since the start of a new collaboration between BCBS of NC and Headway, children and adolescents have attended their first mental health appointment within 5.4 days, an improvement over national averages that suggest delays often as much as several weeks to more than a month or longer.

Alzheimer’s Treatment: Whole blood exchange treatment could decrease the formation of amyloid plaques which are thought to cause Alzheimer’s, according to a new study from UTHealth in Houston.

Diabetic Care Plan: RxBenefits is partnering with Tria Health to find members with diabetes and comorbidities, reach out to create a customized care plan, and share the info with the members’ physicians. Patients can get a $50 gift card or a copay card, which offers $0 generics and $25 off some brand diabetes drugs. UnitedHealthcare and its PBM, OptumRx, meanwhile will offer insulin and some emergency-use drugs at $0 copay for some fully-insured members in 2023. Other drugs include epinephrine for allergic reactions, naloxone for opioid overdoses, albuterol for asthma attacks and glucagon for low blood sugar. The health plan announced the new offering in order “to address inflationary pressures and keep patients out of the ER.”

Lifeline: The new suicide and crisis hotline, 988, went live last week. The number is meant to simplify texting or calling the existing National Suicide Prevention Lifeline’s network of over 180 call centers across the country. Many of those local crisis centers were in “different phases of readiness for the 988 rollout” due to issues like workforce shortages and lack of coordination across multiple stakeholders. SAMHSA expects the volume of texts and calls to the National Suicide Prevention Lifeline to rise to 7.6 million next year, compared to 3.1 million in 2021 and 3.6 million so far this year. There are some reported issues - 988 allegedly performs nonconsensual active rescue, meaning the operators will contact emergency services without a person’s consent if they deem the situation is dire enough.

It’s Urgent, Right? Will Farrell once asked everyone to just stop what they are doing and listen because he was handed an urgent news story. Well, Tufts Health Plan members in Rhode Island now have access to something urgent in their homes, effective July 18 – urgent care. The health plan is working with intsED to provide the visits. The member’s PCP or care manager can request them, which seems like a way for the plan to limit unnecessary visits. Sounds a bit like telehealth meets home care but it is yet another example of a consumer-focused healthcare service.  Ready Responders is an example of another urgent care type service that payers have adopted – Ready Responders can go into homes and do strep tests or check vitals.

Extra Point: So 83-year-old Uncle Mike, the tenured political science professor at Gonzaga and the Jesuit priest who married Janine and me, is in town this week – bringing all his peccadillos with him. He has fallen asleep at least a dozen times mid-sentence since arriving. 'What’s wrong with Uncle Mike?' my daughter Sophie asked yesterday, scared for the answer. 'I think he’s dead' Janine said, 'go check him Bry.' My mother-in-law Ellen was in the corner laughing for some reason. Uncle Mike simply fell asleep and when he awoke to the dog barking, he repeated the same story about how his parents used to take him to the 5 and 10 for Christmas but one year didn’t because he got Bs in grammar class. Both Michael and Ellen live somewhat independently most of the year, which is moderately alarming and yet remarkable, battling an encyclopedia of conditions, dementia, vertigo, osteoarthritis, prostate cancer, skin cancer, anxiety and the diabetes that Michael swears he doesn’t have. 'Well, I do take this pill every day to control my blood sugar….my regular endocrinologist gave it to me…and my feet really bother me, but I’m not diabetic,' he said. I’m pretty sure you are Uncle Mike, but say this for him, he may have some idiosyncrasies, but he can eat what he wants as far as I’m concerned because, nearest I can tell, he’s blessing all the food and he’s the one who may be a key vote for me when it’s my time. He and his sister are the face of aging in America and highlight so much of the challenge ahead….but when they are here, thank goodness, because they sure do bring a bit of levity.

20: Percent of adults who have received a surprise bill for themselves or a family member this year, despite the No Surprises Act that went into effect at the beginning of the year. About 1 in 5 received a bill over $1,000, according to a Morning Consult survey. Those who received unexpected bills were most likely to get them for in-network lab work that was sent to an out-of-network lab. Unsurprisingly, 1 in 4 survey respondents indicated they have skipped or delayed healthcare services because they’re worried about these unexpected costs.

Cataract Reversal: Aetna no longer requires prior authorization for cataract surgery for most patients as of July 1^st, reversing the policy that was implemented in July 2021. Some exceptions apply, as Medicare Advantage members in Georgia and Florida will still face PA requirements for one of the most common procedures performed in the US.

Flaw In Diabetes Management? According to a survey conducted by BCBS Arizona, 1 in 10 Arizona adults have diabetes. The insurer is teaming up with the Arizona Department of Health Services and others to create a Diabetes Action Plan to work on lowering HbA1c, reducing outcomes disparities and performing routine surveillance to monitor progress. Plan design can be a challenge for diabetic management. Physicians may recommend eye exams to prevent diabetic neuropathy, for example, but patients in high deductible plans may not be able to afford these, and physicians typically only get value-based incentives if patients actually get these services.

Inflation Adjustment, Sort Of: BCBS Kansas will be providing a 1% cost relief adjustment in reimbursement to most providers beginning September 1, 2022. According to the plan, “this relief is meant to help ease a portion of the effects [providers] have been feeling from the recent pricing hikes across our country.” The adjustment will apply to all professional services except clinical lab and ambulance.

Adolescent Psych Training: Aetna recently expanded its program offerings with Psych Hub, an online mental health educational platform, by launching an Adolescent Treatment Training Series. The series gives in-network behavioral health providers, Aetna clinicians, and CVS Health’s licensed counselors at some MinuteClinic locations access to evidence-based courses and resources to identify and treat adolescents and young adults at risk of suicide. This builds off the adult suicide prevention continuing education series launched in 2021. BCBS Michigan and Henry Ford Health recently launched their own collaboration to improve suicide prevention. Providers share data in what’s called the Michigan Mental Health Innovation Network for Clinical Design.

Construction Spike:  Harrison Ford may be able to go back to his roots as a construction worker given a recent boom in healthcare building projects. 70% of the 89 construction and design firms in Modern Healthcare’s 2022 survey say they are seeing increased demand for a behavioral health component in their medical projects.

Quizlet: As many as 15% of the US population have this condition, it’s more common in women than men but it shares many of the same characteristics as other diseases, so it’s difficult to diagnose. Ben Stiller had this condition in Along Came Polly pretty much at the mere mention of this spicy food. One specialist deals with these patients more than others, but PCPs tend to be the first to attempt diagnosis. There’s a great opportunity to construct a chronic care value-based arrangement for these patients given the high cost of treating and getting patients to goal. Anemia, fecal occult blood and unintended weight loss can be very helpful in diagnosing and creating protocols. What’s the condition? Click here.

Kidney Expansion: Approximately 1 in 3 adults in the U.S. are at risk for kidney disease. Somatus, a provider of integrated kidney care, has partnered with the Kidney Care Center to create a multi-state partnership to expand coverage for the treatment of chronic kidney disease and end-stage kidney disease in Illinois, Indiana, Georgia, Tennessee, Pennsylvania and Florida. The partnership uses an innovative care model that brings together local teams, AI and machine learning to provide care.

Going Retro: Maybe not as retro as a Polaroid, but there is a new bundled payment program BCBS of TX is launching for knee and hip replacement services in partnership with the clinically integrated network MPOWERHealth. Payment will be retrospective, based on the entire episode from replacement surgery to post-op care.

In Home Urgent Care: UPMC’s program has treated more than 200 UPMC Health Plan members in their homes since its launch in September 2021, saving the health plan money while increasing patient satisfaction, according to UPMC. The program only serves Allegheny County currently but is looking to expand in the state.

Extra Point: As Archie once said, ‘why do they always give me a shot where the pain ain’t…?’  It was classic Bunker—worried, agitated and usually offensive. I wonder what he’d make of all the changes in healthcare – urgent care clinics, for one, are often staffed by allied health providers. Bunker only wanted ‘regular doctors’ as he called them and, even though he didn’t know it, he had a bit of managed care in him. ‘Do I really need this, um, needle?’ he would argue. If there’s one delivery model set to face some turbulence between now and 2025 it may just be urgent care. Even though it has found an important niche in the health system, particularly in areas where doctors and nurses are hard to find, the advent of more front-line tele models and nurse hotlines and apps will likely continue to be a volume diverter that hurts these retail clinic models at least those in competitive, saturated markets. ‘They absolutely have a place but when we start seeing the ambulance show up every hour to take patients to the hospital, that’s a big flag for me,’ says Valerie Andrews, a network manager who just moved into the Connecticut market. ‘My sense is 20-40% of cases would self-resolve too, so there’s a value question here.’ The ones able to use data and use their clinic to do urgent and follow-up care, to identify and change behavior, and ‘have a PCP traffic cop mentality,’ have sustainability.

$100: The per member per day fine health plans will now face if they do not post the negotiated rates they pay to in-network providers and potential out-of-network billable amounts patients may owe, due to a new regulation that went into effect last Friday. Though hospitals have been slow to post their prices since that transparency rule went into effect, the much larger potential fines health plans face seems to be having the desired effect. Many large plans, including United Healthcare, have already posted the required information. But even full health plan compliance won’t automatically give consumers the information they need. The required format for this data – machine-readable files – is almost impossible for most consumers to interpret.

Not So Stranger Things: In a poll we did of 12,107 teens 13-18 years old, 64% said their favorite TV show is Stranger Things, 53% said their favorite sport is probably Pickle Ball, and less than 2% said they want to be a doctor or nurse when they grow up. So much for solving the clinician shortage, but at least this generation will know how to conquer zombies and hit plastic balls.

Predictive Health: Memorial Hermann and genomics company Helix are partnering to give 100,000 people genetic data intended to help them and their providers assess risk for serious health conditions such as cardiovascular disease and certain cancers.

Costly Screens: While most preventive screenings are free to patients, those whose screenings turn up issues that need further diagnostics often find themselves responsible for hundreds or thousands of dollars in copays. Recent research published by the University of Michigan’s Center for Value-Based Insurance Design uncovered average costs for people who needed additional testing after preventive cancer screening: $152 for further imaging or biopsies after mammograms, $155 for a biopsy after a suspicious result on a cervical cancer test, $100 for a colonoscopy after a stool-based colorectal cancer test; and $424 for follow-up tests after a CT scan to check for lung cancer. Blue Cross NC recently came out with a policy that will remove copays for one of these situations. As of June, the health plan covers 100% of screening colonoscopies after a positive stool-based or direct visualization test.

Reimbursement Cuts: Two midwestern Blues are cutting rates. In September, BCBS Nebraska starts to apply Medicare’s multiple procedure payment reductions for therapy and radiology procedures and payment for any procedure submitted with modifier 52 will be reduced by 50%. BCBS Michigan will also begin applying a multiple procedure reduction for PT, ST, and OT in October. The plan announced the change will result in an average reimbursement of 83% of the allowed amount for all subsequent therapy services done on the same day.

Speak Your Mind: Spoken language patterns can predict with 93% accuracy if a person is at risk for psychosis, a symptom of Schizophrenia, and if the condition will progress within 2 years, a National Institute of Health study has found.

Extra Point: When our youngest Tommy was just about two his pediatrician said he wasn’t saying words because his tongue was tied, so Dr. Leo referred us to a specialist who had fancy degrees on his wall. Tommy laid back in the dentist-type chair and the doctor, an ENT by training, took out what I swear was a pizza cutter, plugged it into the wall, took an uncomfortably long deep breath and with Tommy screaming bloody murder and my right hand holding down Tom’s shoulder, the doctor went in. He cut the “tie” and some blood emerged after maybe 6-7 seconds he pulled the cutter back, turned to me and said “What do you think?”  What do I think!?  I couldn’t believe that the ENT-trained doctor with the fancy degrees was asking for MY medical opinion. I get it, he wasn’t asking me to diagnose cancer, but still.  I breathed, shrugged a bit and said “Well doc, I think we can keep going, let’s get a bit more of it.”  I couldn’t believe I said it and if you could have only seen my bride’s face in that moment. On the one hand I was a tad bit alarmed that this trained surgeon was asking for my advice, but on the other all these years later I suppose I realize that doctors are human. So doc nodded, re-engaged that pizza cutter and went back in, cutting “a bit more” of that tie and, well, within a few days Tommy was speaking. And now some 13 years later says all sorts of words, some of the bad ones that George Carlin told us we can’t say on television, and some good ones too, like precipitous and incandescent and his latest thesaurus classic, ephemeral, which to be honest I had to look up. It apparently means things that don’t last forever, like conversations or arguments or those moments when your kids are little and you have no idea what you’re doing, hold on for dear life, cherish a good hot meal, and hope to God you don’t screw them up too much.

$12-36: The amount Optum claims their new lab benefit management solution can save health plans on a per member per year basis. Optum is launching a new program to combat unnecessary clinical testing, which can account for up to 30% of all tests ordered. Optum will work with Avalon to administer the solution.

As Good As It Gets? Jack Nicholson’s character Melvin Udall in the 1997 movie put OCD on the map, showing moviegoers just how debilitating obsessive-compulsive disorder can be when ordering breakfast, navigating sideways, and trying to court the waitress. 25 years since the movie debuted, some 2.3% in the US suffer from the condition and the World Health Organization considers OCD among the top 10 most debilitating conditions. Health insurers have been forced to improve coverage policies given mental health parity laws and because a significant portion of patients with OCD don’t respond to first-line drug treatments. More recently, some insurers like HCSC and Highmark have started to cover a neurostimulation system called BrainsWay. It will be interesting to see how widely adopted coverage will become and if any insurers will relax fail-first requirements. Our assumption is no, but outcomes data may change that approach.

Picture This: A 26-year-old woman with 3 kids is referred to a neurologist. She presents with a malignant brain tumor, and she is pregnant. To stay alive, the woman needs immediate surgery, radiation and chemotherapy that she cannot get while pregnant. This scenario is one of the potential unexpected consequences of the overturning of Roe v. Wade. To read our interview with Mayo Clinic on the issue, click here.

3 RBTs In 6 Months: Colorado ranks high among U.S states for the level of services available to children with autism, according to Autism Parenting Magazine, but there are still barriers to access including a lack of RBTs. “There’s high turnover in RBTs and it’s hard on families,” Lea Anne Paskvalich told us. “I spoke with a family that had 3 different RBTs in 6 months…change is hard for a person on the spectrum.”

Cognitive Therapy Partner: Effective July 15, BCBS Michigan members will have access to more behavioral health providers through AbleTo, a network of approximately 2000 therapists that provide telehealth services, including an eight-week cognitive-behavioral treatment program for adults.

Hawaii vs. Nevada: Thinking about where you can bring your new healthcare service to solve problems, consider Kentucky, Nevada and Wyoming—3 states with among the worst healthcare systems according to a Commonwealth Fund report. Hawaii, Massachusetts, and Connecticut are among the states with the best overall performance based on 56 metrics including access, quality, cost, health disparity, and health outcome metrics. COVID-19 response played a major role in overall rankings and was part of why Hawaii came out on top.

Digital Experience Upgrade: 57% of payers say it’s challenging to provide a seamless digital experience for members throughout their member journey– including everything from the process of enrolling and setting up benefits to proactively reaching out about care management programs after getting a new diagnosis. Unsurprisingly, health plans generally struggle to design good experiences for their members. Most payers in the Forrester and Smart Communications poll describe their digital experience as basic and 63% said it is a top priority to improve.

Mobile Health: Insured and uninsured individuals in Las Vegas, NV and Richmond, VA will have access to free preventive screenings, mobile units, and community events aimed at identifying, preventing and managing chronic conditions under a CVS project to expand mobile care. 14 other cities are part of the Project Health program.

Grassroots: In cities like Philadelphia and Houston, a myriad of individuals are working together to address housing instability, city planners in places like Dallas are bringing greenery into low-income neighborhoods, students are working with civic leaders in Memphis to fix food waste and try to halt the social factors driving health decline, and healthcare providers in many states are trying to curtail maternal mortality, an area where the US ranks last among developed countries. Despite many of the challenges the US is confronting and the mood of the country, there is a grassroots spirit that is unfolding. Click here.

Extra Point: It took me 129 minutes to get my mom to turn on the TV this morning.  “Mom, press the down button…the down one. The red thing with the arrow….” Mom and dad are fairly independent as they approach 80 – they drive a bit during the day, they make their own turkey grinders, still cut the lawn and rake the leaves and find time to play backgammon on the porch, but figuring out how to get Netflix to show up is complicated.  I get it, and I try to embrace the good that comes from their independence knowing it probably won’t always be like this. It can be hard to stay independent – as seniors, teenagers who migrate into young adulthood and healthcare providers trying to cultivate freedom and find their niche. Here’s to independence, for as long as you can hold on to it.

29: Percent of 412 schools we polled in the spring who are looking to “hire” allergists, as part of trend of schools becoming more like quasi health centers. Several even report issues with students with allergies and co-occurring eating disorders. By comparison, 74% say they are trying to increase “mental health counselor” staff. Once upon a time if you had an allergic reaction you had to go sit in that wobbly chair next to the art cart in the hallway until mom or dad showed up. Nowadays, schools try to know about your allergy before it happens.

High Deductible, Low Detection: A Harvard Medical School study discovered a potential link between high-deductible health plans and delays in the detection of metastatic cancer. Diagnosis was 4.6 months delayed among those who belong to plans with higher deductibles. “Potential impacts of delayed cancer diagnosis include delayed initiation of palliative care and symptom-relieving therapies, as well as greater dissemination of disease, which further limits therapeutic options,” warns medical student Nicolas Trad.

Fountain of Youth: GRAIL’s multi-cancer early detection blood test called Galleri is starting to get some insurance coverage traction. Fountain Health Insurance is now one of a handful of plans to cover the test. The test claims to find dozens of cancers earlier than standard screening tests by looking for smaller particles of cancer. Many cancers are detected in later stages partly due to only five cancer types having recommended screenings: breast, cervical, colon, lung and prostate.

Digital Coach: Jasper Health will make its digital cancer care support services available to patients via a Walgreens platform that helps patients find and communicate with healthcare providers. Patients will have access to their new Coach+ platform that leverages chat, telemedicine, and human coaching around mental health, sleep, physical activity, and even financial needs for patients dealing with cancer.

Transparency: Turquoise Health, a price transparency platform that publishes hospital and payer rates, is partnering with Ribbon Health, an API data platform company, to make cost of care information more accessible to patients. The Hospital Price Transparency Final Rule and upcoming Transparency in Coverage Rule require both payers and hospitals to disclose prices through a machine-readable file, which is difficult to decipher in its raw form.

Steering Patients: Castlight Health is launching a health, wellness, and care navigation solution through a partnership with BCBS Minnesota. This navigation solution will provide customer care advocates with comprehensive insight into members’ benefits, program eligibility, specialist referrals and gaps in care through member profile dashboards and algorithms to help direct members to the right care.

Mortality Avoidance: NYC Health + Hospitals is using virtual reality technology to help train obstetricians, with the goal of reducing maternal mortality events. The health system developed the VR solution in tandem with Health Scholars, a Colorado-based company. The technology will allow providers to experience simulated maternal mortality scenarios while being guided through a task list based on the hospital’s protocols. The platform can be tailored based on specific providers so that midwives or physicians receive more focused training based on their roles during delivery. Clinicians say that current training simulation methods are time-consuming and can be difficult to schedule given the unpredictability of labor and delivery. They’re hoping VR can speed up training to better combat maternal mortality.

Pre Authorization: The Michigan Legislature passed a bill that aims to reform the state’s prior authorization process by introducing new requirements for payers, such as needing to publish detailed and information around PA requirements. One way to avoid authorizations is to show payers you don’t need to be “managed” – there is a growing, albeit slow trend of payers willing to “lift PAs” and relinquish oversight.

Cap It: There’s now a $25 monthly cap for insulin in Express Script’s Patient Assurance program and  analysis of data gathered from the program shows, unsurprisingly, that the cap resulted in increased medication adherence. Type 2 diabetes patients enrolled in the program improved adherence to their treatments by 2.5% in 2021. In households earning less than $50,000 per year, adherence improved by 5.7%. Who would have thought that if you make insulin affordable, patients are more likely to take it as prescribed?

ExtraPoint: In memory of an old friend who passed this week, I wanted to share this one again….Music can be therapy, for kids on the spectrum and moms and dads who can’t find the keys in the morning. It is therapy on Thanksgiving when your dog eats both pumpkin pies and when big Uncle Fred falls asleep on the remote. Music is also therapy for people with an addiction or traumatic brain injuries, and for people like my grandmother Carmella Antonelli who grew up in the mountains of Napoli and made me laugh when she snuck 2 anisette cookies onto my lap for breakfast. I lived with Carmella for a few years back in the earlier 90s in the latter stages of the Alzheimer’s that took her brain, but not her humor. A person with Alzheimer’s knows the pieces of the puzzle are missing …. and they are terrified. Carmella and I would watch tennis on the TV on Saturday mornings back in Fairlawn New Jersey and listen to Frank’s Fly Me To The Moon. She was 82 and I can’t remember a single time we talked about her Alzheimer’s. My old friend Eric talked about his Alzheimer’s for years. He passed away this week in his 50s. Maybe you know someone who has talked about their disease. Like Carmella, Eric was a young guy when he got the Alzheimer’s. I remember when his son Michael was born, just after Adam Viniteri kicked that ball in the snow to beat the Raiders. Michael talks to his dad here and if there’s a moment that hits home, it’s when the credits roll and the music plays.

#1: The top bestseller in psychiatry this week is none other than the DSM-5 aka “the bible” of the psychiatry world. The latest version of the Diagnostic and Statistical Manual of Mental Disorders, released in March after nearly a decade without updates, has become a surprise hit likely due to increased demand for mental healthcare. The DSM is the top psychiatry bestseller on Amazon and the Wall Street Journal’s list, though physicians warn the book is intended for mental health professionals and not for self-diagnosing. But given the difficulties many still face in accessing mental healthcare, the manual may stay on the bestseller list for a while - for better or worse.

Sleep Well: Premera BCBS will no longer review home sleep studies for prior authorization and medical necessity, effective July 1, 2022. Providers will no longer need to submit a request through AIM Specialty for these services though AIM will still review supplies/equipment and in-lab sleep studies.

The New Oral Health Referral Source: Teledentistry, much like telepsych, is driving up utilization of follow up in-person visits. 97% of 3,562 patients who had a teledentistry visit ended up doing an in-person follow up for diagnostic and restorative services like an oral surgery or endodontic procedure. The researchers from CareQuest say teledentistry resulted in average cost savings of 10-15% compared to in-person visits.

Predictive Analytics Victory: Use of an AI tool resulted in the highest reported rate of type 2 diabetes remission to date according to new research presented at the American Diabetes Association meeting earlier this month. Known as the Whole-Body Digital Twin Platform, the predictive analytic model gathers patient data and then provides guidance for clinicians and patients around proper nutrition, physical activity, and sleep. At 180 days, 94.9% of patients in the AI group achieved an A1C level of less than 6.5% while either taking no diabetes medications or metformin only, and the nine insulin-using patients in the group all stopped using insulin within 90 days because they had lowered their blood sugar to normal levels.

Homeless Health: Healthcare in Action is a nonprofit medical group that provides primary and behavioral healthcare to homeless people in Los Angeles. The group employs both clinicians and social workers to provide care wherever people need it, mostly outside though the group has vans that offer private exam space. After treating patients, patients are offered cell phones that providers can use to keep in touch for follow up care. SCAN Group, the parent company of SCAN Health Plan, debuted Healthcare in Action in January of this year. Within its first four months, the organization had served about 200 patients who otherwise may have had difficulty accessing care in community health centers or clinics.

Mother Nature: Anthem begins offering a new digital solution to support mothers’ maternal mental health in several markets by the end of 2022. Happify Health’s tool incorporates coaching and digital therapeutics while providing access to a range of providers, including obgyns, psychiatrists and dietitians. The tool also allows mothers to connect with each other. Anthem President of Health Solution Bryony Winn wants to “improve every aspect of the pregnancy experience” – whether it pertains to physical or behavioral health.

One Home: Humana is expanding its value-based home care model in Virginia through its subsidiary, Onehome. Onehome creates a single point of accountability and coordinates post acute care, including infusion, nursing, OT, PT and DME in patients' homes. This model will first become available to MA members in Richmond, Roanoke and Southern Virginia counties and will expand to the rest of the state and North Carolina over the several months to reach more than 500,000 members.

Surprise Party:  A recent study done by BCBSA and AHIP revealed that the No Surprises Act has spared commercially insured patients from over two million potential surprise medical bills. Apart from ensuring financial protection from hefty and unexpected medical bills, the study also demonstrates key benefits from the independent dispute resolution (IDR) process that the act establishes. This trend is expected to hold, as 12 million surprise bills are projected to be avoided in 2022.

CenterWell: On June 13th, Humana announced it will be rebranding its pharmacy business to CenterWell. Humana Pharmacy and Specialty Pharmacy will now operate under the name CenterWell Pharmacy and CenterWell Specialty pharmacy, respectively.

Foster To Prison Pipeline: Many pediatricians knowingly treat a child within the foster care system for severe mental illness and when the foster child goes into crisis the knee jerk reaction is often to send them to the ER but this stabilization process often fails and police are often called in. “By age 17, more than half of juveniles in foster care get into trouble with the law,” says Tiona Praylow, MD, MPH, from Riverwoods Behavioral Health. Foster care youth are 244% more likely to reoffend between adolescence and adulthood. Click to read more.

Extra Point: A medical student, federal judge and a healthcare investor walk into a presentation with a trio of panelists on a stage, sitting on bar stools, holding up large circular posterboards resembling traffic lights – one holding green, one yellow and one red. Panelists were given the same list of healthcare sub-sectors and asked to project their collective future as positive (green), proceed cautiously (yellow), or stop (red). The moderator asks for questions and the medical student John exuberantly and perhaps not surprisingly has one for the “green” panelist. The judge Sally, true to form, asks the “yellow” panelist to explain their thinking while the healthcare investor Sharon, smirking a bit, says – “let me hear from the one with the red sign.”  We are trained to carry a healthy level of skepticism and monitor and understand risk.  For my daughter Sophie who’s learning to drive, heck everything is a red—the sidewalk, the car behind and in front, the white cloud above – and yes, even the green light.  “You can go sweetie.” “But what if it turns yellow dad?”  I suppose like many of us she will learn to see risks earlier with experience…the person in red lowered their posterboard. It was a 71-year-old, quasi-retired psychologist who says she is working part-time because she loves the work and wants to keep giving back, and part-time as an advisor to a health insurer. She said OP clinic-based therapy is a red. “Surprised? My colleagues might not be happy with me but I look at it this way – to solve the issue we need more psychologists to do cognitive therapy for all the post-traumatic stress we all deal with, we need therapists to focus on the teen angst, social media, self-esteem conundrum and to head off eating disorders and from my lens having these sessions over a zoom or phone works and makes sense, can address the gaps and at a much lower cost per session. So if you ask me what I think of an in-office therapy practice – I say red.”