31: Percent of 17 to 20 year-olds in my son’s poll of his 1,379 so called Instagram followers who say they found a mental health therapist recently before they head off to college. “It’s a good idea to get that relationship formed before going into college,” says Ivy Patt, a therapist in Connecticut who deals mostly with private pay teens. Most of these relationships will be virtual and from a managed care point of view that’s perfect, as long as it is privately paid and if through insurance, the encounters make sense to “help with the transition” as long as they are necessary. Therein lies the rub. Payers have started to more closely monitor tele and OP mental health and engage with big telehealth companies like Talkspace to plug them in as options for 17 to 20 year olds like Jack’s buddies, but also adults and seniors. The goal is access, meet network adequacy requirements and help address the growing importance of mental health. But to ensure utilization of these sessions doesn’t go unchecked and adds value, expect insurers to buy these companies for more control – one, Anthem, already has via its acquisition of Beacon which has a college-focused offering – and others like United and Humana likely will. If you’re a mental health practice or one focused on higher levels of care, the short answer is you might want to be thinking about how to tap into the virtual world that kids like Jack live in, and if you’re not careful be prepared for more pressure and competition from insurers.
Pay For Shrinkage: Several insurers are now looking to enter contracts with pharmaceutical companies based on lowering the total cost of care for type 2 diabetics or those with cardiovascular disease. These arrangements look a lot like the early ones the UK built to force drug companies to either agree to good outcomes like tumor shrinkage or send money back. These arrangements have been difficult to create since it’s not easy to agree on the target points and terms, like what’s an acceptable time to shrinkage and how do we quantify failure when maybe the drug added 2 or 3 months of quality life for a patient they otherwise wouldn’t have had. This new era of pay for outcomes in medicine will be led in part by insurer non-profits. What will be most interesting is how this trickles down to prescribers and patients. For successful drugs, it could increase reimbursement for administering the most effective drugs, but it also likely accelerates white bagging in the specialty space. And more broadly, expect insurers to use these findings to inform specialists and patients with chronic disease about what works and what doesn’t, and design new outcomes based arrangements from that.
3rd Time’s A Charm?: Spectrum Health and Beaumont Health are exploring a merger, which would create Michigan’s largest health system. The 2 nonprofit systems combined would operate 22 hospitals and 305 outpatient locations. Spectrum’s integrated health plan, Priority Health, would also be overseen by the new combined health system. Beaumont does not currently have its own health plan. This is the 3rd attempted merger for Beaumont in 2 years, with previous plans for consolidation with both Summa Health and Advocate Aurora falling through.
Too Late: If you have teenagers you know all too well that many are already at the party when they ask to go and Anthem is about to start doing what parents ought to, applying a reimbursement penalty for providers who fail to get pre-authorization when it’s required for commercial patients. The late notification penalty has been in the provider manual since 2019, but Anthem has not been enforcing it until now. Sounds like that parent manual my dad tried to hand me when we walked out of the maternity ward in 2003. “You’re going to need this,” he said, but I never opened it until Jack was at the party. In Anthem’s case, if required PAs are not obtained before services are rendered, reimbursement will be reduced 50%.
Midwest Hub: Big 10 fans may not love this but the largest independent physician groups in Illinois and Indiana, DuPage Medical Group and The South Bend Clinic, are planning to merge, creating a “hub for regional expansion.” DuPage has over 800 doctors but currently has no locations outside of Illinois. By partnering with South Bend Clinic, the group will gain another 170 providers with 11 clinics across Indiana.
Oregon Funding: CareOregon is investing $7.5M in its behavioral health provider network, to make sure members have access to the care they need. The money will go to 25 behavioral health providers who serve 85% of the highest needs patients across the state. Funds are intended to be used for retention bonuses, housing support, or other financial incentives to support these essential workers.
Sooner The Diagnosis The Better: Colon cancer screening kits are now being shipped to certain people BCBS of Oklahoma has identified as lacking access to more traditional screening. A vendor, Home Access Health, sends kids to members and the results are eventually shared with the patient’s PCP within 3-4 weeks. This is one of several emerging value based models the insurer is creating to improve access and incentivize better coordination.
Parkinson’s Challenge: The cause of Parkinson’s is widely unknown with 85%+ of cases classified as sporadic and not genetic and in this piece we interviewed UPMC’s board-certified clinical specialist Chris Childers about the challenges in helping payers understand the need for therapy for this population. Click here to read more.
Extra Point: Sometimes it’s hard to find work, life, balance beam me up Scotty Pippen was a better defender than Michael Jackson’s best song was Billie Jean King beat Bobby Riggs with an old wooden racquet ball is a really difficult sport if you’re slow like a turtle necks are in style for only certain people magazine editions from the 1990s are still sitting in most doctor waiting rooms, but no one sees them anymore since they are looking at their iPhone apps now have a way to show you where to get your colonoscopy, which I have to book soon if I can just stop this run on sentence. I used to volunteer in kindergarten class journaling hour back in 2005, which is where run-on-sentences run free. Kids named Maggie and Connor string together consonants like cheese, without a single piece of punctuation, all the while sniffling and coughing and in some cases falling off their chairs. It’s funny for a 5-year-old, but not so much for an adult whose job it is to communicate with people in a crisis. I was thinking of this yesterday when I read through the medical notes from my Uncle’s cardiologist whose description of why his patient couldn’t get stents or a bypass due to multiple arterial blockages was about as clear as a 5-year-old’s kindergarten journal. Random words. No punctuation. Jibberish to the laymen. I hope teens and 20 somethings coming of age in the era of texting keep this in mind, particularly if they end up in healthcare – slow down, separate thoughts, be simple, avoid semicolons and every once in awhile just stop, listen and use a period.