66: Percent of adults in the US who have a personal or familial experience with alcohol or drug addiction, according to a new KFF poll, highlighting how substance use disorders affect not only individuals but also their friends and family. 27% of adults who have a relative with an addiction report that their mental health was significantly affected by it, but only 46% got treatment.
Bye Bye Pre Approval? United Healthcare will begin a two-phased approach to eliminating some prior authorization requirements in September. This will occur across commercial, MA and Medicaid plans and most procedures that will no longer require authorization are in the genetic testing, imaging, and physical therapy families, along with a few DME, hysterectomy, cardiology and spine surgery codes. In 2024, the health plan will implement a national Gold Card program where eligible providers only need to follow a “simple administrative notification process” rather than the PA process for most procedures.
Nurse Recruits: UnitedHealth’s Optum is working with the online school Capella University to launch a new educational program for nurse practitioners. Students in the program can practice real-world skills through Optum’s network of clinics. The first offering will be a Master of Science in Nursing, with classes starting in October, and they plan to launch a Family Nurse Practitioner program at a later date.
Behavior Change: Horizon BCBS will end its relationship with behavioral health provider Quartet Health in September in what is the latest sign of big insurers moving behavioral health spending from 3rd parties to network providers. The health plan partnered with Quartet to help integrate medical and behavioral health care and identify people who needed mental health support but were not getting treatment. As some context, not that long ago, in 2019, Horizon started a value-based program to recruit outpatient providers to its substance use treatment network offering case rates, no pre-authorization requirements and incentive payments (e.g. 10% of commercial claims and 15% of Medicaid claims paid out per year if meeting outcomes measures like readmit penalty reduction).
Pay For Follow-Up: Priority Health in Michigan recently updated how they pay for case management/collaborative care services. PCPs or their employees can now be reimbursed for any care management telephone services within seven days of an in-person visit or leading up to a procedure within the next 24 hours. Back in 2005, this sort of coverage was unheard of even for cancer patients until another Michigan insurer finally agreed to pay for follow-up telephone calls after an internal study found they reduced avoidable hospitalizations. Under Priority’s policy, providers can rebill for any previously denied claims going back to January, and effective July 1, waived member copays and deductibles for fully insured commercial members receiving behavioral health collaborative care services.
20 Visits For Diabetes: Insurer CareFirst is partnering with Ryse Health, a company focused on the treatment of Type 2 diabetes, to improve long-term outcomes through a value-based arrangement. Members with diabetes can see Ryse providers 20 times in their first three months through either virtual or in-person visits. The program will also ensure follow-up appointments with endocrinologists happen more quickly, within two weeks. CareFirst said clinicians will have the final say in treatment decisions, but one imagines a value-based program like this may be less reliant on pricey GLP-1 medications, at least as a first option.
Student Referral Gap: Charlie Health and Mantra Health, both behavioral health companies focused on adolescents and young adults, are partnering to broaden access for undergraduate and graduate students seeking behavioral health care. Mantra Health already focuses on students but only offers virtual care and other services like peer support and education. The partnership will allow Mantra to refer students needing more intensive services to Charlie’s IOP program. One gap that we know remains for college-age students is a system for campuses to flag when students are isolated – a kind of software system that would prompt student services to reach out rather than “passively” offer a clinic or hotline. “I like the database idea because you create a more holistic set of information,” says Haley Gregory, an MSW from New Jersey. “Leaving it up to one professor at these big schools, even small ones, is asking a lot – the students will invariably find their person – maybe it’s a coach, a roommate, a waiter at the diner – but oftentimes they will insulate after trauma or due to depression or the transition to school, so having some data that student services can monitor makes sense.”
Strange But True Partners: Home health provider MedArrive has partnered with virtual cardiology company Heartbeat Health to bring cardiovascular services to the home. MedArrive nurses and technicians assess patients and connect them virtually with a Heartbeat Health cardiologist for more comprehensive treatment, medication prescriptions, and referrals to in-person treatment.
Extra Point (From The Archives): I slid the old Peter Gabriel cassette into the boom box last night, rewound for 10 seconds, flipped the tape, hit PLAY, then STOP, then flipped and rewound 3 more times and alas there it was, In Your Eyes. I held it high like Lloyd Dobbler, stood atop the coffee table, and told my kids, “This was a quintessential 80s moment,” epitomizing an era of persistence, optimism, big hair, great songs, and surprising yet perfect marriages like Lloyd’s with Diane Court. When we rewind healthcare in 10 years, I suspect we may see the same thing – partnerships that come out of left field but oddly work: like insurers with universities to train nurses, dentists and allergists teaming to treat gum disease in those with asthma, autism therapists and gastroenterologists linking up to address GERD in kids on the spectrum and dermatologists and teen therapists working in concert to halt acne-induced suicide attempts. As Diane told Lloyd, “No one really thinks it will work, do they?” No, said Lloyd. “You’ve just described every great success story.”