3.5: Percent of middle-class Americans with medical debt, more than any other class, according to a KFF estimate. Experts think this is because middle-income Americans, who earn $50,000-$100,000 a year, are more likely than those with lower incomes to seek care but they don't qualify for Medicaid or charity care to help pay for it and often fall into the gap between affordable ACA plans and Medicaid. Those with higher incomes, and typically better insurance coverage, have the least amount of medical debt unsurprisingly.
Wait For It: Unranked in 2023, the #1 payer priority heading into 2024 will be managing GLP1 weight loss medications. “It’s dominating our time,” one source said. A southern Blue plan pharmacy director told us this week that the plan is undergoing a study into the outcomes and costs for members with diabetes taking GLP1 medications and an antidepressant, as well as members taking medication for anxiety or another mental health condition and a GLP1.
Say Cheese: Cigna uses SmartScan technology to provide at-home oral health scans to ~16.5 million dental members via mobile phone. Members will take 5 guided photos of their teeth and mouth at no cost, which will be analyzed by SmartScan and reviewed by a dentist. The photos should help screen members for oral health issues such as cavities and gum disease.
4-Headed PBM: Blue Shield CA is making changes to its pharmacy benefit management operations next year, scaling back its reliance on CVS Caremark and spreading operations across four other companies, including the Mark Cuban company. They will handle pricing models while Amazon Pharmacy will handle delivery for nonspecialty drugs, PBM Prime will develop a value-based care approach to negotiating discounts with pharmaceutical manufacturers and claims will be processed by Abarca. Blue Shield projects they will cut drug spending by 15% though they will still use Caremark for all specialty drugs, which are often much more expensive than others.
And On The 7th Day: Blue Cross NC is updating its behavioral health length of stay guidelines in order to more effectively manage transition of care and reduce total length of stay, according to the health plan. Concurrent review approvals for inpatient and residential treatment centers receive no more than a 7-day length of stay that took effect earlier this month.
Late Diagnosis: Families often wait six to 12 months to get their child an evaluation for autism and other neurodivergent conditions, and in some parts of the country, it can be up to two years, according to Meliora Health’s chief medical officer Cheryl Tierney. Bend Health, a virtual pediatric mental health company, is now offering virtual psychological and neuropsychological assessments with the ability to get children into testing within two to three weeks, and digital health companies Meliora Health and As You Are offer similar digital diagnostic tools to improve access to evaluations.
Don’t Call It A Comeback, Yet: St. Charles Health System in Oregon is considering ending all contracts with Medicare Advantage plans and urging seniors to opt for traditional Medicare instead. The hospital says that dealing with MA plans has led to interruptions in care, higher denials and differing outcomes based on the type of insurance patients have. They haven’t left any networks yet but said they will be considering their participation with Humana, PacificSource and others over the next few months.
Aisle 7: Grocery chain Kroger is launching its third Medicare Advantage plan partnership with Intermountain’s health plan SelectHealth. The plans target Medicare-eligible Kroger shoppers and will be offered in Colorado, Idaho, Nevada and Utah next year. Kroger already operates plans with Elevance and Michigan insurer Priority Health.
Extra Point: Our 22-year-old got her first job out of college this month at, of all places, an architecture firm and her first assignment involves the design of an urgent care psychiatric facility in New England. There are now more than 4,000 such same-day mental health emergency centers in the US by our count though just a fraction are dedicated solely as a triage system for mental health emergencies. They were configured initially to give police an alternative place to take people other than hospital ERs. “It was really first a lot about helping in domestic violence situations and has now emerged to become quite critical for families who are in the midst of a potential suicide situation,” says Allie King, a communications director for a Missouri county police force. The urgent care centers sometimes open up to help the uninsured as The Collaborative did in Nashville in 2018 but “we ended up having waiting lines” due to the influx of people with employer insurance, Adam Graham, the program’s emergency director told us at the time. It’s interesting how so much of the public is on board – in Florida, The West Central Mental Wellness Coalition was formed in 2019 with support from the Rays baseball foundation, Florida Blue, and many hospital systems, including leader Baycare. Now called “Tampa Bay Thrives,” funding for these centers is not just from patients and insurance but also grant-funded as a community service. The question for healthcare investors is just how many of these centers are truly needed, how to staff them, and perhaps underappreciated how to quickly connect patients to the next level of care. Amy Flutes said the 10-12 cases she sees a day at her center in Missouri are “high crisis” and “we stabilize” but “sometimes struggle with finding a suitable facility or available psychiatrist for their situation.” Roughly half of psychiatrists in the US are only taking cash pay and many more have full panels. Flutes said they often have to look out of state or “have to settle” for helping the family get their loved one to a center that “isn’t perfect.” For investors, can you design a system that limits wait time, is efficient in a suicide process and importantly can help find that next level of care? Said our daughter, “I didn’t realize all of this Dad….we just need to figure out how to design the space and the waiting area to be suited to people in a mental health crisis.” I know kiddo. And it’s great you're doing this important job. “You know that it’s George Costanza’s dream job,” I told her. “Dad! Seriously, why does everything have to be a Seinfeld reference?”