1. 319: The number of high school students in our poll of 500 who said they have a friend who vapes.
2. In-Home Behavioral Coverage Kick Off: Starting this month, Blue Massachusetts now covers in-home behavioral health monitoring and therapy for those under 19, as well as intensive care coordination, community based treatment, mobile crisis intervention.
3. Transgender Boost: Transgender employees with the University of Michigan will now have new medical services covered starting this fall under a new BCBS policy here – procedures now covered include face and neck hair removal, facial feminization surgery and Adam’s apple reduction. The benefit has up to a $30,000 lifetime limit.
4. You Grant: There’s a major trend unfolding among insurers in the number of grants and the dollar amount of them dedicated to wellness, physical activity, social determinants and other ‘preventive’ or lifestyle related programs. BCBS of Oklahoma has 14 such programs it is supporting this year including the OK City Community College Foundation focused on food insecurity, Palomar, an OK program to help kids exposed to domestic violence, The Center for Individuals With Physical Challenges that offers a sports camp, ReMerge for families who have faced addiction, and Tulsa’s Children’s Museum to expand playground and other physical activity programs. These are really the new network for insurers, not simply a check the box. The impact of these programs and insurer support will vary--primary care practices are unlikely impacted over a 10-year-period whereas hospitals and surgeons who rely on volume from unhealthy patient populations are likely impacted to some degree. The programs are more so a signal to medical groups and therapy groups interested in getting insurer attention – that designing pilots with a preventive element to them for high risk populations will get attention.
5. August, And Everything After: First the album title for Counting Crows hit 1990s record that included the anthem Mister Jones….and now it’s a new policy from Anthem of Georgia who is moving ahead with a new policy affecting therapy providers. Pre-authorization will now be required for PT, OT and speech therapy as of August 1st. The insurer originally was going to require this in April but had to delay the change due to trends in group membership, provider status and other ‘system’ issues.
6. Urgent Care Maybe Not: There were 47 ambulance trips from an urgent care clinic in my home town last week, according to several sources – suggesting at first that the clinic is being mis-used to some extent, but when probing further the hospitals in the area who get these cases say that ‘more often than not’ it’s a case of the urgent care PA or NP just not being clinically educated enough to diagnose and treat, so they ‘refer to the hospital for liability reasons….’ An example of one such case is chronicled here that we wrote about a few years ago: click here for story on urgent care Observation Case
7. The New Diagnostics: The rise in policies and coverage around remote monitoring and telehealth and social determinant services are fascinating to watch as more insurers agree to pay for these at similar or in some cases higher levels than face-to-face care, simply to address shortages and access to care problems. Still, when I sat down with 3 medical directors earlier this month about how they view these services, two of the three put them in the ‘diagnostics’ category. ‘That’s really how I think of telehealth and even social determinants – yes it’s a way to evaluate and manage and counsel, particularly if mental health, but I would view these services as more so an extension of diagnostics,’ said Andy Kellogg, a former health plan medical director now retired. To that end, if you are investigating adding these services or thinking about owning them, consider how insurers may manage them and use them in benefits. ‘If I were still in charge I would still be thinking of these as the diagnostic and then establish the payment and benefit similar to how we might do it for lab or even imaging….outside of a risk model, in fee for service you would want to manage these or use them to understand what’s happening, not to replace the treating provider’
8. 50: The percent of all lifetime cases of mental illness that begin by age 14. And 75% develop by age 24, according to the National Alliance on Mental Illness. Talkspace, an online therapy company, now has a service for teens rather than just adults. With parental consent, teens can be connected with a licensed therapist in their state. By 2022, we think that the national telehealth community will get behind a change in policy to allow credentialed/licensed therapists to treat a patient outside their region. Full story: click here
9. Shattering Policy: The non-profit Shatterproof is now teaming up with insurers nationally in most states to help provide guidelines and recommendations for addiction centers of excellence. Our prior reports on this non-profit suggest that there is demand in several markets to help families stung by addiction – namely to help guide them about where to go for treatment. For behavioral health providers, it’s clear that being on Shatterproof’s short list of recommended providers will ultimately be important if looking to be considered as centers of excellence and looking to get increasing volume from the major referral sources of these cases.
10. Extra Point: I will have to pay full freight, or close to it, for a tartar debridement procedure that Guardian Dental just won’t pay for….and who could blame them? My usual dentist retired 3 years ago and I’ve failed to find a new one, so I’ve gone all that time without a check-up even while traipsing my own kids from appointment to appointment….My lapse landed me in the dental chair Wednesday facing a terrifying tartar battle – my hygienist, 20-something Rachel, scraped my teeth and gums with fearless vigor, while making jokes ala Tim Whatley of Seinfeld fame…. I suffered, gripping the chair, sweating, choking, hanging on for dear life….Rachel asked if the front desk gave me the skinny on the cost of the procedure. ‘I just won’t be able to do the cleaning today, too much tartar – that’s next month…you’ll need debridement….’ Now for someone who works in healthcare, at least in the research world, it’s a tad bit embarrassing that I talk about the importance of oral health but then don’t go to the dentist. Sort of like those primary care doctors who have heart disease and smoke….'So we can submit this to Guardian for reimbursement but they don’t cover it….,’ according to Cindy, the care coordinator. Personally, I don’t want to go through the procedure ever again (like ever, Taylor Swift might say), so if paying full price (around $300) is another deterrent then I’m happy to pay. In fact, I called Guardian who said they usually evaluate the patient’s factors and, if they haven’t been to the dentist for several years, coverage is usually denied.