Friday Forum

A weekly digest on the business of behavioral health – the good, the bad, the great

200,000: Highmark’s increase in membership now that state regulators approved an affiliation agreement with HealthNow New York last week. They will be the primary Blue plan in western and northeastern NY, plus in central and western Pennsylvania, West Virginia and Delaware. If you’re doing managed care contracting and looking to expand your healthcare business in this region, Highmark matters – it can help you take a young model to another state, or on the flip side put pressure on payment and utilization.

Cancer Care Bundle: Memorial Sloan Kettering in New York is partnering with Carrum Health to launch a new cancer care bundle for any employers that collaborate with the cancer center. The partnership will offer bundles that cover in-person treatment at MSK for eligible patients with non-metastatic breast and thyroid cancers. For these patients, the bundle will cover complete medical treatment for up to two years. For patients with all forms of cancer, bundles will cover remote diagnosis, treatment planning and care guidance.

Losers From Cigna’s Tele Play: As predicted, payers will insource telehealth and Cigna’s newly formed health services sector, Evernorth, is acquiring telehealth vendor MDLive. Cigna has partnered with MDLive for a while, but by bringing the telehealth company in-house the plan can handle lower acuity patients and incent patients to use MDLive. This means risk to commercial primary care and urgent care.

Hospitals Strike Back: Like the Empire, if you thought hospitals were just going to let the outpatient and telehealth providers take over, think again. Hospitals continue to find ways to hold on to patients post discharge. In Rhode Island, the Blue plan is partnering with Butler Hospital’s transition to outpatient program leveraging the staff to do counseling, medication support and case management up to 3 months after leaving the hospital. Humana meanwhile has partnered with central US health system Mercy to expand access to virtual healthcare for MA patients. The value-based agreement allows patients of Mercy’s health system in Arkansas, Kansas, Missouri and Oklahoma to access Mercy’s 300 clinicians for in-home virtual support.

Yellow Flag: UPMC out of Pittsburgh is piloting a new machine learning tool that will help inform patient transfers between the health system’s hospitals. The algorithm will predict mortality for patients who may be transferred to another hospital for a higher level of care. Patients at highest risk will be flagged so that they can converse with their providers and families about the benefits and risks of transfer. The algorithm, known as SafeNET, is not meant to make medical decisions for patients, but instead to flag the patients for which these decisions are most crucial.

Atlanta Dream: The WNBA team has partnered with Anthem BCBS to address social injustice and promote health and well-being throughout Atlanta. The two organizations will undertake efforts to address food insecurity, mental health and health disparities.

Back In The Game: Aetna recently announced the company will re-enter the ACA marketplace in January 2022, though individual markets have not been confirmed yet and likely will not until later this year. Aetna left the individual market in 2017, and was subsequently acquired by CVS Health. After some volatile years, the individual marketplace is growing. In 2021, 30 payers entered the individual health insurance market across 20 states and over 60 payers decided to extend their footprints.

App Wins vs. Office For SMI: For patients with bipolar, schizophrenia and major depression, a University of Washington School of Medicine study has concluded that mental health apps are just as effective and cost less than clinic. The 163 participant study revolved around costs of using a smartphone app called FOCUS in which 49% had a diagnosis of schizophrenia or schizoaffective disorder, 28% had bipolar disorder, and 23% had major depressive disorder. The treatment was given through the app with the help of a support specialist which included daily self-assessments and on-demand 24/7 digital interventions. Researchers compared results from the patients using the app to a clinic-based group intervention of 90 minutes per week. The app cost was $1,011 vs. $1,956 for group-based intervention.  A question we would have is how the health insurer pays or handles the “on-demand” element. It’s likely to be a PMPM, not FFS.

Extra Point:  Elaine Benes got an earful if you recall when she tried to pawn off a bag of muffin stumps to a homeless shelter back in the bizarre 1990s Seinfeld world.  “You just assume homeless will eat anything huh….but where’s the top of the muffin!” the shelter’s director complained.  Elaine’s argument – that “if the homeless don’t like ‘em, they don’t have to eat ‘em” – well, it seems a bit heartless I think, even if well intentioned. Seems we’re having a similar dilemma today: one Covid vaccine being rolled out to underserved and homeless populations is a potential gamechanger, but reportedly 65% effective, the others 95%. Even if efficacy on one is much higher when all is said and done, perception matters. We took a van of seniors from an affordable housing community in Hartford to a clinic last Saturday. Barbara, a former school teacher now 77, was thankful and happy to be getting the vaccine, but said many of her relatives in other cities don’t have transportation like this, and are “reluctant” about getting a vaccine that isn’t at the top.  -BC