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Pivoting From Reactive To Proactive Innovation

Six months into the pandemic, the organizations that are thriving share one characteristic—nimble reaction to change. But the big question ahead is whether the field can move from reactive to proactive innovation.

What is the difference? With reactive innovation, executives wait for good ideas to be presented and then try to implement the ideas they believe are positive for their organization. The health and human service field has a history of reactive innovations—payers like state and county governments or Medicaid plans change what they want and release new RFPs or regulations. Provider organization executive teams react. The swift reaction of provider organizations to the pandemic—bringing up telehealth to scale—is an extreme example of this.

Proactive innovation is when executive teams identify emerging opportunities in the market and create new products and services to meet those market needs. Proactive is anticipating what customers will want and creating those future solutions. Proactive innovation is an essential part of planning for future sustainability— identifying the “the next big thing” that will be the financial anchor for their organization— whether it is home-based services, hybrid care models, primary care, new integrated care coordination approaches, or something else entirely.

Where are specialty provider organization executive teams with this pivot from reactive innovation to proactive innovation? Four executives who are making it happen on the ground offered their perspectives in the recent web briefing, Operating Behavioral Health Programs In A Pandemic: Success Stories From Arizona, New Jersey, & Ohio. The panelists included Susan Devlin, Executive Director, Comprehensive Behavioral Health Care of Bergen County; Jeff O’Neil, President and Chief Executive Officer, Greater Cincinnati Behavioral Health Services; Steven Sheets, President and Chief Executive Officer, Southwest Behavioral and Health Services; and Christy Rosado, Senior Vice President, Sales, Genoa Healthcare.

None of the three provider organizations have closed their face-to-face service delivery during the pandemic—and they found creative ways to sustain a hybrid model of virtual services with in-person outreach in the community. But all the executives acknowledged that while they were “making it up as we go” (to quote Ms. Devlin), the key to future success is look beyond the status quo with proactive planning.

Making The Shift To Virtual   

For the three provider organizations, telehealth was largely new territory as they had done little to none before the pandemic. While the pivot was quick—out of necessity and thanks to teamwork—there was a steep learning curve. To make this happen, new processes had to be developed, staff and consumers had to be trained, and technology had to be upgraded.  A key (and continuing issue) for all the provider organizations is the digital divide—many consumers either lacking access to high-speed internet, the equipment to access virtual services, or the ability to fully participate in those services. But they made virtual work over the past six months with creativity. For example, Ms. Rosado said that Genoa came up with the concept of a “virtual waiting room” where they could have conversations with consumers waiting to see clinical professionals. And Mr. Sheets noted that video visits yielded the unique advantage of letting clinical professionals see consumers “where they are” and get a sense of their living conditions that impact health.

Managing With New Operational Challenges From The Pandemic     

The pandemic brought many new operational challenges to serving consumers. Ms. Devlin said at one point, 25% of staff at Comprehensive Behavioral Health Care of Bergen County were out — quarantined, dealing with day care closures, or juggling other issues at home. She added that early on, they had to invest significantly in stocking up on personal protective equipment (the sourcing of which became a full-time job) and later had to retrofit their facilities with plexiglass shields, touchless doorknobs, and more. Mr. Sheets echoed the challenge of escalating expenses and noted that while some facility-based indirect expenses came down as they pivoted largely to virtual operations and virtual care delivery, there was a huge uptick in spending on technology—laptops, phones, a telehealth platform, etc.

For pharmacists, keeping in touch with current consumers and onboarding new consumers who needed prescriptions was no easy task, as they transitioned from onsite to online, said Ms. Rosado. Mr. O’Neil pointed out that managing a remote workforce was challenging—they quickly discovered that remote work requires “more structure, more process, and more training.” Much thought had to be invested into ensuring staff connectivity and rethinking communication and supervision protocols.

Engaging Consumers & Staff In The Midst Of Change    

The panelists pointed out that engagement—of consumers and team members—was another critical area requiring innovation and “outside the box” thinking. Ms. Devlin shared that for consumers who needed to come in for face-to-face visits, staff set up “a tent in the parking lot.” Staff also made up “activity gift baskets” with puzzles, snacks, and movies and dropped them off for consumers especially challenged by the isolation enforced by the pandemic. She said that tapping into the expertise and dedication of long-time staff and the goodwill of consumers was a key element in navigating through the crisis.

Mr. Sheets’ team sent multiple texts and emails to consumers to remind them about appointments and just to check in. They also sent staff gift cards for free lunches and “fun self-care packages” to let them know that management had not forgotten about them. “We did everything we could to let staff know that we’re here, we understand, and we’re flexible,” he said.  “Every touch point needs to be intentional.”

Mr. O’Neil said that with 10,000 people in their care management program, they needed an innovation that matched the scale of the challenge. His organization created a “COVID Work Safe” team that helped to prioritize issues, respond to the immediate situation, and engage in long-term planning. To get a better sense of consumer needs, their team conducted two assessments—the first was to evaluate basic needs and concerns of consumers and prioritize; the second was to determine the best service modality—video, telephonic, or face-to-face—for each consumer. Getting consumers their medications was also a big concern, so Greater Cincinnati Behavioral Health Services partnered with Genoa to set up a “mobile injection van” to go out and deliver medications.

Support services like onsite pharmacies had to up their game as well. Ms. Rosado said they introduced curbside pickup of prescriptions and also mailed more medications (an effort that increased 50% in volume from pre-pandemic days). And where permitted, pharmacists jumped in as staff extenders to administer long acting injections to consumers. For their staff, Genoa has done themed video calls (including a Christmas in July) and “talk while you walk” phone calls to keep the camaraderie up in the remote environment. “You can’t overcommunicate!” said Ms. Rosado.

Making The Pivot    

These creative approaches and nimble responses to the pandemic are fundamental to success in a crisis. But over the next six months, as the pandemic moves from emergency to the “next normal,” the sustainability challenge will shift to longer-term strategies—and the investment required to make them happen. Mr. Sheets said it well—that the crisis must not preclude planning for the future and service expansion. “We have to challenge the behavioral health system to think differently—to think about the long term rather than just what’s a catchy trend. Otherwise we will be part of those who fail within three years of the crisis.”

A total of 21 Medicare Advantage plans earned 5 stars, the highest, in the latest CMS release of star ratings for 2021. The 21 health plans earning 5 stars include KelseyCare Advantage, Kaiser Permanente, UnitedHealthcare, CarePlus by Humana, Tufts Health Plan, Health Partners, Capital District Physicians’ Health Plan, Quartz Medicare Advantage of Wisconsin, Cigna, Health Sun (now owned by Anthem), BlueCross Blue Shield Health Now New York, and Martins Point, to name a few.

A total of 375 plans of the 400 rated for 2021 had ratings between 3 and 4.5 stars:

  • A total of 63 plans were rated 4.5 stars.
  • A total of 110 plans were rated 4 stars.
  • A total of 141 plans were rated 3.5 stars.
  • A total of 61 plans were rated 3 stars.

Just four plans earned the lowest rating of 2.5 stars: Bright Health, AgeWell New York, Prominence Health Plan, and Virginia Premier.  Prominence HealthFirst of Texas is the only contract getting a low performance warning for consistently low-quality ratings of 2.5 or fewer stars from at least 2018 through 2021. An estimated 417 plans were rated not applicable as there was not enough data available or the plan was too new to be rated.

The average Star Rating for all Medicare Advantage plans with prescription drug coverage improved to 4.06 out of 5 stars in 2021 from 4.02 in 2017. About 49% of Medicare Advantage plans that offer prescription drug coverage will have an overall rating of four stars or higher (an increase from 45% in 2017). About 77% of Medicare beneficiaries who enroll in Medicare Advantage plans with drug coverage will be in plans with four or more stars in 2021 (compared to 69% in 2017).

For the 2021-star ratings, no new measures were introduced. However, on March 31, 2020, CMS adopted changes to the 2021-star ratings to accommodate disruption to data collection posed by coronavirus disease 2019 (COVID-19), as well as changes to the 2022-star ratings to account for expected changes in plan performance. CMS increased the weight of patient experience/complaints and access measures from 1.5 to 2 for the 2021-star ratings.

The Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Part C and D Star Ratings each year to measure the quality of health and drug services received by beneficiaries enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs, or Part D plans). The Star Ratings also reflect the experiences of beneficiaries; the ratings are intended to help beneficiaries finding the best plan for them.

A link to the full text of “CMS Fact Sheet – 2021 Part C & D Star Ratings” may be found i at www.openminds.com/market-intelligence/resources/101320cms2021starratingsfactsheet.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

Over the past decade, there has been a running disagreement with many of the non-profit organization executives and board members. One view is that non-profit organizations need to be run like for-profit organizations—that they need efficiencies that treat donor contributions and grant funding just like for-profit organizations treat their investors’ money. With great care.

And non-profit organizations need profit margins to invest in their future growth and mission-based work. “Non-profit is just a tax status,” as some have said. Non-profit organizations are granted tax exemption because they do charitable work for the communities they serve; with the margins they generate. These margins start with budgeting (yes, budgeting a profit), are delivered through efficient strategy execution, and are then available to build a portfolio of services and assets in the community.

Most non-profit organizations operate with breakeven budget expectations. So, in a conversation with Mark Mishek, President and Chief Executive Officer of Hazelden Betty Ford Foundation, Monica E. Oss, Chief Executive Officer, OPEN MINDS, was intrigued to learn why and how their organization budgets—and delivers—a margin.

As leader of the nation’s largest non-profit addiction treatment provider organization, Mr. Mishek fully espouses the mantra of “No Margin, No Mission” (conferred on health care by the late Sister Irene Kraus, founding chief executive of the $3 billion Daughters of Charity National Health System). “I grew up on the acute care side of health care where the need for capital is huge, and capital comes from margin. The purpose of margin for a non-profit is to reinvest,” Mr. Mishek said. At Hazelden, they set an Earnings Before Interest, Taxes, Depreciation, and Amortization (EBITDA) target of at least 10% each year. Interestingly, they are scaling back to a 9% goal for 2021 to allow for restoration of financial stability after the pandemic.

Growth does not come with a “business as usual” mindset, elaborated Mr. Mishek. Provider organization executive teams that continue to depend on traditional revenue streams and referral sources may run out of cash and close their doors at worst, or barely survive but “not go anywhere” at best. And the pandemic is not an excuse for lack of planning. The pandemic has deferred or altered the focus of some initiatives and investments at Hazelden but has not put the lid on their growth plans. “The focus is on staying open and staying safe in all the eight states we operate in. We are rechanneling investments from brick and mortar facilities to virtual services and operations infrastructure. But growth continues to remain an imperative because there is a big unmet need out there that demands our attention,” Mr. Mishek explained. Only 1 in 10 of the nearly 20 million Americans with substance use disorders currently get the treatment they need—so it’s going to take a lot of scaling to expand access to care. “Growth is a mission mandate, not just a nice idea,” he underscored.

Executives who don’t see a path to achieve the margin needed to reinvest in growth should be thinking about new service lines, affiliations, or partnerships because “the only way to be a player in the increasingly competitive, consumer-driven market is size and scale.” Mr. Mishek offered three strategies, based on Hazelden’s own experience, for executives to employ in scaling up—follow the money, learn from the competition, and pursue win-win partnerships.

Following The Money

Executive teams need to keep their eye on where and how customers want to spend their available resources. One path is optimizing current services and customer relationships. The other is planning for their “next big thing”—the future services that will anchor their customer relationships and financial sustainability. Hazelden is looking at a seamless hybrid model of care as their “next big thing.” Mr. Mishek explained that the continuum of care for addictions will look different. “We want consumers to be able to get in and out of levels of care easily, where each level is paid for. And we want them to be able to choose virtual vs. in-person care as they prefer.” The pandemic has accelerated the adoption of virtual care, and Hazelden was well-prepared with its RecoveryGo suite piloted in 2019. RecoveryGo is a suite of virtual care tools for addictions recovery—an intensive outpatient program, a robust consumer portal for education and care management, recovery support services, and a family program. While the future is not just telehealth, the pandemic has shown how much consumers and families prefer virtual components. “Digital is a whole way of life—from consumer conveniences to the education of counselors,” said Mr. Mishek, and Hazelden is set for the transformation in care.

Mr. Mishek noted that Hazelden will always be a center of last resort for residential treatment but is also looking to expand to address the needs of those who are “further down the pyramid.” The addictions pyramid concept was made popular by Thomas McClellan, founder of the Treatment Research Institute and former deputy director of the Office of National Drug Control Policy. He explained that if all U.S. adults are placed in a pyramid, the bottom is a broad base of people who almost never use drugs, alcohol, or other substances. About halfway up are 40 million people who “misuse” substances; about three quarters of the way up are 21.4 million people with addictions; and at the top are 4.1 million people with the most chronic and severe addictions—the only group that gets any sort of substance abuse treatment. “The universe of say, problem drinkers, needs help and represents a $62 million market,” said Mr. Mishek.

Hazelden also maintains excellent relationships with health plans and offers solutions to their most pressing problems—whether that’s network expansion, geographic coverage, or clinical quality. “When a large employer in Seattle liked our quality of care but was reluctant to have their employees travel to us, we opened an outpatient facility in Seattle,” noted Mr. Mishek, as one example of expansion. They also go “all in on contracting”—Hazelden has a contract with every Blues plan in every market they’re in—and given the agreements between plans, consumers can move seamlessly from outpatient to residential, even across states. This becomes a selling point for the plans. Health plans want to stop consumers from going to out-of-network addictions treatment provider organizations that do not offer quality care and Hazelden has helped them “make the in-network providers more attractive.” Mr. Mishek added, “We’re here to play ball. We’re game for case rates and pay for performance (but not downside risk). But we have to negotiate acceptable case rates and factor in outliers—we can do all that because we have strong metrics and strong financial analysis capabilities.”

Matching The Competition

Another key to scaling up is keeping pace with the competition. Attracting customers—both payers and consumers – is about offering the “best value” when compared to other options. Mr. Mishek thinks that the growing footprint of private equity in the behavioral health market has fostered a new level of sophistication and consumerism. “We have a lot to learn from our competitors—they are investing in top-of-the-line marketing, online presence, search engine optimization, call centers, and other options to increase consumer access and convenience, and we have to catch up,” said Mr. Mishek. Hazelden is focused on excellence in care and virtual marketing to gain an edge over the competition.

Delivering convenience, education, and information may mean “doing stuff you don’t get paid for” but Hazelden sees that as part of the investment to establish its brand. They want to become a go-to source of complete online information and education on addiction disorders and treatment. “We want to be the Mayo Clinic of addictions,” Mr. Mishek asserted. Addictions treatment provider organizations that are “not doing much more than the traditional 12-step program,” are not poised for growth and success, he said.

Seeking Partnerships & Affiliations   

Changing customer expectations and more competition have sped up the product life cycle and the need for nimble innovation. For many organizations, collaboration may be the best option to remain competitive. As an example, Hazelden recently created a partnership with Emory Healthcare to create the Addiction Alliance of Georgia. With philanthropic support, the two organizations will seek community partners throughout Georgia to advance addiction-related clinical care, education, and research. Emory expects this unique public-private partnership to become a national model for promoting addictions recovery. The alliance will work with the Georgia Department of Public Health, the Georgia Department of Behavioral Health and Developmental Disabilities, Grady Health System, Morehouse School of Medicine, the Medical Association of Georgia, and federally qualified health centers throughout the state.

And Mr. Mishek gave other interesting examples of potential collaborations. Multiple provider organizations coming together and forming a management company to manage backroom operations and develop infrastructure is another good way to “scale up without losing local identity and independence,” he suggested. These coalitions bring capital to the table and enable early adoption of evidence-based practices. He also suggested looking at partnerships with health systems and with digital health start-ups. He said that capitation-based payments offer opportunities to partner with health systems on holistic treatment. “Primary care professionals don’t know substance use or mental health and they don’t want to be loaded with one more thing to do, but that’s where we can come in with strategic partnerships,” he noted. And he added that the digital-only addictions treatment companies “haven’t caught fire yet” and may need traditional provider organization partners to be successful in the long run.

At the end of the day, “The inability to produce margin and to raise capital sounds the death knell if you don’t get out there and find your kindred partners. Find nonprofits like you that share your values and understand the need to grow. Survival requires sizing up and scaling up,” summed up Mr. Mishek.

Medicaid and CHIP enrollment combined grew from almost 71 million people in February (the approximate “onset” of coronavirus disease 2019 (COVID-19)), to nearly 75 million in June, representing a 5.7% increase. Medicaid enrollment grew 6.2% during that period, with nearly 4 million more people enrolled in the program. CHIP grew about 0.5%, with enrollment increasing by more than 23,000 beneficiaries.

Overall CHIP enrollment increased in 36 of 37 states reporting. Montana was the only state that reported an enrollment decrease in 2020. However overall Medicaid and CHIP enrollment increased for all 37 states. The number of unemployed in these 37 states increased dramatically, from approximately 7.5 million individuals to approximately 23 million (about a 205.4% increase) in these states between March and April. However, unemployment then decreased 11.9% between April and June 2020.

These findings were presented in “Medicaid & CHIP Enrollment Trends Snapshot Through June 2020,” by the Centers for Medicaid & Medicare Services (CMS). Researchers for CMS tracked total Medicaid and CHIP program enrollment trends for adults and children over a 12-month period between July 2019 through June 2020. The goal was to determine recent trends in CHIP enrollment.

A link to the full text of “Medicaid & CHIP Enrollment Trends Snapshot Through June 2020” may be found at www.openminds.com/market-intelligence/resources/092920medicaidchipenrollment.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On October 1, 2020, the North Carolina Department of Health and Human Services (NCDHHS) announced it awarded a $7 million contract to United Providers of Health (UPOH) to address unmet health care needs of historically marginalized communities. The sole source contract is to provide preventative health care services, connections to mental health supports and help securing non-medical social determinants of health such as food and housing. Funding for the contract is supported by Coronavirus Relief Funds. The goal is that combining mental health services with primary care will reduce costs, increase the quality of care, reduce the burden on hospitals, and mitigate the spread of coronavirus disease 2019 (COVID-19).

UPOH will use the Hope4NC Helpline to connect with residents in the community who call or text for assistance. After receiving a Hope4NC Helpline request, UPOH will connect individuals with needs for housing, medical care, and financial counseling to services. UPOH will provide access to a statewide network of Certified Peer Support Specialists who can connect behavioral health service recipients with primary care professionals. The target population includes (but is not limited to) people living in rural counties designated by the North Carolina Office of Rural Health as being high poverty areas. The target population also includes people and communities with limited access to physical health professionals for preventive and acute care, and or behavioral health professionals.

The contract with UPOH began on September 29, 2020 and runs through December 30, 2020. NCDHHS paid UPOH half the contract value about 10 days after contract execution to support initial startup costs and to use to provide services agreed to in the contract. UPOH will work against those funds and provide documentation to support the expenditures. At the time that the first payment is exhausted, UPOH will be reimbursed for eligible expenses.

UPOH is an Independent Providers Association (IPA). Its network includes small mental health, addiction treatment, intellectual/developmental disability, provider organizations and primary care physician practices, who deliver services to underserved individuals with high health care needs. The services will be tailored to the needs of historically marginalized populations and address existing health disparities by delivering culturally competent care. UPOH will offer counseling to those dealing with the financial uncertainty posed by potential eviction or termination of utilities and by assisting community members coordinate with social services and other supports, especially those involved in the COVID-19 response.

NCDHHS did not publicly post the procurement, consistent with the procurement flexibilities granted in Executive Order declaring a state of emergency to respond to and prevent spread of COVID-19.

For more information, contact:

  • Victor Armstrong, Director, Division of Mental Health, Developmental Disabilities and Substance Abuse Services, North Carolina Department of Health and Human Services, 306 N. Wilmington Street, Bath Building, Raleigh, North Carolina 27601; 984-236-5002; Email: victor.armstrong@dhhs.nc.gov; Website: https://www.ncdhhs.gov/divisions/mhddsas
  • United Providers of Health, 9650 Strickland Road, Suite 103-189, Raleigh, North Carolina 27615; 919-701-6603; Email: info@upoh.org; Website: https://upoh.org/

On October 2, 2020, Pennsylvania Governor Tom Wolf signed an executive order to launch a comprehensive, whole-person health reform plan that focuses on improving affordability, access, and value for physical and behavioral health for Pennsylvanians, regardless of how they receive or purchase health care coverage. The key goals of reform are aligning the Commonwealth’s health care payment and delivery systems to provide efficient whole-person care, eliminating health inequities resulting from systemic racism, and holding health care corporations accountable.

A newly established Interagency Health Reform Council will develop proposals by December 31, 2020, to modernize and reform Pennsylvania’s health care, such as aligning programs where feasible, including the joint purchasing of medications, aligning value-based purchasing models, and using data across state agencies to promote evidence-based decisions. The Council’s report will identify all policy and legislative changes needed to adopt the proposals. In the absence of legislative action, the Council will develop initial health care cost growth benchmarks by March 31, 2021 and make accompanying recommendations for development of future year cost targets.

The Council will be composed of commonwealth agencies involved in health and the governor’s office. In addition to the work of the Council, the plan calls for establishing Regional Accountable Health Councils and a Health Value Commission, as follows:

  • Regional Accountable Health Councils (RAHCs): The Department of Human Services (DHS) will add requirements to form five RAHCs across the state into the managed care agreements. The RAHCs will be required to collectively develop regional transformation plans, based on community needs assessments, to reduce disparities, address social determinants of health, and align value-based purchasing arrangements.
  • Health Value Commission. The governor will work with the legislature to pass legislation that establishes the Health Value Commission. It will be charged with keeping all payers and providers accountable for health care cost growth, to provide the long-term affordability and sustainability of Pennsylvania’s health care system, and to promote whole-person care. The Health Value Commission would be led by up to 15 commissioners appointed by the governor and the General Assembly who have an expertise in the health care marketplace, including the heads of five state agencies. The commission would establish a statewide health care cost growth benchmark, in addition to spending targets to support primary care, behavioral health, and value-based purchasing. The commission would monitor payor and provider organization performance relative to these benchmarks. Additionally, the commission would perform public interest reviews of large provider organization mergers, acquisitions, corporate affiliations, or changes in ownership across the commonwealth, adding a new layer of transparency for Pennsylvania consumers, businesses, and communities.

A link to the full text of “Pennsylvania Governor’s Executive Order 2020-05 To Establish A Health Care Reform Council” may be found at www.openminds.com/market-intelligence/resources/100220paeohealthreformcouncil.htm.

For more information, contact:

  • Pennsylvania Office of the Governor, 508 Main Capitol Building, Harrisburg, Pennsylvania 17120; 717-787-2500; Fax: 717-772-8284; Website: https://www.governor.pa.gov/

In this presentation, the objectives are to:

  • Review the immune system and understand how it affects physical and mental health
  • Share wellness tips to improve physical and mental health
  • Explore ways to practice wellness

Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

In this presentation, the objectives are to:

  • Behavioral Health Care as an Unmet Need Within Orange County
  • The Need for Screening in Primary Care
  • What to do After Screening
  • Integrated & Collaborative Care Models
  • The Future: Discussion/Question & Answer

Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

Between 2018 and 2019, the number of people in the United States age 12 and older who had a behavioral health disorder rose by 5.9% to 61.2 million. The majority of the rise was due to an increase in mental health disorders. During 2019, about 51.5 million people had a mental health disorder, representing 20.6% of the total civilian, non-institutionalized population age 12 and older. About 19.3% had an addiction disorder, representing 7.7% of the population. Within the two groups, about 9.5 million people had both mental health and addiction disorders, representing about 3.8% of the population.

The prevalence of serious mental illness (SMI) increased among adults ages 18 to 49 between 2018 and 2019, to reach 13.1 million people in 2019, representing 5.9% of the total civilian non-institutionalized population in the age group. The 13.1 million with SMI represented 25.5% of the 51.5 million with a mental health disorder in 2019. Between 2008 and 2019, the prevalence of SMI rose across all age groups.

Change In Prevalence Of Serious Mental Illness From 2008 To 2019
Age Group 2008 Rate 2008 Number 2019 Rate 2019 Number Percent Untreated
18+

3.7%

8.3 million 5.2% 13.1 million

unreported

18 to 25

3.8%

1.2 million 8.6% 2.9 million

43.6%

26 to 49

4.8%

4.8 million 6.8% 6.8 million

34.9%

50+

2.5%

2.3 million 2.9% 3.4 million

unreported

These statistics were reported in the “2019 National Survey on Drug Use and Health” (NSDUH) by the Substance Abuse and Mental Health Services Administration (SAMHSA). Additional findings were as follows:

  • Major depression episodes significantly increased across all age groups under age 50. Major depressive episodes with severe impairment significantly increased in adolescents and young adults between 2018 and 2019. Suicidal thoughts and behaviors significantly increased in young adults and adults aged 26 to 49 between 2009 and 2019.
  • The number of people with opioid use disorder decreased significantly from 2.1 million in 2018 to 1.6 million. Pain reliever misuse decreased significantly from 2018 for those between 12 to 17 years of age and continued trending downward for adults ages 18 to 25 years. Heroin initiation dropped by 57% between 2018 and 2019.
  • The number of adults age 26 and older who reported past month and past year daily marijuana use increased. Past-year marijuana use disorder significantly increased in adolescents.
  • The number of adults age 26 and older using methamphetamine increased. Prescription stimulant misuse declined among adults ages 18 to 25.

SAMHSA published the NSDUH findings in a report. The highlights were featured in a presentation given by Assistant Secretary for Mental Health and Substance Use, Elinore F. McCance-Katz, M.D., Ph.D. The report presents the results of a nationally representative survey about the prevalence of addiction treatment disorders, behavioral health disorders, and the receipt of treatment services among the civilian, non-institutionalized population aged 12 and older. Data were collected via annual interviews from January to December; the sample was composed of approximately 67,500 individuals from all 50 states including the District of Columbia. The report presents statistics on the following topics: initiation of substance use; substance use (alcohol, tobacco, marijuana, cocaine, heroin, hallucinogens, and inhalants, as well as the misuse of opioids, prescription pain relievers, tranquilizers, stimulants, and sedatives); perceived risk from substance use; substance use disorders; mental illness, serious mental illness, and major depressive episode; suicidal thoughts, plans, and non-fatal attempts for adults aged 18 or older; and substance use treatment and mental health service use.

A link to the full text of “Key Substance Use & Mental Health Indicators In The United States: Results From The 2019 National Survey On Drug Use and Health” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/091720nsduh2019keyindicators.htm.

A link to the full text of “Presentation On The 2019 National Survey On Drug Use and Health” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/091720nsduh2019presentation.htm.

OPEN MINDS last reported on this topic in “Opioid Misuse Down 11% From 2017 To 2018,” which published on September 8, 2019. The article is available at https://www.openminds.com/market-intelligence/news/opioid-misuse-down-11-from-2017-to-2018/.

For more information, contact: Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, Maryland 20857; Fax: 240-276-2135; Email: media@samhsa.hhs.gov; Website: https://www.samhsa.gov/

There has long been tension between art and science—and this has been a point of contention in health care as long as we can remember. In the article, When Should A Process Be Art, Not Science? in Harvard Business Review (HBR), the authors define art as “judgment-based work,” with variability in the process, which is valued when all customers don’t want the product or service to perform the same way. Science is about reducing variability and “creating complex rules that spell out exactly what to do in every possible circumstance….” They argue that artistic and scientific approaches need not be at odds but must be carefully harmonized.

As we move more populations and more services to managed care models of financing and service delivery, understanding how to make the art and science work together is critical. There is a need to standardize processes to support the work of clinical professionals and the operational infrastructure of provider organizations while allowing clinical judgment to thrive. Interestingly, the authors of the HBR article say that the key to managing “artistry” is performance metrics. “An artistic process has to rely on external measures of success. Artists need continual exposure to customer feedback, which prevents them from constructing their own idiosyncratic notion of quality.”

But in value-based contracts now, there are few standardized performance measures and even fewer benchmarks. The question is how to bring in the standardization we need for cost control but allow the clinical judgement that is essential for better consumer outcomes. This issue was front and center in our recent session, Navigating Health Plans: Keys To Developing Long Term Relationships, at the 2020 OPEN MINDS Management Best Practices Institute. Three payer executives—Katherine Hobbs Knutson, MD, MPH., Senior Vice President, United Health Group and Chief Executive Officer, Optum Behavioral Care; Ann O’Grady, Senior Vice President and Chief Clinical Officer, New Directions Behavioral Health; and Robert Ciaverelli, MD, Behavioral Health Medical Director, CareFirst—along with George Kolodner, MD, Founder and Chief Innovtion Officer, Kolmac Outpatient Recovery—debated the art vs. science dimension on three critical elements of payer-provider relationships—goal setting, performance measures, and communication.

Alignment On Goals

Dr. Ciaverelli pointed out that we are still in a “supply drain situation,” where there is increasing demand and inadequate supply of behavioral health services (especially on the outpatient side). So, the payer’s first goal is to give consumers what they need when they need it by expanding network access. And growing that network needs more than “a list of names in the phone book,” he said. It requires knowing provider organizations and having relationships with them, enticing them with better rates, and ensuring that they will get the payer’s consumers “at the front of the line.” He added, “I became the center of trying to recruit provider organizations into our network and having them grow, in terms of reach and geography. It is a win-win situation as payers and providers both want to grow. It takes a bit of desperation and wanting to do things differently.”

Dr. Hobbs Knutson admitted that fee-for-service structure has created a major lack of alignment on goals for payers. “We reimburse providers at higher rates for facility-based and residential care when we know the most effective care is out in the community—outside high-cost, restrictive locations. We don’t have enough access to outpatient settings, the quality of treatment is questionable, and costs are high.” The goal, she said, is to align the whole system and deliver the most effective clinical care in the most convenient location (in the community). “We get better results when we marry the priorities of people getting better with cost savings.” Provider organizations should consider alternative payment models to align on incentives, Dr. Hobbs Knutson suggested. “Practice has the risk of being shaped by payments. Provider organizations and payers must align to drive payments that support the best clinical practice,” she suggested.

Measures That Matter

Access is always the most critical measure, Ms. O’Grady emphasized. So, payers want to see measures such as time between when a consumer calls and the first appointment, especially for substance use. “Ten to twelve days later no longer works,” she said.

With access becoming increasingly important, Dr. Ciaverelli predicted that we’ll see payers moving to more “open table” type of scheduling where they allow consumers to scan (via apps and online) across the network for the earliest appointment they can get with a provider organization that offers the services they are seeking. And payers will give preference to provider organizations that offer blocks of appointments for open table scheduling.

In addition to access, payers are looking for measures that are recovery and outcomes focused, reiterated Dr. Hobbs Knutson. “We need genuine cost measures—such as reduction in emergency department visits and inpatient admissions—and need to know how they were driven by specific interventions that are evidence-based. There are lots of not so great measures out there. We get a lot of pre-post comparisons where the reasons for cost reduction are not clear,” she said. She offered a couple of examples of good measures. For a co-occurring disorders program offering prevention, education, and Screening Brief Intervention and Therapy (SBIRT), it would be important to measure how many people complete the screening, how many people who screen positive are engaged in treatment, and how many complete treatment. For evidence-based programs it is also good to extrapolate long-term health and cost outcomes, such as “when treatment is completed, the recovery rate is xx%.”

From the provider organization perspective, measurement has always been a “less comfortable area of collaboration,” in Dr. Kolodner’s opinion. But provider organizations need to be proactive and creative even if there are no defined measures. For instance, Kolmac has been measuring outcomes for the 250 consumers they’ve treated primarily through telehealth so that if telehealth relaxations are removed post-pandemic, they will be able to go to payers with evidence about why that’s not a great idea. “We know that with telehealth, 90% of consumers are completing withdrawal management and 80% are moving into follow-up treatment. And when we compare that with the decades of data we have on in-person care, we know that telehealth has the same efficacy.”

Dr. Ciaverelli—leaning more toward art than science—said, “It doesn’t matter what you are measuring as long as you can show what happened over time. Consumer self-reports are important. We want to know how they are they progressing.”

Communication & Problem-Solving

Provider organizations and payers need to have continuous dialogue, especially when there is disagreement. Ms. O’Grady noted that provider organizations may be clear on where they want to go with their programs but must stop to ask payers what they need. “Payers know where we need to improve access, we know what specialty services we need, we’re looking at data and trends to identify hot spots and needs by service or geographic area. It’s important for providers to reap the benefits of the great data payers have.” She also encouraged provider organizations to continue the conversation with payers if they are not hearing what they want to hear. “Don’t try to do end runs,” she urged.

Dr. Kolodner has the principle of “Don’t let payer treat the patient. It’s hard to dictate ‘You have 18 intensive outpatient sessions, do what you can.’ If I find that my own staff are ready to discharge a consumer who is not ready for discharge simply because their insurance has run out, I tell them the insurance company can decide what they pay, not when we discharge consumers.” If provider organizations focus on doing quality work, they can go to payers with the evidence and make the case, he suggested. And he added that it’s important to build relationships with the clinical leaders in the payer organizations as they can help those on the administrative side make better decisions based on treatment efficacy.

For provider organization executives, the implications are clear—get ready for value-based reimbursement, focus on evidence-based clinical practices, build relationships with payers, listen and align, and innovate. Helping consumers get better will continue to be an art and a science. But it’s important to show how you are moving the needle, so demonstrating outcome measures takes top priority.

On September 24, 2020, a federal district court judge denied class action status to a lawsuit filed by people in custody of the U.S. Immigration and Customs Enforcement’s (ICE) who sought release to avoid infection with coronavirus disease 2019 (COVID-19). The detainees are held in three county correctional facilities in central Pennsylvania: Clinton County Correctional Facility (CCCF), Pike County Correctional Facility (PCCF), and York County Prison (YCP). The petitioners alleged that they have health conditions putting them at high risk for more severe COVID-19 complications.

Class-action status was denied because the petitioners’ claims were not similar enough to move forward as a group. The judge noted that the petitioners as a group alleged having more than 30 health conditions, and the three facilities each have different cleaning and safety protocols. As a result, the court might have been required to certify more than 90 subclasses, without counting those petitioners with multiple health conditions.

The complaint, Thakker et al. v. Doll et al., was filed against ICE on March 24, 2020, by the American Civil Liberties Union (ACLU) of Pennsylvania, the ACLU Immigrants’ Rights Project and National Prison Project, and the law firm Dechert LLP, on behalf of 13 people in immigration detention who are at high risk of severe COVID-19 complications. The petitioners alleged that the conditions of confinement for these individuals violated their constitutional rights.

The court initially granted the motion for a temporary restraining order (TRO) and ordered that the individual petitioners be released from detention on March 31, 2020. On April 13, 2020, the TRO was extended for 14 days. On April 17, 2020, the petitioners amended their complaint to include new individual petitioners and to add class allegations, to which they appended several new declarations and exhibits. The same day the petitioners filed a motion for class certification and appointment of class counsel. On April 27, 2020, the district court issued an order granting in part ACLU-PA’s motion for a preliminary injunction and denying it in part. Plaintiffs who had been detained at PCCF could remain free, but those at YCP and CCCF were to return to detention. Those ordered to return filed a motion for a stay and reconsideration, and on April 28, 2020, the court allowed those who were sick to remain free but ordered those without symptoms to return to detention.

As of August 7, 2020, YCP housed 63 ICE detainees on the chronic care list for medical conditions listed by the Centers for Disease Control and Prevention (CDC) as associated with higher risk for COVID-19 complications. CCCF housed 37 detainees on the same list, and PCCF housed 12 such detainees.

A link to the full text of “U.S. District Court For The Middle District Of PA: Decision On Thakker et al. v. Doll et al.” may be found at www.openminds.com/market-intelligence/resources/092420thakkervdolldecision.htm.

PsychU last reported on this topic in “CDC Names Seven Conditions Most At Risk For Coronavirus; Age No Longer Considered A Risk Factor,” which published on August 10, 2020. The article is available at https://www.psychu.org/cdc-names-seven-conditions-most-at-risk-for-coronavirus-age-no-longer-considered-a-risk-factor/.

For more information, contact:

  • Harrisburg Office, American Civil Liberties Union of Pennsylvania, Post Office Box 11761, Harrisburg, Pennsylvania 17108; 717-238-2258; Email: hbginfo@aclupa.org; Website: https://www.aclupa.org
  • Clair Doll, Warden, York County Prison, 3400 Concord Road, York, Pennsylvania 17402-9007; 717-840-7580; Email: crdoll@yorkcountypa.gov; Website: https://yorkcountypa.gov/courts-criminal-justice/prison.html

To monitor the success of integrating behavioral health benefits into its Medicaid managed care system, the Washington Health Care Authority (HCA) established an “early warning system” (EWS) to monitor the access and outcomes for the first six months after the regional Medicaid managed care organization (MCO) contracts went live. The EWS was designed to be a communication tool to monitor key indicators selected by regional stakeholders. HCA began using the EWS in 2016 when the first region for fully integrated managed care launched in the Southwest Region. As each region went live, HCA established the EWS with regional stakeholders; HCA collected and reported on a set of standard indicators, and the regions could track additional measures. The last three regions (Salish, Thurston-Mason, and Great Rivers) transitioned to integrated managed care effective January 1, 2020, and EWS monitoring continued through June 30, 2020.

The EWS used the following standard indicators:

  • Behavioral health claim/encounter rejection and denial rates.
  • Behavioral health provider organization survey responses.
  • State psychiatric hospital average daily census and discharges.
  • Crisis system volume and response in terms of the number of incoming calls to the regional crisis hotline, the number of calls answered, the share answered within 30 seconds, the average response speed, and the abandonment rate.
  • Response times of designated crisis responders.
  • The number of investigations under the Involuntary Treatment Act and the outcomes of the investigations.

The EWS data is used to give the regional stakeholders data to identify and correct problems in the early phase of implementation. After the initial implementation phase, HCA partners with the Department of Social and Health Services Research and Data Analysis (RDA) Division to do ongoing evaluation and monitoring. This evaluation approach leverages tools commonly used to assess relative health plan performance, such as HEDIS (Healthcare Effectiveness Data and Information Set) and state-developed HEDIS-like measures. In early 2019, HCA reported on the first-year outcomes in the first region to go live with integrated care. In the report, “Evaluation Of Integrated Managed Care for Medicaid Beneficiaries In Southwest Washington: First Year Outcomes,” the RDA researchers examined changes in a broad set of health care performance and social outcome metrics in the first year after implementation of the model relative to beneficiary experience in the prior year.

In 2015, HCA began transitioning from a 10-region system with county-centered behavioral health care authorities to a system in which the regional Medicaid MCOs manage physical and behavioral health services for all Medicaid beneficiaries. As of July 2020, the integrated MCO contracts had been implemented statewide. In each region, the EWS was implemented one month after the MCO contracts went live. The MCO contractors are: Amerigroup; Community Health Plan of Washington; Coordinated Care of Washington; Molina Healthcare of Washington, Inc.; and UnitedHealthcare Community Plan. Each region has a choice of at least three MCOs. Crisis services and non-Medicaid behavioral health services for each region are managed by the Behavioral Health Administrative Service Organization (BH-ASO) for the region.

HCA also discussed the transitions in a June 30, 2020, report to the legislature, “Enhancement for Community Based Behavioral Health Services.” In this report, HCA presented metrics and outcomes about the transition to integrate behavioral health into Medicaid managed care. The report was required by a bill passed in 2018 that provided funding of nearly $70 million to help behavioral health provider organizations enhance local community-based behavioral health services. About 80% of the funding was built into the Medicaid per member per month payments to the MCOs. About 20% went to behavioral health organizations in areas that had not been integrated at that time, and to the BH-ASOs in the fully integrated regions.

The funding was to be used for the following:

  • Reduce the use of long-term commitment beds by placing individuals within communities.
  • Transition individuals out of state hospitals when they no longer require inpatient psychiatric treatment.
  • Improve the ability of community behavioral health agencies to recruit and retain staff.
  • Divert individuals with behavioral health issues from the criminal justice system.
  • Improve recovery service options, which includes clubhouse models.

A link to the full text of “Evaluation Of Integrated Managed Care for Medicaid Beneficiaries In Southwest Washington: First Year Outcomes” may be found at www.openminds.com/market-intelligence/resources/012419evalswwaintegratedfirstyear.htm.

A link to the full text of “Washington HCA Report To The Legislature: Enhancement For Community Based Behavioral Health Services” may be found at www.openminds.com/market-intelligence/resources/063020wahcabhenhancement.htm.

OPEN MINDS last reported on this topic in “Washington Medicaid Moving To Integrated Care,” which published on April 11, 2018. The article is available at https://www.psychu.org/washington-medicaid-moving-integrated-care/.

For more information about the EWS, contact:

  • Teresa Claycamp, LMHC, Integrated Managed Care Program Manager, Washington State Health Care Authority, Post Office Box 45502, Olympia, Washington 98504-5502; Email: teresa.claycamp@hca.wa.gov; Website: https://www.hca.wa.gov/contact-hca

For more information about the RDA reports, contact:

  • Division of Behavioral Health and Recovery, Washington Health Authority, Post Office Box 42730; Olympia, Washington 98504; 360-725-2091; Fax: 360-763-4702; Website: https://www.hca.wa.gov/billers-providers-partners/programs-and-services/behavioral-health-and-recovery

On September 24, 2020, United Airlines announced that it would partner with GoHealth Urgent Care and Color to make COVID-19 testing easy to obtain for consumers traveling between San Francisco International airport and Hawaii. Travelers will have the option to take the rapid Abbott ID NOW COVID-19 test either prior to their flight at the airport, or via a self-collected, mail-in test ahead of their trip. These tests will be available beginning October 15, 2020. The California-to-Hawaii testing is the first part of a larger implementation goal of making it easier for travelers to manage quarantine requirements and entry conditions of popular destinations around the world.

United Airlines worked closely with Hawaii officials to ensure that any person traveling between the two destinations, who tests negative on either test, would not be subjected to the Hawaii’s current 14-day quarantine requirement. The rapid Abbott ID NOW COVID-19 test is administered by GoHealth Urgent Care, and their partner Dignity Health. The on-site test provides results in approximately 15 minutes. The mail-in test option will be administered by Color. The mail-in test should be initiated at least 10 days prior to the traveler’s trip, and a sample should be provided within 72 hours of their trip.

United Airlines is a major American airline headquartered in Chicago, Illinois. United operates a large domestic and international route network, spanning several cities across the world.

GoHealth Urgent Care operates approximately 150 urgent care centers. These centers are located in the greater New York metropolitan area, the Portland, Oregon–Vancouver, Washington metropolitan area, the San Francisco Bay Area, Hartford and South Eastern Connecticut, Winston-Salem and Charlotte, North Carolina, St. Louis and Springfield, Missouri, Oklahoma City, Oklahoma, Northwest Arkansas and Delaware.

Color offers distributed health care and clinical testing. Color works with health systems, employers, and national health initiatives around the world,

For more information, contact:

  • Customer Service, United Airlines, Inc., Post Office Box 06649, Chicago, Illinois 60606-0649; 800-864-8331; Website: https://www.united.com/ual/en/us/fly/contact.html
  • GoHealth Urgent Care; 5555 Glenridge Connector, Suite 700, Atlanta, Georgia 30342; 678-774-7100; Website: https://www.gohealthuc.com/
  • Color; 600 7th Street, San Francisco, California 94103; 650-651-7116; Email: support@color.com; Website: https://www.color.com/

Consumers who used a direct scheduling function within a primary care provider organization’s online portal were more likely to obtain visits with their usual primary care professional than consumers who scheduled visits with clinic staff either in-person or over the telephone. The practice of allowing consumers to use an online portal to schedule their own office visits is called “direct scheduling.” Online consumer portals are offered by electronic health record vendors and external health care applications. Compared to usually scheduled visits, the direct scheduled visits were more likely to be for general medical examinations and were more likely to be with the consumer’s usual primary care professional.

The analysis included data for 62,080 consumers and 134,225 completed visits at 17 primary care practices within a large academic medical center. About 8.1% of the consumers used the direct scheduling option between March 2018 and March 2019. Among the direct schedulers, 36.7% made appointments for general medical examinations, compared to 21.9% of visits among those who scheduled through usual means. About 95.2% of the direct schedulers’ appointments were with their usual primary care physicians, compared to 73.5% of appointments for those scheduling through usual means. Across each practice, compared to those who did not use direct scheduling those who did were more likely to be younger, white, commercially insured, and to have more comorbidities.

These findings were reported in “Patient and Visit Characteristics Associated With Use of Direct Scheduling in Primary Care Practices” by Ishani Ganguli, M.D., MPH; E. John Orav, Ph.D.; Claire Lupo, BBA; et al. The researchers analyzed electronic health record (EHR) data from 17 adult primary care practices in a large academic medical center in the Boston, Massachusetts, area. The participants included consumers 18 years or older who were attributed in the EHR to an active primary care physician at one of the included primary care practices, were enrolled in the patient portal, and had at least one visit to one of these practices between March 1, 2018, and March 1, 2019. The goal was to identify consumer and visit characteristics associated with use of the online portal to schedule medical visits.

The full text of “Patient and Visit Characteristics Associated With Use of Direct Scheduling in Primary Care Practices” was published August 27, 2020, by JAMA Network Open. An abstract is available online at https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2769839.

For more information, contact:

  • Ishani Ganguli, M.D., MPH, Assistant Professor, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont Street, 3rdFloor, Boston, Massachusetts 02120; Email: iganguli@bwh.harvard.edu; Website: https://connects.catalyst.harvard.edu/Profiles/display/Person/231

On September 16, 2020, the Department of Labor (DOL) issued a revised temporary rule effective the same day to clarify worker eligibility for emergency paid sick leave to assist working families facing public health emergencies arising out of the coronavirus disease 2019 (COVID-19) global pandemic, and public health emergency leave under Title I of the Family and Medical Leave Act (FMLA). The DOL had issued a temporary rule on April 1, 2020. This revised rule is issued in response to an August 3, 2020, district court decision finding certain portions of that rule invalid because in an exemption for health care workers, the DOL defined “health care provider” so broadly that it included workers “who are not even arguably necessary or relevant to the health care system’s vitality.” The DOL has narrowed it definition to restrict a “health care provider” as someone employed to provide diagnostic services, preventive services, treatment services, or other services that are integrated with and necessary to the provision of care.

Both types of emergency paid leave were created by a time-limited statutory authority established under the Families First Coronavirus Response Act (FFCRA), and both are set to expire on December 31, 2020. The FFCRA and its implementing regulations, including this temporary rule, do not affect the FMLA after December 31, 2020.

The FFCRA was enacted on March 18, 2020. The provisions required job-protected paid sick leave and emergency family leave for employees unable to work due to COVID-19. Up to 61 million employees were estimated to be potentially eligible for paid sick leave or emergency family leave under the FFCRA. The provisions provide for the following:

  • Up to 80 hours of paid sick leave at the employee’s regular rate of pay where the employee is unable to work because the employee is quarantined (pursuant to federal, state, or local government order or advice of a health care provider), and/or experiencing COVID-19 symptoms and seeking a medical diagnosis.
  • Up to 80 hours of paid sick leave at two-thirds the employee’s regular rate of pay because the employee is unable to work because of a bona fide need to care for an individual subject to quarantine, including a child under age 18 whose school or child care placement is closed or unavailable for reasons related to COVID-19.
  • Up to an additional 10 weeks of paid expanded family and medical leave at two-thirds the employee’s regular rate of pay where an employee, who has been employed for at least 30 calendar days, is unable to work due to a bona fide need for leave to care for a child whose school or child care provider is closed or unavailable for reasons related to COVID-19.

A link to the full text of “Paid Leave Under The Families First Coronavirus Response Act” may be found at www.openminds.com/market-intelligence/resources/091620covidpaidleave.htm.

For more information, contact:

  • Amy DeBisschop, Director, Division of Regulations, Legislation, and Interpretation, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue NW, Washington, District of Columbia 20210; 202-693-0406; Website: https://www.dol.gov/agencies/whd/ffcra

In our mapping of the post-pandemic market, one key issue is how health plans will reimburse provider organizations in the year ahead. Anecdotally, we’re seeing more health plan managers looking for provider organizations that can accept value-based reimbursement (VBR) arrangements—particularly arrangements with financial risk. And that makes sense from a macro market perspective. Most analysts predict decreased funding by payers —both government and employers— following the pandemic, and risk-based financial arrangements with provider organizations are one way to align incentives.

A recent market event confirms this general direction and should be incorporated in the 2021 planning of any provider organization that has moved consumer services to telehealth. On September 3, 2020, the Medicare Payment Advisory Commission (MedPAC) met and discussed Medicare telehealth reimbursement policy after the pandemic. The concern cited (common among all payers) was that unlimited and open use of telehealth services has the potential to increase spending under a fee-for-service payment system. A proposed policy under discussion is to permit provider organizations and clinical professionals participating in advanced alternative payment models (APMs)—such as accountable care organizations, episode-based payment models, and primary care focused models—to continue to benefit from telehealth expansions. But for the fee-for-service plan, Medicare would revert to the pre-pandemic rules. MedPAC noted, “Also, the Commission has long supported the movement of Medicare payment policy from fee-for-service to value-based payment such as advanced APMs. Allowing clinicians who participate in advanced APMs more flexibility to provide telehealth services could be another incentive for more clinicians to move into these models.”

Many think this is a likely path for Medicare reimbursement policy, and this policy is likely to be adopted by other payers and health plans as well. This development gives even more credence to the statement made by OPEN MINDS, Senior Associate, Paul Duck, at the session, How To Build Value-Based Payer Partnerships: Best Practices in Marketing, Negotiating & Contracting With Health Plans, during the 2020 OPEN MINDS Management Best Practices Institute. He said, “In the next 10 years, all payer contracts will be value based and all specialty provider organizations will be part of a risk-bearing entity.”

So where are we with value-based reimbursement? From our survey earlier this year, we learned that 58% of specialty provider organizations are participating in value-based arrangements. Of these, 42% participate in a pay-for-performance arrangement with fee-for-service, 22% in capitation for specific services, 18% in capitation for care coordination, and 24% in case or bundled rates. The same survey found that 15% of organizations had more than 20% of their revenue from VBR contracts. Our earlier survey of health plans found that 93% of health plans—including commercial plans, Medicaid, and Medicare—have implemented pay-for-performance reimbursement models. In addition, the use of episodic or bundled payments for specific acute care episodes is gaining traction, with 59% of plans using this model. While only 40% of commercial health plans use episodic payments, 71% of Medicare and 88% of Medicaid health plans use these payment arrangements for behavioral health.

And a just released report shows the continuation of this trend. VBR contracts now account for 26% of hospital revenue. The report notes that growth has been slow and the biggest factors limiting the adoption of VBR are uncertainty that there will be a return on investment and a lack of needed infrastructure.

How do provider organizations overcome their challenges and align to payer priorities? Mr. Duck suggested a focus on three elements—capitalization, population, and information. Invest in infrastructure and technologies; assume accountability for the whole health of the population you serve; and ensure that your team has the data to optimize consumer health outcomes.

The infrastructure issues are significant. There is the technology piece—care management and population health management technology, more robust analytics, network management/claims payment functionality, interoperability, consumer portals, consumer engagement capabilities, remote patient monitoring technologies, and more. But there is also the development of the organizational structure, policies and procedures, and managers with the skillsets to manage programs with downside financial risk.

On the population health side, service delivery systems and clinical programs need to be restructured in many ways. Reward for performance rather than service volume is a key piece. Building continuity of care between separate levels of care. Adopting evidence-based practices (EBP) and implementing those EBPs in a consistent way. Creating community partnerships for social service referrals. These are all part of the “whole person” approach to consumer health management that is tied to risk-based contracting.

Finally, there is moving the organization to a metrics-based management approach. There is the design of reporting systems with leading indicators and predicted modeling of consumer health conditions and resource needs. But, having the reports and having a management team that can act on the reports to improve performance are different issues.

Accepting and succeeding with some form of risk-based contracting will be increasingly important in the ability of provider organizations to develop more productive relationships with health plans and maintain market share. For executive teams, it is important to track the evolving contracting preferences of the payers in their markets. But I would argue it is also important to push health plans beyond the high-cost, low-return, pay-for-performance fee-for-service arrangements to contracting models with more financial control. It is only the latter that will allow real system transformation at the delivery system level.

President Dwight D. Eisenhower is well known for his presidency, but also known for the Eisenhower Matrix for time management. A broader view of the leadership skills of President Eisenhower has come into sharp focus over the past six months as historians profile his administration—and its parallels to challenges facing leaders today. He signed the Civil Rights Act of 1957 and sent Army troops to enforce federal court orders which integrated schools in Little Rock. He had to deal with Joseph McCarthy. He ended the Korean conflict. And, he warned the nation with regard to the corrupting influence of what he describes as the “military-industrial complex.”

So, when the new book, How Ike Led: The Principles Behind Eisenhower’s Biggest Decisions, came out a few months ago, it was at the top of many reading lists. Monica Oss, Chief Executive Officer, OPEN MINDS, had the opportunity to talk to the book’s author and President Eisenhower’s granddaughter, Susan Eisenhower, about her research and her planned keynote at the 2020 OPEN MINDS Executive Leadership Retreat. Her perspective is that positive outcomes are possible with great leadership. “These are not the most dangerous or difficult times we live in. We have been through much worse—two world wars, the Spanish flu, the Great Depression—and have emerged stronger,” she said.

As Ms. Eisenhower says in her book, “Today, tethered to smartphones and transfixed by Twitter and Instagram, we lurch from one demand to another with scarcely a moment to think. Our impulses are reactive, not considered. They are short-term rather than strategic. We have lost our capacity to act in the present while thinking into the future. We are struggling. I have always been one to look forward. Increasingly, however, it has been impossible for me to do this without looking back—at our nation’s journey since my grandfather’s years. What is profoundly striking is how far we have veered from the guiding principles of those days.”

Looking back, she recounted some instances of the crises and turbulent times through which Ike led. At 27 years of age, he was commander of the Tank Corps at Camp Colt in Gettysburg, Pennsylvania when the 1918 influenza pandemic ravaged the training camp. His plan for controlling the pandemic at Camp Colt helped mitigate the losses and establish health care protocols later adopted by the U.S. Army. He went on to serve as Supreme Commander of the Allied Expeditionary Force in Europe during World War II, leading the D-day invasion. He served two terms as President of the United States from 1953 to 1961.

We asked Ms. Eisenhower how she would describe the characteristics of President Eisenhower’s leadership style through all these crises. Three attributes that she spoke about jumped out at me as what health and human service provider organization executives most need while steering out of today’s crisis—strategic and decisive leadership, extreme accountability, and discipline with compassion.

Strategic & Decisive Leadership

Throughout his military and presidential service, Ike was a strategic rather than an operational leader. “He was a clear thinker who could strip any problem down to its essence, prioritize it, and tackle it from a big picture level,” Ms. Eisenhower told us. Her grandfather, she explained, asked for input and information across the entire enterprise, and then made informed decisions. He also thought of all problems “as human problems, grounded in human needs”—a psychological strategy central to managing controversial decisions.

In her book, Ms. Eisenhower notes that the President’s “talent for envisioning a whole, especially in the context of the long game, may explain why he did not necessarily need combat experience to be a brilliant strategic leader. It is also why he never lost the confidence of his superiors during the conduct of World War II, even if his subordinates groused about some of his decisions—many of which, not surprisingly, related to resource allocation and personal authority. Eisenhower’s subordinates simply did not have the same considerations he did.”

As the nation’s chief strategic leader, Ike “developed a process—a staff system—that would assure the collection of all possible facts and facets of any issue,” described Ms. Eisenhower. As a strategic thinker, his mantra was “Don’t sweat the small stuff” and he avoided “being drawn into second- or third-order issues that should be properly handled at a lower level.”

The President also was not inclined toward “groupthink,” says Ms. Eisenhower and was always questioning why things were done a certain way. She notes in her book that “In many ways, Eisenhower was a futurist, and he bristled at the conclusions people reached without reference to or consideration of changing circumstances that might soon make current thinking outdated.” He questioned his own thinking constantly and encouraged push-back from the “smart people” he liked to surround himself with. “In the White House, Eisenhower would elicit the views of his subordinates, referee their debates, listen for new perspectives, and then make his own decision. He was the supreme decider: the strategic leader.”

Accountability Without Caveats

The first chapter of How Ike Led: The Principles Behind Eisenhower’s Biggest Decisions is titled “Accountability Without Caveats” and Ms. Eisenhower spoke at length about this important guiding principle in Ike’s life. As a “plebe” or freshman at West Point, her grandfather quickly learned that there were four answers to a question or order from his superiors—“Yes sir,” “No sir,” “No excuses, sir” and “I’ll find that information for you, sir.” And he carried that lesson with him. “He even took responsibility for the weather forecast during the largest ever military operation (the Allied invasion of Normandy on June 6, 1944),” remarked Ms. Eisenhower.

Ike’s “in case of failure” note to himself before D-day read, “…The troops, the air and the Navy did all that bravery and devotion to duty could do. If any blame or fault attaches to the attempt, it is mine alone.” His granddaughter notes that “Eisenhower wrote such ‘communiqués’ as much for himself as for any kind of public release, should the worst happen. He was not trying to burnish his reputation in writing it, he was reminding himself, and if necessary, others, that he alone was responsible for the outcome of the mission. It was a personal and public form of accountability.”

The President was morally courageous and embodied the principle of “It starts with each of us before all of us,” said Ms. Eisenhower. He took the blame even when he was not wrong. “Ike had enormous regard for the people who were part of his team. He gave them a lot of latitude, and did not much care if they, not he, got the credit for their accomplishments. He also backed them up to the hilt—even when he did not necessarily agree with the ways they sometimes solved their department’s problems.”

Discipline With Compassion

President Eisenhower was extremely disciplined and never let his emotions take charge. The book explains that “His strength came from balance, and such psychological equilibrium required the melding of humility, determination, and human empathy.”

“As a military officer he was a disciplined, clear thinker, who did not allow himself to get pulled into emotional free-for-alls or make any consequential decisions in a noisy contentious room. Richard Nixon remembered, in fact, that Ike never made an important decision in front of others. He would go into his office alone and think about all he had heard. “[Eisenhower] was an emotional man,” Nixon recalled, “but he never made emotional decisions. He did not let his emotions control him.””

Ike believed in being extremely well prepared, for every situation. His determination to focus on and succeed at even the most mundane tasks stood him in good stead. Ike also constantly encouraged the troops in every situation and exhibited empathy for those at the receiving end of his orders. Ms. Eisenhower recounts that “Discovering the “other side” of Ike has left me, frankly, in awe of how he handled some of the most consequential decisions ever undertaken by a general or a president—all while retaining a genuine capacity for empathy and kindness, which belied or survived the hard and painful decisions he’d been compelled to make. I don’t know how he did it, but I saw firsthand that he never became callous, hard, or cynical.”

And for Ms. Eisenhower herself, it has been a process of developing “resilience through osmosis at the dinner table,” she said. As a Washington policy strategist, many decisions she has made have been influenced by her grandfather’s legacy. He taught her to be creative when the chips are down, to control fear and anxiety, and to seek support in community rather than in singular leadership. “And when you know how it’s been, you know you can ask for more—from our nation’s leadership and from those around you,” she said.

All these facets of Ike’s strategic, accountable, and disciplined leadership resonate with the advice I’ve often shared with health and human service executives, especially since March. Think beyond the immediate crisis. Surround yourself with stellar performers. Gather the facts to make informed decisions. And, always question the status quo—business as usual is a myth in the best of times.

A few weeks ago, we wrote about the need for executive teams to build a culture to keep “high performers” in their organizations—the executives who can do strategy, develop the “next big thing,” make decisions quickly, and nimbly change course. It takes an “enterprising culture” to keep these team members—a culture that thrives on achievement, incentivizes productivity, values talent and intelligence, rewards great ideas, and encourages competition. But keeping the high-performing talent is a challenge in health and human services. The field is highly regulated, and change happens reactively and not proactively. The many comments about this challenge—and best practices for moving organizational culture to focus on performance—were enlightening.

The first big takeaway from these discussions came from Diane Gould, President and Chief Executive Officer, Advocates Inc. Her advice? Acknowledge the power of the existing health and human service culture—and the challenge of culture change. “There is a difference between the culture the CEO may think they have, or maybe want to believe they have, and what’s actually true on the ground in an organization.” She explained, “We found this when bringing new performers in to work alongside other executive and senior leaders who have been here for decades—the clash was painful. The very act of recruiting and hiring these folks bumps up against existing culture—so the question is not just what kind of culture attracts stellar performers, but how does a company navigate the actual transition. More attention to culture, the nature of the culture, and what happens when new leaders join is called for.”

Ms. Gould suggests that leadership teams take a hard look at what attributes of organizational culture they value most; what culture attributes are an asset for the future; and the leadership deficits of the current team—including what they avoid looking at. With that clear-eyed assessment, they can develop a plan to move to the next level. “Is it possible to preserve aspects of culture that have mattered most in relation to mission and values, while being fearless in making the changes required to recruit and retain the best possible people?” she wondered.

Building on Ms. Gould’s comments about brave leadership team self-assessment, Mario Jardon, President and Chief Executive Officer, Citrus Health Network, offers this recommendation to leaders— “Surround yourself with talent.” He said it starts with hiring the best and the most qualified team members, rooting them in the organization’s mission and outlook, and then letting them lead and train others. Citrus is accredited by the Accreditation Council for Graduate Medical Education as a sponsoring institution for the psychiatry residency program in affiliation with Florida International University’s Herbert Wertheim College of Medicine. This helps Citrus build a robust recruitment pipeline and nurture a culture of learning.

To retain the high performers, Mr. Jardon suggests, “You need to…pay well and give them a territory.” Cultures thrive when team members feel they have a stake in the outcomes and are contributing to its success. And Citrus gives executives a stake through its Total Quality Management (TQM) approach. TQM is defined as a management approach to long-term success through customer satisfaction in which all members of an organization participate in improving processes, products, services, and the culture in which they work. A performance improvement council made up of leaders from across the organization meets at least once a month to plan how they will reshape services to respond to current market trends and needs, and solve problems, Mr. Jardon explained. Involvement in how the organization achieves its goals and a strong community connection makes the job fulfilling for high performers, he said.

Debbie Reed, President and Chief Executive Officer of Chaddock, has taken this transition one step further—using the “dual operating strategy” framework developed by management guru John Kotter to move their organizational culture. In this book, Accelerate (XLR8), Dr. Kotter argues that when traditional structures hold back organizations from being creative enough and speedy enough to compete effectively, there is a need for two “operating systems.” One system conducts the everyday business, while the second system is a parallel agile network that focuses on the opportunities and demands of the future. In his model, everyone works within the hierarchy, but innovation and big ideas are assigned to enterprising employees who volunteer for the effort and work on changes across the organization. The hierarchy and the volunteer network work together as one, with constant flow of information and activity. The approach succeeds partly because the people who volunteer for the network are already working within the hierarchy.

Ms. Reed explained how they have leveraged Kotter’s dual operating system at Chaddock. “We pride ourselves on being innovative while at the same time having to accommodate the expectations of funders from multiple states. This framework also allows us to challenge and provide increased levels of autonomy for our strategic thinkers (from all levels of the organization) while providing a sense of stability to the majority of our staff,” she said. She explained that the biggest problem they have is in transitioning new programs from development to operations that are integrated with the rest of the organization. “It can be hard for owners of the program who think of it as their ‘baby’ to let the program be absorbed into the hierarchy. Still, we have found this to be an effective way to foster a culture of innovation even while providing a host of highly regulated programs and services.”

Between 2018 and 2019, Medicaid enrollment dropped by 0.7 percentage points, from 20.5% of the United States population in 2018 to 19.8% in 2019. The number of Medicaid enrollees dropped by 3%, from nearly 66 million in 2018 to 64 million in 2019. During this same time period, the share of the population with Medicare coverage decreased from 18.1% to 17.6%, and the number of Medicare beneficiaries dropped by 2.5%, from more than 58 million to nearly 57 million. The share of the population covered by the Veterans Administration declined from 2.3% to 2.2%. In total, the share of the population covered by publicly funded health insurance programs declined slightly from 35.6% in 2018 to 35.4% in 2019.

Overall, about 91% of the population was covered by public or private health coverage, and the remainder were uninsured. Of those with health coverage, about one-third had public coverage (through Medicaid, Medicare, or the VA) and two-thirds had a private insurance plan.

Among people ages 19 to 64, in 2018 about 18.3% of the 193.3 million in this population were covered by a public health insurance program. In 2019, the number of people in this age group declined to 193.0 million and the share covered by a public health insurance program declined to 17.7%.

Among people with income below 138% of the federal poverty level (FPL), the number declined by 5.3%, from 62.2 million in 2018 to 58.9 million in 2019. The share covered by a public insurance option declined from 64.6% in 2018 to 64.1% in 2019.

These findings were reported in “Health Insurance Coverage In The United States: 2019” by the United States Census Bureau. The report presents statistics on health insurance coverage in the United States based on information collected in the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and the American Community Survey (ACS). It compares health insurance estimates from each source.

A link to the full text of “Health Insurance Coverage In The United States: 2019” may be found at www.openminds.com/market-intelligence/resources/091420healthinsurancecoverage.htm.

For more information, contact:

  • Public Information Office, U.S. Census Bureau, 4600 Silver Hill Road, Washington, District of Columbia 20233; 301-763-3030; Email: pio@census.gov; Website: https://www.census.gov/en.html

 

On September 22, 2020, the Centers for Medicare and Medicaid Services (CMS) announced that it will expand the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. Non-emergency ambulance transportation services are covered under Medicare Part B for Medicare beneficiaries who need to ride in ambulances to certain medical appointments, most often for dialysis treatment. During 2017 and 2018, about 20% of Medicare fee-for-service (FFS) payments for non-emergency ambulance services were improper, at 22.6% in 2017 and 18.6% in 2018. The RSNAT Prior Authorization Model tests whether prior authorization before the service is furnished and before a claim is submitted for payment reduces Medicare costs while maintaining or improving the quality of care.

The RSNAT Prior Authorization Model began in New Jersey, Pennsylvania, and South Carolina in 2014. It expanded in 2016 to North Carolina, Virginia, West Virginia, Maryland, Delaware, and the District of Columbia. The model was initially scheduled to end on December 1, 2020. However, in 2018, based on an initial evaluation, CMS determined that expanding the program nationwide would result in lower Medicare spending, even after accounting for costs of operating the model.

The second model evaluation report released in September 2020 found that the model reduced RSNAT service use by 63% and RSNAT expenditures by 72% among beneficiaries with end stage renal disease and/or severe pressure ulcers during the first four years of the model. This decrease in RSNAT service expenditures caused a total decrease of Medicare FFS expenditures of 2% (about $650 million over four years). The report did not find evidence that the model adversely affected quality of care.

For the expansion, the mode will continue past December 1, 2020, in the current states. The national expansion will follow the same design as the current model. The announcement noted that CMS is continuing to monitor the COVID-19 Public Health Emergency and will take that into account when determining the timeframe for expansion into additional states. CMS will release more information on the national expansion and implementation dates for additional states.

A link to the full text of “Evaluation Of The Medicare Prior Authorization Model For Repetitive Scheduled Non-Emergent Ambulance Transport: Second Interim Evaluation Report” may be found at www.openminds.com/market-intelligence/resources/092220evalrsnat.htm.

A link to the full text of “Certification Of The Medicare Prior Authorization Model For Repetitive Scheduled Non-Emergent Ambulance Transport” may be found at www.openminds.com/market-intelligence/resources/032818priorauthrsnat.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

Over the past decade, the 44 states operating Medicaid Money Follows the Person (MFP) demonstrations from 2008 through the end of 2019 have transitioned more than 101,540 beneficiaries with disabilities from institutional settings to community placements paired with supportive services. The highest number of transitions were reported by Ohio (13,207 transitions) and Texas (13,114 transitions). Maine and South Carolina reported the fewest number of cumulative transitions, at 143 and 157 respectively. As of December 2019, 15 states represented about 78% of cumulative transitions, and the top five states (Connecticut, Ohio, Tennessee, Texas, and Washington) accounted for slightly less than half (45%) of all cumulative transitions.

The MFP launched in 2007 to help states rebalance their Medicaid long-term care systems, and 17 states were among the initial funding cohort. The Patient Protection and Affordable Care Act of 2010 strengthened and expanded the MFP program, allowing more states to apply. The MFP funds are for an enhanced matching rate to cover the cost of transitioning a beneficiary with disabilities from an institutional setting to a community setting, and an enhanced match rate for 12 months of home- and community-based services (HCBS). States awarded MFP funding were permitted to target beneficiaries in specific settings or with specific types of disability, such as frail elderly, individuals with physical disabilities, individuals with intellectual/developmental disability (I/DD), or individuals with serious mental illness (SMI). States are permitted to choose the populations and types of facilities on which to focus their MFP transition efforts.

During calendar year 2019, the 42 states and District of Columbia operating MFP programs transitioned a total of 4,173 Medicaid beneficiaries from institutional settings to community settings and home-and community-based supportive services (HCBS). The number of transitions in 2019 was 46% below the 2018 level of 7,671 transitions. In 2019, about 15 states accounted for 86% of transitions, and five states (Connecticut, New York, Pennsylvania, New Jersey, and Louisiana) accounted for 45% of all transitions. Six of the MFP states (Delaware, Illinois, Kansas, New Hampshire, Tennessee, and Virginia) and the District of Columbia submitted reports but reported zero transitions during 2019. In fact, all but Tennessee said they intended to end their MFP programs in 2020. Within this group of states, during 2018 Delaware, Illinois, Kansas, and New Hampshire reported no transitions. The District of Columbia, Tennessee, and Virginia represented a combined total of 443 transitions in 2018.

During 2019, about three-quarters of transitions involved frail elderly persons (38% of transitions, or 1,603 people) and people with physical disabilities (also 38% of transitions, or 1,568 people). About 12% (497) transitions were among people with I/DD; 5% (333 transitions) were among people with other types of disabilities, and 4% (172 transitions) were among people with SMI. During 2018, about 74% of transitions involved frail elderly and people with physical disabilities; 16% involved people with I/DD; 8% involved people with SMI; and 2% of people with other types of disabilities.

The highest number of I/DD transitions were in Washington (85), New Jersey (75), Texas (74), and North Carolina (70). The next highest state was Louisiana (31). The states with the highest percentage of I/DD transitions as part of the total were:

  • Texas, where its 74 I/DD transitions represented 51% of the total 146 transitions.
  • North Carolina, where its 70 transitions represented 47% of the total 148 transitions.
  • Washington, where its 85 transitions represented 37% of the total 323 transitions.
  • New Jersey, where its 75 transitions represented 26% of the total 291 transitions.

The highest number of SMI transitions were in Connecticut (77), Ohio (65), and Georgia (13); the next highest state was Colorado (7). The states with the highest number of SMI transitions as part of the state’s total transitions were:

  • Ohio, where its 65 transitions represented 29% of the total 222 transitions.
  • Connecticut, where its 77 transitions represented 15% of the total 502 transitions.
  • Colorado, where its 7 transitions represented 7% of the total 104 transitions.
  • Georgia, where its 13 transitions represented 6% of the total 216 transitions.

These findings were reported in “Money Follows the Person: State Transitions as of December 31, 2019” by Kristie Liao and Victoria Peebles for the Centers for Medicare & Medicaid Services (CMS). The report was released in August 2020.

A link to the full text of “Money Follows the Person: State Transitions as of December 31, 2019” may be found at www.openminds.com/market-intelligence/resources/081120moneyfollowsperson1219.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

So, the Presidential debate September 29th, 2020 was full of surprises—no need to say more. But we learned a new term—the “K-shaped recovery.” The more we learned, the more it became obvious that this is a concept with big implications for any organization serving consumers with complex support needs.

So, what is the K-shaped recovery curve? When we talk about economic recovery after a crisis in terms of letters—V, U, L—we are referring to the speed of the recovery. Rapid recovery with sharp decline and sharp return, sharp decline with a period of stagnation followed by a rapid rise, and sharp decline followed by lingering economic stagnation, respectively. But what all of these descriptors assume is that the entire economy recovers at once. In a K-shaped recovery, different parts of the economy recover at different times. The challenge is that a K-shaped recovery from the current crisis would serve to reinforce the already uneven economic situation of different sociodemographic groups. Essentially, a K-shaped recovery would deepen the divide between the “haves” and the “have-nots.”

Right now, the stock market has recovered largely due to the Federal Reserve Bank keeping interest rates near zero and buying an unprecedented amount of corporate bonds. While a little over 50% of households own some stock, 84% of stocks are owned by 10% of the population. But beyond the stock market, the rest of the economy—overall employment, the flow of goods and services, and the gross domestic product—is down. Some industry sectors—like general merchandise retail, online retail, and technology-enabled services—have had a tremendous boom. Other sectors like travel and tourism, entertainment, clothing. retail, and restaurants have seen a bust.

Bloomberg columnist, Barry Ritholtz, describes it, “Once a nation of ‘Haves’ and ‘Have Nots,’ we are now a nation of ‘Haves,’ ‘Have Nots,’ and ‘Have Much More.’ The last category has left the first two in the dust.” The K-shaped recovery theory is that about a third of the economy will recover rapidly, while the rest will have a slow return with lingering unemployment.

The workers in the most negatively affected sectors are low-wage workers and more likely to be women, mothers with school-age children, Black, Hispanic, and/or without college degrees. And the worst is yet to come for these workers.  Thousands of layoffs will soon be announced—at Disney, American Airlines, United Airlines, Marriott, Hilton, Uber, and Kohls to name a few. The economic situation caused by this public health crisis is also speeding automation. Hotels, hospitals, airports, public transport, and health care entities are increasingly using robots for cleaning and other tasks. For example, the Pennsylvania Turnpike laid off 500 employees after it went with cashless tollbooths.

So, what does this have to do with serving consumers with complex support needs? The situation coming is created by the domino effect, with one event setting off a chain reaction. First, consumers most likely to be at the bottom of the K-shaped recovery have higher-than-average incidence of chronic conditions—the conditions that have a higher mortality rate from COVID. These are the same consumers who are more likely to be uninsured and/or to have limited resources for private payment for health care services.

At the same time, with the economic effects of the pandemic, we are unlikely to see government social service spending keep pace with the new level of need. In fact, social service spending in the United States has declined in real terms over the past decade. Spending on supports like income, nutrition, and housing assistance—adjusted for inflation—dropped 11% per capita, from $885 per person in 2009 to $786 in 2018.

And these two factors—more consumers with chronic conditions in dire financial situations with limited social service supports—are occurring at a time when provider organizations are going to be increasingly accepting value-based contracts with downside financial risk. With the well-documented link between social factors and health care costs, this puts provider organizations in a position of needing to provide social supports for the consumers they serve in order to “balance the books” on value-based reimbursement.

How to approach this challenge? The solution would depend on the characteristics of the consumer population and the financial risk parameters of the contract. One constant is the need to invest in the data systems that allow an understanding of the relationship between consumer health status, consumer social service needs, and consumer health care spending patterns. This allows organizations to adopt an integrated “whole life” approach to consumer care coordination. Another element is consumer engagement in managing their chronic conditions. There is the need to use technology of all types to gain efficiencies and leverage the reach of your service team. For non-profits, there is the need to rethink the criteria currently in use for allocating charitable services. But as the field moves ahead with more value-based reimbursement, with financial risk for provider reimbursement, the possibility of a K-shaped recovery is a factor to incorporate in long-term population health planning.

Florida is planning to remove low-priority consumers from its Medicaid waitlist for long-term care waiver services, as called for by House Bill No. 1373, which went into effect on July 1, 2020. The legislation directed the Florida Department of Elder Affairs (DOEA), which maintains the waiver waitlist, to include only those consumers screened as high risk of nursing home placement. On September 17, 2020, the Florida Agency for Health Care Administration (AHCA) began developing proposed rules to implement House Bill No. 1373. The laws is expected to reduce the number of people on the waitlist from the current 59,259 to 1,562.

Currently, all applicants who completed the long-term care screening process were entitled to written notice from DOEA informing them of their waitlist placement. That notice also included contact information for the Aging and Disability Resource Centers (ADRC), instructions for requesting an administrative fair hearing, instructions for requesting a copy of the completed screening tool and the priority score, and instructions for requesting a rescreening in the event of a significant change in condition.

Under the new law, individuals with low-priority risk scores will not be added to the waitlist, and the DOEA will not send a notice. Instead, the DOEA will maintain contact information for each individual with low priority score for purposes of any future rescreening. ARDC personnel shall inform individuals with low priority scores about community resources available to assist them and inform them that they may contact the ARDC for a new assessment at any time if they experience a change in circumstances. The law did not include a definition of “low priority.” However, a draft proposal is in development in which AHCA will define the “low priority” cut level.

A link to the full text of “Florida Legislature Committee Substitute for House Bill No. 1373” may be found at www.openminds.com/market-intelligence/resources/062220fllsubhb1373.htm.

AHCA’s progress on developing the proposed rules can be followed at https://www.flrules.org/gateway/ruleno.asp?id=59G-4.193.

For more information, contact:

  • Mallory McManus, Communications Director, Florida Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee, Florida 32308; 850-412-3623; Email: AHCACommunications@ahca.myflorida.com; Website: http://ahca.myflorida.com
  • Rebecca Roberts, Spokesperson, Florida Department of Elder Affairs, 4040 Esplanade Way, Tallahassee, Florida 32399-7000; 850-414-2000; Fax: 850-414-2004; Email: information@elderaffairs.org; Website: http://elderaffairs.state.fl.us/

The COVID-19 pandemic has disrupted the health and human service landscape – and with it, the behavioral health delivery system. As part of their on-going commitment to the field, Otsuka America Pharmaceutical, Inc. commissioned an update to its acclaimed publication, the Trends in Behavioral Health Guide, Second Edition (The Guide) that was released in 2019. This new publication, Trends in Behavioral Health: A 2020 Update on the US Behavioral Health Financing and Delivery System (Trends in Behavioral Health 2020 Update), was released and is available for download free of charge on PsychU.org.

This new analysis of how the behavioral health field has changed as a result of the pandemic found several major shifts in financing and delivery including:

  • Positioning for new methods of digital service delivery and telehealth
  • New reimbursement models
  • Rapid consolidation
  • Increasing importance of social determinants of health
  • Challenges of dealing with the shift from fee-for-service to value-based payment

This important update represents the very latest impacts on the U.S. financing and delivery system and will inform and educate providers, payers, and all those serving the health and human services market. It is a compelling must-read that reaches beyond the pandemic and discusses the major trends and their related shifts to the behavioral health financing and care delivery system. Many of those trends were first presented and explained in The Guide but have further accelerated throughout 2020. Crucial topics covered in detail in The Guide include:

  • Accountability, integration, and risk
  • Managed care organization consolidation
  • Continued growth in accountable care organizations
  • Mergers, acquisitions, affiliations, and failures
  • Entrance of non-traditional players in the market
  • Emergence of virtual health plans
  • Bundled payments and new payment models
  • New integrated care models emerging for value-based care
  • Provider organizations and partnerships
  • Social determinants of health
  • Improving access to care

With the sweeping changes in the market landscape, the Trends in Behavioral Health 2020 Update provides decision-makers a timely update that is certain to provide key market intelligence to inform strategic planning in the upcoming year.

On September 4, 2020, the Centers for Disease Control and Prevention (CDC) released interim technical guidance on rapid antigen testing for coronavirus disease 2019 (COVID-19) during the pandemic. Antigen tests can be used at the point-of-care; the currently authorized devices return results in about 15 minutes. Antigen tests for COVID-19 are generally less sensitive than viral tests that detect nucleic acid. Rapid antigen tests can be used for screening testing in high-risk congregate settings in which repeat testing could quickly identify persons with a COVID-19 infection to inform infection prevention and control measures, thus preventing transmission.

The possible uses for rapid antigen testing include testing for diagnosis, screening, or surveillance. The definitions are as follows:

  • Diagnostic testing COVID-19 is intended to identify current infection in individuals and is performed when a person has signs or symptoms consistent with COVID-19, or when a person is asymptomatic but has recent known or suspected exposure to COVID-19. Serial antigen testing within a closed congregate setting, such as a long-term care facility or a correctional facility, could quickly identify someone with a COVID-19 infection and prevent further transmission.
  • Screening testing for COVID-19 is intended to identify infected persons who are asymptomatic and without known or suspected exposure to COVID-19. When used for screening testing in congregate settings, test results for COVID-19 should be considered presumptive. A follow-up nucleic acid test may not be necessary when the pre-test probability is high, especially if the person is symptomatic or has a known exposure. When the pretest probability is low, those persons who receive a positive antigen test should isolate until they can be confirmed by a follow-up diagnostic test.
  • Surveillance testing for COVID-19 is intended to monitor for a community- or population-level infection and disease, or to characterize the incidence and prevalence of disease. Surveillance testing is used to gain information at a population level, rather than an individual level, and results of surveillance testing are only returned in aggregate to the requesting institution.

The guidance is intended for clinical professionals who order antigen tests, receive antigen test results, and/or perform point-of-care testing, as well as for laboratory professionals who perform antigen testing in a laboratory setting or at the point of care and report those results. This guidance applies to all uses of antigen tests and is not specific to any particular age group or setting.

A link to the full text of “CDC Interim Guidance For Rapid Antigen Testing For COVID-19” may be found at www.openminds.com/market-intelligence/resources/090420covidantigenguidance.htm.

For more information, contact:

  • Coronavirus Disease 2019, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia 30329; 800-232-4636; Email: cdcinfo@cdc.gov: Website: https://www.cdc.gov/coronavirus/2019-nCoV/index.html

Utah recently revised its crisis standards of care (CSC) to ensure that the criteria do not discriminate against persons on the basis of age and disability. The revise was required by the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS), which had received complaints about Utah’s standards. On August 20, 2020, OCR announced it had reached an agreement with the state about the revised criteria.

OCR had received a complaint from the Disability Law Center alleging that provisions of the 2018 Utah CSC guidelines and its 2020 Annex discriminate based on disability. The complaint alleged that Utah’s guidelines unlawfully disqualify persons with advanced neuromuscular disease, dementia, cystic fibrosis, and other disabilities requiring assistance with daily living from receiving lifesaving care during a public health emergency. The complaint also alleged that the guidelines rely on assessment tools that deprioritize people with disabilities for conditions unrelated to their ability to survive coronavirus disease 2019 (COVID-19).

OCR enforces a number of federal antidiscrimination laws, including Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disabilities Act, Section 1557 of the Patient Protection and Affordable Care Act, and conscience and religious freedom laws. After OCR provided technical assistance to Utah, the state chose to update its CSC plan to:

  • Remove prior language permitting the use of a consumer’s long-term life expectancy as a factor in the allocation and re-allocation of scarce medical resources and instruct provider organizations to remove such factors from existing provider organization CSC plans.
  • Remove categorical exclusion criteria on the basis of age, disability, and functional impairment, instead requiring an individualized assessment based on the best available objective medical evidence.
  • Rescind resource-intensity and duration of need as criteria for the allocation or re-allocation of scarce medical resources and instruct provider organizations to remove such factors from existing provider CSC plans. This protects consumers who require additional treatment resources due to their age or disability from being given a lower priority to receive lifesaving care due to such need.
  • Add language stating that reasonable modifications to the use of the state’s primary instrument for assessing likelihood of short-term survival should be made when necessary for accurate use with consumers with underlying disabilities. Such reasonable modifications ensure that people with disabilities are evaluated based on their actual mortality risk, not disability-related characteristics unrelated to their likelihood of survival.
  • Incorporate new protections against provider organizations “steering” consumers into agreeing to the withdrawal or withholding of life-sustaining treatment, clarifying that consumers may not be pressured to make particular advanced care planning decisions, must be given information on the full scope of available alternatives, and that provider organizations may not impose blanket “Do Not Resuscitate” policies for reasons of resource constraint or require consumers to consent to a particular advanced care planning decision in order to continue to receive services from a facility.
  • Incorporate language stating that hospitals should not seize and re-allocate personal ventilators brought by a consumer to an acute care facility to continue pre-existing personal use with respect to a disability. Under this language, long-term ventilator users will be protected from having a ventilator they take with them into a hospital setting taken from them to be given to someone else.

OCR closed the complaint as satisfactorily resolved without any finding of liability. This is OCR’s seventh resolution regarding discrimination concerns during COVID-19.

A link to the full text of “Utah Crisis Standards of Care Guidelines” may be found at www.openminds.com/market-intelligence/resources/081320utahcrisisguidelines.htm.

For more information, contact:

  • Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue Southwest, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov; Website: https://www.hhs.gov/ocr/index.html

Approximately 62% of United States physicians reported a reduction in income during the coronavirus disease 2019 (COVID-19) pandemic, according to a survey of more than 5,000 physicians. Of those who reported income reductions, about 25% said their income dropped by more than 50% during the pandemic; 28% said their income dropped by 26% to 50%; and 33% said their income dropped by 11% to 25%. About 15% said their income dropped by 1% to 10%.

In addition to asking how the COVID-19 pandemic affected income, the survey also asked about burnout and changes to stress relief behaviors. Nearly 65% said their burnout had gotten more intense during COVID-19, while 6% said their burnout had gotten less intense, and 30% said there had been no change. Approximately 33% of physicians said they were exercising more, while 31% said they were exercising less during COVID-19. Approximately 29% said they were eating more than they did before COVID-19. Approximately 19% of physicians said they were drinking alcohol more during COVID-19, and 19% said they were drinking alcohol less often. About 20% said they were using prescription stimulants or medications less during COVID-19, compared to 2% who said they were using them more.

These findings were presented in “2020 Physician COVID Experience,” by researchers for Medscape. From June 9, 2020, to July 20, 2020, the researchers surveyed more than 7,400 physician Medscape members in the United States, the United Kingdom, France, Germany, Spain, Brazil, Portugal, and Mexico. More than 5,000 of the respondents were from the U.S. The goal was to determine the impact of COVID-19 on physicians’ personal and professional lives.

The full text of “2020 Physician COVID Experience” was published in September 2020 by Medscape. The full report can be downloaded at https://www.medscape.com/slideshow/2020-physician-covid-experience-6013151#1.

For more information, contact:

  • Christine Weibe, Senior Director, Features Content, Medscape, 825 8thAvenue, New York, New York 10019; 212-301-6700; Website: https://www.medscape.com/

During 2019, about 8.0% of the civilian non-institutionalized population was uninsured, representing 26.1 million people who lacked health insurance at any point during the year. Between 2018 and 2019, the percentage of people without health insurance coverage decreased in one state and increased in 19 states. Across the states, the uninsured rate in 2019 in Medicaid expansion states ranged from 3.0% to 12.2%. In non-expansion states, the uninsured rate ranged 5.7% to 18.4%.

Of the 92% with health insurance, 68.0% had a private plan and 34.1% had public coverage. Additional details were as follows:

  • Private coverage: About 56.4% had employment-based coverage, 10.2% had an individual plan, and 2.6% had TRICARE.
  • Public coverage: About 18.1% were enrolled in Medicare, and 17.2% were enrolled in Medicaid; another 1.0% had coverage through the Veterans Administration and CHAMPVA.

The share of uninsured children (age 19 and under) rose from 5.2% in 2018 to 5.7% in 2019. The share of uninsured children in Medicaid expansion states rose from 3.8% to 4.2%. In non-expansion states, the share of uninsured children rose from 7.3% to 8.1%.

These findings were reported in “Health Insurance Coverage In The United States: 2019” by the United States Census Bureau. The report presents statistics on health insurance coverage in the United States based on information collected in the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and the American Community Survey (ACS). It compares health insurance estimates from each source.

A link to the full text of “Health Insurance Coverage In The United States: 2019” may be found at www.openminds.com/market-intelligence/resources/091420healthinsurancecoverage.htm.

For more information, contact:

  • Public Information Office, U.S. Census Bureau, 4600 Silver Hill Road, Washington, District of Columbia 20233; 301-763-3030; Email: pio@census.gov; Website: https://www.census.gov/en.html

We appear to be entering the third phase of telehealth adoption. There was Telehealth 1.0, the pre-pandemic use of telehealth, with less than 0.01% of total visits delivered virtually. Then, there was Telehealth 2.0—the past six months—where Medicare telehealth claims rose from 13,000 to 1.4 million claims per week from March to April 2020. In the 2.0 era, 80% percent of behavioral health visits were virtual, compared to 30% of primary care visits.

And now we are slowly pivoting to the post-pandemic era, Telehealth 3.0. Surprise (or not), telehealth visits in all of health care are now on the decline. Data from MDLive found that telehealth comprised 69% of all visits in April but dropped to just 21% in July. And starting October 1, both UnitedHealthcare and Anthem will stop waiving the cost of copays, coinsurance, and deductibles for virtual visits not related to COVID-19. Other special policies for telehealth set to expire on December 31 include Cigna, Humana, and Aetna.

As the market shifts, the strategic questions are not specific to telehealth, but involve telehealth. First, as the landscape shifts, how do executive teams shift their service lines to the “next normal?” Second, what role will digital health technologies—telehealth, remote monitoring, and more—play in evolving service lines? And, third, how do executives plan to leverage the power of the virtual in their “next normal” strategies?

Service models must leverage the power of virtual. Whether services are delivered in homes, schools, community settings, residential facilities, primary care clinics, or in the emergency room—provider organization executives need to think about how each service line will leverage digital. And, the digital considerations can’t be an afterthought—something ‘added’ to an existing consumer experience. Rather, executive teams need to rethink their solution starting with digital services first. Justin Barad, an orthopedic surgeon and founder and CEO of OssoVR, said, “If we want to change the perception of health care past something that’s old-fashioned and archaic, we should take the best technology in other fields and use it to push the limits of what’s possible in health care.”

These topics were the focus of the session, Virtual Health: How To Expand Access & Build A Seamless Consumer Experience, at the 2020 OPEN MINDS Management Best Practices Institute. Three provider organization executives—Shawn Brooks, Executive Director, Special Projects at Centerstone; George Kolodner, MD, Founder and Medical Director at Kolmac Outpatient Recovery; and Diego Garza, MD, Vice President of Strategy and Innovation and Director of Telehealth at MindPath Care Centers—shared what they are doing to make digital services work in the long term. They elaborated on two elements in navigating to the digital first era—double down on convenience and access for competitive advantage, and reengineer workflows and culture for the new service landscape.

Convenience & Access Are Key Performance Measures    

Consumer expectations for “instant gratification” and extreme convenience (as defined by Netflix, GrubHub, Uber, and Amazon same-day delivery) will only grow in our increasingly virtual world. Consumers will gravitate to programs and organizations that make it easy and even “fun” to do business with them. Some organizations in the market space—Talkspace, Ginger, Heal, and others—were designed from the get-go to deliver a seamless virtual experience for consumers—from online scheduling to price transparency to the ability to be matched with a clinical professional of choice. How traditional service provider organization executive teams can reengineer their service lines to leverage the plethora of apps and social platforms with “gaming,” rewards, points, self-management tools, peer connections, and groups, is the question.

Our panelists have started with online scheduling and same day access to improve the virtual experience. “I’ve always wanted to eliminate scheduled appointments in favor of treating people as soon as they present, and telehealth made it possible. Now when a consumer in alcohol withdrawal calls us at 1 pm on Friday, we don’t have to say, ‘We’ll see you Monday morning’ but can begin treatment immediately,” said Dr. Kolodner. Since going virtual, Kolmac has seen new business from consumers in alcohol withdrawal grow from 10% to 40% of overall services because of its “ability to respond immediately.”

At MindPath Care Centers, an on-demand feature in their “virtual walk-in clinic” allows new and current consumers to get a therapy or medication management appointment with a clinical professional in 30 minutes or less, said Dr. Garza. In addition, he shared that clinical professionals who are in session with a consumer have their appointment calendar open and can schedule the next visit before the consumer “leaves”—this has helped tremendously with engagement and care continuity. And when a consumer is in crisis, the clinical professional can initiate an appointment and send a link by text.

It’s also important to address any consumer pain points. Mr. Brooks cautioned, “Never overestimate the consumer’s tech savvy.” Centerstone hosts a “tech session” for first-time consumers prior to their telehealth visit to troubleshoot ahead of time and make sure they are comfortable and know how to use the platform.

Centerstone, Kolmac, and MindPath all survey their consumers regularly and get valuable feedback. At MindPath, they found that after two to four telehealth appointments with a clinical professional—nearly three quarters of consumers said they wanted to continue with telehealth. “Putting thought into the consumer experience” is the single most important factor in taking telehealth to the next level, said Dr. Garza.

Mr. Brooks said that telehealth is about meeting consumer where they are, whether that’s at home, in a congregate or community setting, or even in a “video room” in the provider organization’s facility—if that’s what they prefer. The ability to combine virtual and in-person care, especially for high acuity consumers, is what sets specialty provider organizations apart from the competition, pointed out Dr. Garza. And Dr. Kolodner reminded us that finding out who does better in which setting is not just about what consumers like but also about efficacy and outcomes.

Workflow & Culture Need A Remake For New Service Models

New service lines—designed to leverage the power of virtual and excel on consumer convenience—will require new workflows, new technology infrastructure, and an enhanced management model and culture that embrace virtual for the long-term. Dr. Garza pointed to the importance of integration of the telehealth platform with the electronic health record system for increased efficiencies. He also commented that regardless of the platform, it’s important to establish the workflows, train staff, and break down any cultural resistance to the new ways of doing business. Every process, from appointment scheduling to documentation to billing to any supervision and peer consultation must be built into the workflow.

And Mr. Brooks mentioned how the people issues are key to making investment in technology platforms work. “Get the business processes/workflows right and everything else will fall in place. The platform is secondary, said Mr. Brooks. “It’s like if you know how to drive, you can drive a Nissan, a Cadillac, or a beamer,” he explained.

Executives need to think of telehealth not as a new service line in itself, but as one of many digital tools to leverage in the design of their next suite of service offerings. To build on the advice, below are recommend four elements for a best practice design process for the “next normal:”

  1. Keep the “true north” of customer needs (both consumer and payer) as a guide.
  2. Monitor the competition (particularly nontraditional competitors) to understand the “gaps” in the market that call for innovative new services.
  3. Use a “digital first” approach to design services to meet those customer needs.
  4. Set performance measures for new services at the start, measure them repeatedly, and adjust the service design to maximize performance on an ongoing basis.

In his presentation, Preparing For The New Normal: What’s Keeping Executives Up At Night? during the 2020 OPEN MINDS Management Best Practices Institute David Klements, Chief Executive Officer, Qualifacts, discussed the future of digital health services. His discussion centered on the issues, challenges, and opportunities facing specialty provider organizations as we move from “crisis normal” to the “new normal.”

To start, he focused on the current state of specialty provider organizations. A recent national survey conducted by Qualifacts and the National Council For Behavioral Health had some interesting findings—for example only 9% of behavioral health provider organizations said they could survive financially without some external assistance if the “crisis period” lasted a year or more. On the service side, 60% of behavioral health provider organizations are providing 80% or more care virtually (compared to just 2% of organizations pre-pandemic). Post-pandemic, 43% of provider organizations say virtual will constitute 40% to 60% of their overall service delivery.

What shifted the perspective of many executives on services in the months ahead was Klement’s discussion of service lines and product development. Mr. Klements said, “We need to accelerate product development for the new normal. We can’t use legacy systems from a time when less than 2% of services were being delivered digitally. What every provider organization needs is a remote-first product library.” He talked about the need for functionality that integrates all workflows—including digital—and allows for seamless digital communication between clinical professionals, their supervisors, and consumers. The strategic point—every service needs to be designed thinking of what can be done digitally first—not how to add digital service components later.

It appears we’ve reached another inflexion point in service delivery platforms. Instead of moving from inpatient hospital services to outpatient clinic services, the shift is from clinic-based services to digital. But the question remains the same for executive teams. If you have unlimited funding for digital services, what proportion of consumers would need clinic-based, face-to-face care? What executive teams need to do as part of the market positioning and service development is think digital first—and only use clinic-based services on an as-needed basis.

But making this transition work is about more than just designing new service lines with value-based reimbursement packages. Mr. Klements emphasized that there are operating process workflow issues and staffing challenges to address. On the workflow side, Mr. Klements discussed the difficulty in adapting 20-year old legacy EHR systems to the functionality required for virtual service delivery. The service delivery workflows of the new models require EHRs synced to the virtual care platforms for seamless scheduling, documentation, billing, follow-up, and more. And with the increasing use of remote patient monitoring technologies, robust data interoperability is key.

And the challenges of digital first service lines go beyond system design. There are staffing and culture issues involved in this shift. In their survey, only 26% of clinical professionals surveyed reported that they “preferred” to deliver service virtually. And 47% of clinical staff are concerned about maintaining connections with peers and supervisors in a virtual care environment. Executives need to plan for continuous training and establish opportunities for clinical professionals to debrief in teams, share challenges and solutions, and provide feedback. Staff working remotely need an alternative to water cooler conversations and “sticking their heads in” to consult with colleagues in order to make the digital transformation desired by consumers and health plans also work for clinical professionals.

The U.S. Commission on Civil Rights (USCCR) recommends that Congress phase-out an exemption to the Fair Labor Standards Act (FLSA) that allows employers to pay less than minimum wage to people with disabilities. Following an examination of the exemption, the USCCR found that the Department of Labor (DOL) and the Department of Justice (DOJ) have consistently failed to provide adequate regulation and oversight, and they have allowed the program to operate without meeting the needs of people with disabilities. The exemption is the FLSA section 14(c) waiver program. The USCCR determined that the section 14(c) waiver program was inconsistent with the civil rights protections for people with disabilities.

The FLSA sets the federal minimum wage and regulates the number of hours per week that employees are permitted to work. Currently the federal minimum wage is $7.25 an hour.

For the section 14(c) waiver program, the FLSA rules require employers to apply for a certificate and submit to federal monitoring to ensure that the sub-minimum wages are used if and only if workers are “in fact disabled for the work they are to perform.” About 100,000 people with disabilities are employed through an FLSA section 14(c) waiver program. As of January 1, 2020, there were 1,558 14(c) certificates either issued or pending renewal by the DOL Wage and Hour Division (WHD) to certificate holders in 46 states and the District of Columbia. Only four states have no 14(c) certificate employer: Maine, New Hampshire, Rhode Island, and Vermont. Four other states, Alaska, Maryland, Oregon and Texas, are in the process of phasing out sub-minimum wages, although they still have operating 14(c) certificates

The USCCR key recommendations include the following:

  • Congress should repeal Section 14(c) with a planned phaseout period to allow transition among service provider organizations and people with disabilities to alternative service models prioritizing competitive integrated employment.
  • The phased repeal of 14(c) should reconceptualize how the federal government can enhance the possibilities for success and growth for people with disabilities.
  • Congress should expand funding for supported employment services and prioritize capacity building in states transitioning from 14(c) programs.
  • Congress should assign civil rights oversight responsibility and jurisdiction, with necessary associated fiscal appropriations to conduct the enforcement, either to the DOL or to the DOJ Civil Rights Division.
  • Congress should also require that the designated civil rights agency issue an annual report on investigations and findings regarding the 14(c) program.
  • During the phaseout period, Congress should require stringent reporting and accountability for 14(c) certificate holders, and following the phaseout, Congress should continue to collect data on employment outcomes of former 14(c) employees.

The WHD issues 14(c) certificates to four different types of entities, for-profit business establishments, hospital/residential care facilities, schoolwork experience programs, and non-profit community rehabilitation programs. About 93% of certificates were held by Community Rehabilitation Programs, also known as sheltered workshops and congregate work centers. Illinois held the most Community Rehabilitation Program certificates, with 121 as of January 2020, followed by Missouri and California, with 96 and 95, respectively.

A sheltered workshop is a facility-based vocational service program where people with disabilities work segregated from people without disabilities; the participants are thought to be unable to succeed in a competitive employment setting. Sheltered employment activities include assembling, packaging, and light manufacturing for commercial endeavors. 14(c) subminimum wages may also be paid in environments that are more integrated. The wages rates are meant to align with the participants’ productivity. The programs also receive public funding, including federal Medicaid and Vocational Rehabilitation (VR) dollars, to provide employment-related habilitation and rehabilitation services to individuals with disabilities.

The recommendations were released in “Subminimum Wages: Impacts On The Civil Rights Of People With Disabilities” by the U.S. Commission on Civil Rights (USCCR). The researchers analyzed an exemption to the Fair Labor Standards Act (FLSA), the section 14(c) waiver program, that allows employers to pay less than the minimum wage to individuals with disabilities. The analysis considered federal enforcement of the civil rights of individuals in the program.

A link to the full text of “Subminimum Wages: Impacts On The Civil Rights Of People With Disabilities” may be found at www.openminds.com/market-intelligence/resources/091720usccrsubminwage.htm.

For more information, contact:

  • Angelia Rorison, Director of Communications and Public Engagement, U.S. Commission on Civil Rights, 1331 Pennsylvania Avenue Northwest, Room 1150, Washington, District of Columbia 20425; 202-376-8371; Email: arorison@usccr.gov; Website: https://www.usccr.gov/

It’s no secret—social factors affect health care spending. Last year, Bechara Choucair, MD, Senior Vice President and Chief Community Health Officer, Kaiser Permanente, provided the health plan perspective on social determinants of health in his keynote, Mind, Body, Community: Kaiser Permanente’s Unique Approach, at The 2019 OPEN MINDS Management Best Practices Institute. The message was reiterated by Andy McMahon, Vice President, Health and Human Services Policy, UnitedHealthcare Community, in his discussion of housing issues at the keynote session, Housing Is Health Care: A Post-Pandemic Look At Integrating Social Determinants Of Health. And, Allison Rizer, the former Vice President of Strategy and Health Policy, UnitedHealthcare, focused on the new opportunities for social support services in Medicare in her keynote, Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid.

There are three big issues in the nexus between health care and social supports. First, what funding is currently available to pay for social supports? Second, what are the measurable health care cost offsets for payers and health plans that underwrite social services, and what services for what consumers have a positive return? And third, how do health plans and provider organization executives design and deliver social support programs with positive financial results?

How health plans are addressing non-health issues was the focus of our recent conversation with John Lovelace, President, UPMC For You, who will keynote The 2020 OPEN MINDS Executive Leadership Retreat on October 28 with his presentation, A ‘Whole Life’ Approach To Managed Care: Emerging & Future Health Plan Models. We discussed how 80% of hospitals and health systems say they are committed to addressing social needs as part of clinical care—but more than 70% of hospitals report not having sustainable funding to address social needs. And almost 40% of hospitals report having no current capabilities to measure quantifiable improvements in health outcomes and cost savings from their strategies to address social needs.

But provider organizations claiming, “We don’t do that,” is not going to fly, said Mr. Lovelace. “Behavioral health carve-outs are out and human service carve-ins are in. We need to treat people and deal with their lives,” he asserted. And with the shift to value-based payment models, health plans are looking for provider organizations to create new initiatives that will yield shared savings. Savings on unplanned health care can then be invested right back into social services that will further help to improve health outcomes.

How is UPMC addressing social service safety net issues? The system has a number of initiatives coordinated through their new Center For Social Impact. Launched in December 2019, the Center’s role is to “coordinate, evaluate, and expand programming and innovations that address both the social needs and social determinants of the communities UPMC serves.” The Center’s mission is to translate the work of UPMC’s “unique payer-provider laboratory” to develop replicable evidence-based practices in housing, employment, and workforce training; improve service coordination with local government, expand rural health care, and address the unique needs of individuals with special needs (from consumers with intellectual and developmental disabilities, to people of color and the LGBTQI+ populations) that the UPMC Health Plan serves.

UPMC Health Plan, is owned by the University of Pittsburgh Medical Center and has eight licensed business units. UPMC For You is the government health plan, covering consumers on Medicaid, dual eligibles, and those on long-term services and supports. Community Care Behavioral Health Organization covers the Pennsylvania Medicaid carve-out for behavioral health services. “We are 50% insurance and 50% provider organization. And about 40% of our transactions are internal—our insurance division buys services from our provider organizations for our consumers. This gives us resources and leverage to engage on social determinants of health,” explained Mr. Lovelace. “We are not going to solve everything ourselves, but we are investing in partnerships to address the social determinants with the greatest impact on health. UPMC Health Plan’s priorities are to solve lack of housing for people with intellectual and developmental disabilities (I/DD), chronic unemployment, food insecurity, and institutional racism for the populations they cover.” He described a few of the initiatives that UPMC Health Plan has created to address the social needs of their members—in care coordination, housing, and employment.

Care Coordination, Including Social Services. UPMC’s Community Care Behavioral Health business unit, through its managed behavioral health programs, contracts with provider organizations to serve as “community paramedics” who go out to the homes of consumers tending to use a high volume of unplanned health care to support and stabilize them. The goal of their care management activities is to connect consumers to a full spectrum of community supports and services for “non health things.” Mr. Lovelace sees this as an opportunity for provider organizations.

Housing. UPMC has run a permanent supportive housing program for three decades because people who are homeless tend to have a lot of unplanned health care, especially if they have mental illnesses or substance use disorders, and are disabled or have chronic conditions, explained Mr. Lovelace. And they’ve seen that consumers who have housing better engage with their primary care provider organizations and take their medications. In the past, UPMC has leveraged funding from the U.S. Department of Housing and Urban Development—which traditionally supports only the chronically homeless and has many restrictions. “About 80% of those who become eligible for housing vouchers don’t use them because of the lag between application and qualifying and because of the cumbersome restrictions,” he pointed out.

So UPMC is now looking for new housing finance models and partnerships that will “lower the bar” and help more consumers get housing sooner. They’ve had conversations with Fannie Mae about low-interest loans. And they are partnering with a local non-profit, Community Human Services, that will provide housing supports while UPMC provides care management. “Consumers who get housing have to agree to talk to us, and see their primary provider,” explained Mr. Lovelace.

Employment. The Pathways to Work is a new UPMC Health Plan program serving consumers covered by the health plan who are unemployed or underemployed. The program also serves I/DD consumers seeking jobs and job training. The program hires individuals for jobs at UPMC—and in three years, the program has hired nearly 600 individuals previously on Temporary Assistance for Needy Families (TANF). UPMC Health Plan serves as a direct referral service and connects its Medicaid consumers to job supports across the state as part of the Medicaid Work Support Initiative through the Pennsylvania Department of Human Services. The health plan partners with community organizations to create an employment pipeline and also supports public policy campaigns to break down barriers to work. “It’s about more than employment, it’s about career planning,” said Mr. Lovelace. The health plan is trying to address the “benefits cliff” issue that causes individuals with disabilities to lose benefits (food stamps, housing, and heating subsidies) when they earn more than the minimum wage. With more than 2 million jobless claims filed in Pennsylvania since the pandemic began in March, the health plan is supporting consumers who have lost their jobs and connecting them to resources and opportunities. “We know that having a stable job leads to better overall health for many individuals,” said Mr. Lovelace.

For over a decade, the health and human service field has been focused on getting primary care and behavioral health services in sync. The Substance Abuse and Mental Health Services Administration (SAMHSA) has spent significantly on grants for integration and for certified community behavioral health centers. Medicare launched a new reimbursement model supporting coordinated care. But the adoption of integrated primary care/behavioral health models has been slow for many reasons. There are reimbursement issues, cultural issues in care delivery, and interoperability challenges with electronic health records (EHRs). As a result, the proportion of consumers served through delivery systems that are integrated in terms of services, finances, and information is small.

But the time has come that every specialty provider organizations needs a primary care strategy. That doesn’t mean they necessarily deliver primary care service—but that is one of the options. For payers and health plans, integration means a “whole person” approach to care coordination. The “ideal” model has medical, behavioral, and social needs addressed together in a system that has seamless consumer services, integrated data at the consumer level, and alignment of financial incentives. From the provider organization perspective, the question is to determine, even if your organization can’t be the entire solution, how to create (through new capability development, mergers, or collaboration) a system with these characteristics.

Two changes in the market over the past few months have altered the path to primary care integration for specialty provider organizations. We have seen primary care move to virtual and in-home models—eliminating the need for brick-and-mortar primary care facilities. And, primary care and specialty care coordination models are moving to non-fee for service reimbursement models.

But how have specialty organizations fared in adding primary care services to their portfolios? We heard some examples at the session, Specialty Primary Care Models That Work For Consumers With Complex Needs during the 2020 OPEN MINDS Management Best Practices Institute. The session featured Lantie Elisabeth Jorandby, MD, Chief Medical Officer, Lakeview Health; Lisa Suttle, Regional Vice President of Clinical Services, Meridian Health Services; Tracy Douglas-Wheeler, Vice President, Community Health, Meridian Health Services; and Jim Sorg, PhD, Director of Care Integration, Tarzana Treatment Centers—and was moderated by OPEN MINDS, Senior Associate, Joe Naughton-Travers.

Lakeview Health is a 200-bed residential treatment facility in Florida for adults that have a dual-diagnosis of substance use and mental health disorders. They recently embedded primary care and are staffed with psychiatrists, internists, and primary care professionals. Meridian Health Services started as a behavioral health organization in the 1970s and later added primary care, dental services, addictions treatment, intellectual and developmental disability services (I/DD), foster care, and children’s services. Today, Meridian is a Federally Qualified Health Center (FQHC) serving more than 40,000 consumers in 33 counties and 250 schools. Tarzana Treatment Centers is just a few months short of becoming a an FQHC and offers residential and outpatient mental health and addictions treatment, primary care, HIV-AIDS and Hepatitis C care. They serve about 10,000 consumers a year. Tarzana contracts with primary care physicians and employs mid-level clinical professionals in primary care at all sites. These three specialty provider organizations have two common themes in their approached to integrating primary care—comprehensive assessments and ongoing coordinated care management.

Comprehensive Assessments

All three organizations agreed that it all starts at intake—it’s important to assess the consumer for all conditions—behavioral, medical (and even social)—no matter what they present for. At Lakeview, consumers—who enter for detox initially—are assessed by an internist or psychiatrist on their first visit. After about 72 hours, when they have been stabilized, they see a mental health professional for evaluations. They administer a “battery of assessments”—PHQ-9 for depression, GAD-7 for anxiety, MoCA for cognitive dysfunction, and the MDQ for bipolar disorder. “We administer the assessments initially and throughout the 4-6-week treatment plan, and reassess where they are at the end of their stay,” said Dr. Jordanby. Lakeview also monitors other conditions that could lead to a relapse in sobriety, such as the ability to manage chronic pain and the impact of past trauma.

At Meridian, said Ms. Suttle, staff doing intake are trained to ask, “What’s going on with this consumer I am seeing today?” and to assess for all complexities. The initial assessment even includes questions about housing, employment, and other social determinants of health. “We have grant dollars to provide support services, but we won’t know what they need if we don’t ask,” she said. And often, consumers with behavioral health needs “won’t come in to see us until it’s a full-blown crisis or they are in the emergency room. So, we go out to homes, porches, garages, and schools—wherever we can assess them safely—and bring them in.”

And at Tarzana, in addition to a “self-medical,” or obtaining a full history from the consumer at intake, staff screens for substance use and other conditions. “We use motivational interviewing to engage consumers who don’t want to screen for conditions other than those they present for,” said Mr. Sorg.

Ongoing Coordinated Care Management

All three organizations have embraced a comprehensive approach to individual care coordination. Tarzana coordinates care for consumers with chronic conditions as well as for incarcerated populations, and for consumers discharged from hospitals. “From the data of one of the health plans funding this service, we saw that we helped reduce hospital admissions as well as emergency room visits by just over 5%,” said Mr. Sorg. They are now extending the care coordination beyond the health home program through case management services for all consumers with mental illness and substance use disorders. The case manager is the “human link” in the absence of an integrated EHR, said Mr. Sorg. The case manager interfaces between systems, dives into a standalone information portal that pulls consumer data from the different EHRs and manages referrals and transitions between clinical professionals. The case managers also help consumers with navigating housing assistance and other social service benefits.

Lakeview has a slightly different approach based on the same concept. “At Lakeview, we have consumers for six weeks and then they go back into the community. So, we have a strong after-care team that provides wraparound care and sets up seamless transition to outpatient primary care, occupational or vocational therapy, or other needed services. We are just the foundation, so we help integrate them back into their lives,” Dr. Jordanby explained.

And at Meridian, “referral coordinators on the primary care side look at the consumer’s medical records and push referrals to behavioral health,” said Ms. Douglas-Wheeler. Then the behavioral health team contacts the consumer proactively for follow-up care. Community health workers partner with the clinical professionals caring for a consumer to address social determinants of health. “We want to get community health workers into consumers’ homes to set up virtual visits with primary care professionals so consumers can talk about what’s going on and what’s hindering them from access to care.”

What strategic advice do the panelists have for provider organization executives that want to adopt a more holistic approach to complex care? Cross-train and educate your clinical professionals for care coordination, emphasized Dr. Jordanby. Ms. Suttle advised clinical professionals to “think out of the box, use resources across the board, and pull on other specialty areas.” And Ms. Douglas-Wheeler suggested bringing primary care or specialty clinical professionals in on a contract basis for starters—and to be sure to involve all staff at the front end, as part of the assessment process.

Clinical professionals affiliated with health systems had better performance scores on the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS) for 2019 than non-affiliated clinical professionals. The system-affiliated clinical professionals were more likely to receive a positive payment adjustment, and bonus payments than non-affiliated professionals, and they were less likely to receive a negative payment adjustment.

MIPS requires eligible clinical professionals to submit performance data on certain measures and activities in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. Performance in the four categories determines whether participating MIPS eligible clinical professionals receive a positive, neutral, or negative adjustment to their Medicare Part B allowed charges for covered professional service under the Physician Fee Schedule.

On a scale of 0 to 100 possible points for MIPS performance scores based on the 2017 performance year, affiliated professionals scored an average of 79 points compared to 60 for non-affiliated professionals. Higher MIPS scores represent better performance. About 97.1% system-affiliated clinical professionals and 82.6% non-affiliated professionals received a positive payment adjustment. About 73.9% of system-affiliated clinical professionals and 55.1% non-affiliated professionals received a bonus payment adjustment. About 2.8% of system-affiliated clinical professionals and 13.7% of non-affiliated professionals received a negative payment adjustment.

MIPS is one track of the Quality Payment Program (QPP) established to implement certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In the 2017 and 2018 performance years, MIPS eligible clinical professionals included physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, osteopathic practitioners, and chiropractors who billed Medicare Part B covered professional services. MIPS eligible clinical professionals who did not participate in MIPS for the 2017 performance period were subject to a negative 4% payment adjustment in 2019.

These findings were reported in “Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System” by Kenton J. Johnston, Ph.D.; Timothy L. Wiemken, Ph.D.; Jason M. Hockenberry, Ph.D.; et al. The researchers conducted a cross-sectional study of 636,552 clinical professionals with MIPS data for 2019, which is based on their performance in 2017. The goal was to assess whether clinical professionals who were affiliated with a health system had performance scores and value-based reimbursement under the 2019 MIPS that were different relative to their non-affiliated peers. About 48.6% of the clinical professionals were affiliated with a health system.

The full text of “Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System” was published September 8, 2020, by JAMA. An abstract is available online at https://jamanetwork.com/journals/jama/fullarticle/2770411.

PsychU last reported on this topic in “2% Of Eligible Clinical Professionals Participating In MIPS In 2018 Received A Negative Rate Adjustment,” which published on March 2, 2020. The article is available at https://www.psychu.org/2-of-eligible-clinical-professionals-participating-in-mips-in-2018-received-a-negative-rate-adjustment/.

For more information, contact:

  • Kenton Johnston, Ph.D., MPH, Associate Professor, Health Management and Policy, College for Public Health and Social Justice, Saint Louis University, 3545 Lafayette Avenue, Salus Center, Room 362, Saint Louis, Missouri 63104; 314-977-3236; Email: kenton.johnston@slu.edu; Website: https://www.slu.edu/public-health-social-justice/faculty/johnston-kenton.php

As of October 1, 2020, the highest rate of coronavirus disease 2019 (COVID-19) testing was in Massachusetts, at 10.2 tests per 1,000 population. It was lowest in Florida, Mississippi, and Arizona, all at 1.0 tests per 1,000 population. After Massachusetts, the next highest testing rates were Rhode Island (8.5 tests per 1,000 population), North Dakota (7.1 tests per 1,000 population), and Arkansas (5.8 tests per 1,000 population).

Also, as of October 1, 2020, Texas had the highest number of new daily cases (5,755), followed by California (3,461), and Wisconsin (2,272). Vermont had the fewest number of new cases, at just three.

South Dakota had the highest percentage of daily positive cases (25.9%), followed by Idaho (21.2%), and Wisconsin (21.1%). Maine showed the lowest percentage of daily positive cases at 0.4%. Overall, 22 states were below the 5.0% percent positive rate (as rounded up or down by tenth) recommended by the World Health Organization (WHO) in May 2020 as the threshold for considering reopening. The WHO recommended that for reopening with the lowest risk of spread, the percent positive rate should remain below 5% for at least two weeks.

These statistics were presented in “Johns Hopkins University and Medicine Coronavirus Resource Center: All State Comparison Of Testing Effort.” It is an active research project updated daily. Researchers for Johns Hopkins analyzed publicly available state COVID-19 testing data from multiple, unspecified sources. The goal is to report current trends in COVID-19 infection and deaths. Testing rates are presented as seven-day rolling averages to account for fluctuations in daily state reporting. New cases of COVID-19 are presented as daily counts, as reported by each state.

The full text of “Johns Hopkins University and Medicine Coronavirus Resource Center: All State Comparison Of Testing Efforts,” is continually updated by Johns Hopkins University and Medicine Coronavirus Resource Center. A copy may be found online at https://coronavirus.jhu.edu/testing/states-comparison. The testing trends comparison is posted at https://coronavirus.jhu.edu/testing/tracker/overview.

For more information, contact: 

  • Karen Lancaster, Assistant Vice President, External Relations, Johns Hopkins University, 3400 North Charles Street, Baltimore, Maryland 21218; 443-997-9909; Email: klancaster@jhu.edu; Website: https://www.jhu.edu/

There is almost universal agreement that the use of telehealth will continue after the pandemic recedes. The path to more telehealth was paved by the emergency telehealth regulatory changes enacted by the U.S. Department of Health and Human Services (HHS) as part of the Public Health Emergency declaration for the pandemic. The new telehealth rules were adopted by most health plans. And on July 23, 2020, HHS extended the emergency period for 90 days, through October 23, 2020. Most health plans followed suit, with some extending the new rules through December 2020.

The big question is whether these rules will become policy post pandemic. Making the HHS regulations permanent would take an act of Congress. And most health plans have not announced their intentions. But the devil is in the details, so to speak. Will all telehealth continue to be covered? What about telephonic visits? Will virtual care delivered by any type of professional, from and to any location—and for all types of services—be covered? Will acceptance of intrastate licensure become widely adopted? And, most importantly, how will telehealth be paid for? Fee-for-service? At the same rates as face-to-face? In payment bundles? These are the questions that keep executives of provider organizations up at night.

At the recent 2020 OPEN MINDS Management Best Practices Institute, they gathered some of the executives of health plans who will be making these decisions together to provide some perspectives—and their view of what the future holds. The executive roundtable, Telehealth – What Will The Payers Change Post-COVID-19? Let’s Ask Them, featured Roberta Montemayor, Regional Network Manager OptumHealth Behavioral Solutions; Amy Pearlman, Vice President, Clinical Provider Strategy, Beacon Health Options; and Sean Schreiber, Executive Vice President, Network & Community Health, Alliance Health. Their short answer to the questions above—“we’re not ready to commit” to permanent rules for telehealth. But the discussion provided some interesting insights on the key issues that will drive those decisions.

Health Plans Are Seeking Provider Organization Input

The panelists discussed the early trajectory of the move to telehealth. At the start of the pandemic, telehealth use increased by more than 1000%, but has since leveled off with roughly half of all services now virtual. For Anthem, it was members accessing care for the first time. For Alliance Health it was current consumers switching from in-person to virtual. For Optum, the increase in telehealth visits did not decrease in-person visits, “which is just something we have to factor into our decision making,” said Ms. Montemayor.

It was clear from the discussion that health plans expect telehealth to be a critical component in the care continuum, likely some hybrid of in-person and virtual. Exactly what that looks like will be different for different professionals and provider organizations depending on the consumers served and the setting. During the crisis, Optum permitted and paid for Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) virtual visits at the same rate as in-person but does not plan to continue to do so when the public health emergency is over. “Optum was studying the feasibility of supporting virtual IOP and PHP care before COVID, but was not prepared to support telehealth for the more intensive services until we were confident that our providers were confident that delivering care in that way was effective,” explained Ms. Montemayor. “We’ll continue to do our due diligence.”

Executives of health plans are concerned about security, workflow, and efficacy—and are seeking input from provider organization executives to help shape future programs and payments.  All three health plans on the panel—Optum, Beacon, and Alliance Health—have sent surveys to provider organizations seeking feedback. “If you [provider] are contacted by your payer asking for feedback and data around telehealth use during COVID, that’s not a bad thing, it’s your opportunity to tell us how things are going,” noted Ms. Pearlman. “Payers are still trying to figure out what the landscape will be like post-pandemic and are looking for concrete claims and utilization data to help inform those decisions.”

Telehealth Visits Paid On Par With In-Person

Panel participants all said that behavioral health telehealth visits were—and would continue for the foreseeable future—to be paid on par with in-person visits as a means of ensuring greater accessibility to treatment despite a sustained, nationwide shortage of skilled professionals in behavioral health. Access to care is the driving issue for health plans because ready access to outpatient behavioral health treatment is associated with lower health care spending. The panelists implied that if data connects telehealth to increased access, improved no show rates, increased consumer engagement, and better follow-up care coordination, health plans will continue their current telehealth reimbursement policies. But they were quick to point out that this isn’t an “either/or” in all instances. For some consumers and some care plans, a hybrid model would be required.

And health plans are investing in building the telehealth capacity of their networks. During the pandemic, Alliance Health gave provider organizations funds to pay for smartphones and data plans to ensure that consumers could access care virtually. Optum, Anthem, and Beacon also provided funding and support to ensure consumers have access to the technology needed to participate in telehealth visits. For each of them, the support and resources provided varies by market. During the pandemic, “Anthem pivoted care management resources to assist members in accessing telehealth, and also has a relationship with the social care network, Aunt Bertha, to direct members to available community resources,” said Ms. Pearlman. Anthem also helped direct consumers to Medicaid programs that help them get equipment and basic data plans for smartphones.

The Changing Face Of Virtual Care

No telehealth conversation would be complete without talking about health plan investments in a wide variety of digital care platforms. But the panelists made it clear that traditional provider organizations are the core of their service delivery system. Ms. Montemayor said, “Our network is our providers, solo practitioners, small and mid-sized groups and larger, regional groups. We have no plans to switch to a vendor only model. We do see that vendors could augment the network as they might be better positioned to offer some of the services into which we are looking to expand into such as crisis response or on-demand behavioral health.”

So how should provider organization management teams plan for an uncertain future with regard to telehealth reimbursement?  It is important to remember that providing telehealth services on a fee-for-service basis is not exactly an innovation—it is the platform for current service delivery. The strategic task ahead is to develop new “high value” hybrid programs for specific consumer groups—programs that combine in-office, home-based, and virtual care in a way that optimizes consumer experience and decreases service costs. And, this new service line development needs to both measure the value of the service (from consumer and payer perspectives) and calculate the return-on-investment (ROI) of the program to payers.

In Monica E. Oss’ closing address at the 2020 OPEN MINDS Management Best Practices Institute, Navigating The Crisis – Best Leadership Practices To Survive A Crisis & Emerge As A Market Leader, she pointed out that every organization needs a “next big thing”—that  “next generation” service that will be the anchor of sustainability in the years ahead. How should executive teams “imagine” the future of health and human services and their next service line? Mobile and tech-enabled, said four executives from Netsmart at the thought-provoking session, The Future Of Care – What You Should Be Thinking About Now during the Institute.

Why? They gave three reasons—the legacy of forced innovation, advances in technology, and changing payer preferences.

First, the COVID-19 crisis has forced the adoption of telehealth, and when it comes to remote services, the field is unlikely to return to the previous volume of face-to-face services. Danielle Ross, Virtual Chief Information Officer, Netsmart, noted that over the past few months, “…organizations rapidly accelerated long-standing initiatives focused on least restrictive treatments, person-centered approaches, holistic care, and client engagement.” And the pandemic pressures of increased operating costs, reduced cash flow, potential staffing shortages, and potential reimbursement cuts have made the case for continued virtual operations.

Second, the technology deployment is moving beyond telehealth. We’re seeing advances in artificial intelligence, remote patient monitoring technologies, and wearables. And, lastly, this trend for mobile and tech-enabled care is meeting the needs of payers—lower costs, immediate access, and overall better value.

In short, COVID has created a runway for mobile and tech-enabled care to take off—and the money will follow. What are the opportunities for specialty provider organizations in a mobile home-based environment? One option would be to seek collaboration with home care provider organizations to provide specialty services (mental health, addictions, autism, etc.) to their consumers. The other option is to become a specialty home care provider organization managing care for complex consumers that home health agencies may prefer to avoid or don’t know how best to care for. In that model, specialty provider organizations can expand the services they offer to their current consumers—including social work services to help navigate community resources, physical and occupational therapy, management and monitoring of activities of daily living, speech language pathology services to address cognitive issues, and personal care assistance especially for consumers dealing with dementia.

The question is how do specialty provider organizations prepare for a mobile and tech-enabled future. The speakers highlighted several emerging technology competencies that will be needed in the years ahead—telehealth, mobile tools for the workforce, electronic visit verification, and consumer conveniences.

Telehealth: Telehealth is a foundational technology for mobile care. Not every service and every clinical professional needs to deliver services in-home. Rather, “hybrid” models of care will emerge that combine telehealth with face-to-face in-home care. For example, the behavioral health clinical professional paying a home visit can bring in a primary care clinical professional via telehealth. It’s a great way to “bring the experience to any device any time and extend your provider network,” said Matthew Arnheiter, Senior Vice President of Innovations, Netsmart.

Tools to support mobile work: Route optimization technology can help to determine which clinical professional to send to a specific location and efficient routes to reduce travel time. Clinical professionals will need a disconnected solution to view consumer charts and documents in the field as well as securely manage and sync data when offline. Staff tools need to be optimized for laptops as well as tablets. Mobile and desktop enabled secure instant messaging between clinical professionals and supervisors is another critical tool. Messages can be associated with a consumer to be saved back to the chart.

Electronic visit verification: Mr. Arnheiter noted that electronic visit verification (EVV) systems will be required for all mobile services starting January 2021.  EVV doesn’t just provide documentation that a visit occurred but can also can help organizations manage their workforce and clinical professionals manage their schedules. With an EVV system, organizations can track physical locations of staff, what tasks have been completed, what visits have been missed and why, and can capture electronic signatures for verification. Think of it this way, said Mr. Arnheiter, “In the old days, we were told to expect the cable guy to come sometime between the hours of 8:00 am and noon, but they often did not show at all. In today’s world, Amazon tells you where your package is, when it will be delivered, and that it was delivered. Information is delivered directly to your phone. EVV systems can do the same.”

Consumer access and consumer engagement: Another essential is a sophisticated call center that enables quick response to consumer requests and speedy access to care. The call center should monitor availability of all clinical professionals in the field, track all inbound calls, find and dispatch the nearest resources, and keep field staff informed about assignments and schedule changes. Consumer engagement takes continuous effort beyond access. Provider organizations must enable consumers to view information in their charts; engage the consumer in education, assessments, and activities; and be sure to employ remote patient monitoring devices. Gamification—applying point scoring, reward, etc.—is all the rage and can be used to inspire consumers to share and interact, during visits and at other times as well.

The paths to future sustainability are going to vary by organization—by the consumers served, service specialties, geographies, payers, and more. But the push to mobile and tech-enabled services is going to affect every sector of health and human services.

On August 10, 2020, the federal Department of Health and Human Services (HHS) re-opened the Phase 2 Provider Relief Fund application portal for Medicaid and Children’s Health Insurance Program (CHIP) provider organizations because federal data indicated that only 4% of eligible organizations applied during the earlier application period from June 9 through July 20. This distribution is intended for Medicaid and CHIP provider organizations with no Medicare revenue, including behavioral health provider organizations and those that provide Medicaid home- and community-based services. The portal will be open through August 28, 2020.

After the Medicaid and CHIP targeted application period closed on June 20, HHS realized that the provider organization response rate was unexpectedly low. Executives of many provider organizations told HHS they were confused about their organization’s eligibility and about the application process. On July 31, HHS announced it would re-open the application portal, and would allow it to accept applications from Medicare provider organizations, Medicaid and CHIP provider organizations, and dental provider organizations.

The Provider Relief Fund, created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, is intended to replace about 2% of provider organization revenues. For the Phase 1 Provider Relief Fund general distribution in April, HHS used payment information from the Centers for Medicare and Medicaid Services (CMS) to distribute $30 billion directly to Medicare provider organizations proportionate to their share of 2018 Medicare fee-for-service reimbursements. The Phase 1 general distribution offered provider organizations financial relief payments equal to a maximum of 2% of their annual Medicare service revenues. Provider organizations that are not required to submit comprehensive cost reports to CMS were asked to submit revenue information to a portal to receive the balance of their 2% payment of General Distribution funds via a subsequent $20 billion funding round that ended June 3, 2020.

Among provider organizations that serve Medicaid and CHIP beneficiaries, 62% received the maximum Provider Relief Fund payment to replace 2% of revenue during the Phase 1 General Distribution, and 38% received either no payment or a payment that amounted to less than 2% of service revenue. Many provider organizations with low Medicare revenues and higher Medicaid revenues did not complete their applications by the deadline. A large share of those missing the application deadline receive the bulk of revenue from Medicaid or CHIP plans or are dental provider organizations.

Provider organizations eligible to apply for funding through the re-opened portal include those that bill Medicare, Medicaid, Medicaid managed care, or CHIP who have not already received 2% of their total service revenue from the Provider Relief Fund. In an infographic, “Rules of the Road”, about the expanded portal, the National Council for Behavioral Health clarified that this opportunity can be used by provider organizations with the following circumstances:

  • Received an automatic payment from the Medicare Phase 1 General Distribution Fund, but did not yet receive a second payment.
  • Rejected the initial payment from the Phase 1 General Distribution Fund.
  • Missed the initial June 3 deadline to apply for funds.

Reyna Taylor, National Council’s vice president of public policy said a key problem was confusion around the HHS eligibility FAQs for the Medicaid provider portal even after the Medicare distribution submission deadline closed. Many Medicaid provider organizations thought that they should wait for the Medicaid distribution opportunity, and not accept the much lower Medicare distribution. Others mistakenly thought that receipt of funds through the Paycheck Protection Program excluded them from the Provider Relief Fund, so they did not apply. However, when the Medicaid distribution opened, they learned that one of the requirements to receive funds through the Medicaid distribution was that the provider organizations must not have received funds from the General Distribution or must not have received funds equivalent to 2% of annual service revenue. Ms. Taylor said about 30% of National Council members found themselves ineligible for the Medicaid distribution because they received an initial Medicare direct payment from the General Distribution but were confused about whether to apply to the second round of funds from the General Distribution for Medicare provider organizations or wait for the Medicaid distribution. During June and July, trade organizations, including the National Council and the National Association of State Directors of Developmental Disabilities Services, expressed concern to HHS about the prior lack of clarity and the unintended result.

The “Provider Relief Fund Rules of the Road” infographic was published August 14, 2020, by the National Council. An abstract is available online at https://www.thenationalcouncil.org/wp-content/uploads/2020/08/20_PRF_RulesOfRoad_infographic2.pdf?daf=375ateTbd56.

A link to the full text of “National Council Letter To HHS About Specific Mental Health & Substance Use Health Care Provider Fund Distribution” may be found at www.openminds.com/market-intelligence/resources/061820natcouncilltrhhsremhsacaresactprf.htm.

PsychU reported on various aspects of the CARES Act Provider Relief Fund in the following articles:

  • “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured,” which published on May 4, 2020, at https://www.psychu.org/hhs-begins-releasing-100-billion-cares-act-funding-to-provider-organizations-for-relief-assistance-treating-the-uninsured/.
  • “24 Provider Organizations Receive Over $100 Million In CARES Act Provider Relief; New York & Presbyterian Hospital Tops The List,” published on June 10, 2020, at https://www.psychu.org/24-provider-organizations-receive-over-100-million-in-cares-act-provider-relief-new-york-presbyterian-hospital-tops-the-list/.
  • “$15 Billion HHS Relief Fund For Medicaid & CHIP Provider Organizations Is Open For Applications,” published on June 29, 2020, at https://www.psychu.org/15-billion-hhs-relief-fund-for-medicaid-chip-provider-organizations-is-open-for-applications/.

For more information, contact:

  • U.S. Department of Health and Human Services, 200 Independence Avenue Southwest, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov; Website: https://www.hhs.gov/
  • Sophia Majlessi, Assistant Vice President, Public Relations, The National Council for Behavioral Health, 1400 K Street Northwest, #400, Washington, District of Columbia 20005; 202-621-1631; Email: SophiaM@TheNationalCouncil.org; Website: https://www.thenationalcouncil.org/

The one word that keeps coming up in discussions with health plan executives is “transformation.” And, they’re not talking about transforming themselves. They are talking about the transformation in service delivery that provider organizations need in order to be “valuable” in the post-pandemic health and human service system. And, that transformation is more than just adding telehealth. They’re talking about integration of services and data, engaging consumers with complex needs, and driving a definable value proposition.

Making that transformation was the focus of last week’s OPEN MINDS Care Innovation Summit: Solving the Problem Of Access For Consumers With Complex Care Needs. The summit featured case study presentations of three “transformational programs.” Vail Connect presented by Vicky Couillard, Executive Director and Shelly Zuzek, Director of Integrated Care, Vail Place; In-Home Addiction Treatment (IHAT) model presented by Shelley Halligan, Corporate Director of Clinical Services and Rick Ashcroft, Payer Relations, Aware Recovery Care; and the Klamath County Medicaid and Medicare programs, presented by Annette Fowler, Chief Operations Officer, Cascade Comprehensive Care.

At the outset of the summit, OPEN MINDS Senior Associate, Paul Duck, provided the framework for thinking about the transformation that is taking place right now. These transformations are focused on solving the most pressing health plan problems—access to care, engagement in care, and reduction of uncoordinated and unnecessary care for consumers with multiple conditions.

The transformations include features like quick access appointment programs, technology-enabled and hybrid care delivery, use of technology tools for consumer engagement, and use of analytics for consumer care coordination. The emerging models are focused on “whole person care” that integrates the management of services from a consumer-centric perspective.

But how do provider organization executives move along the continuum of transformation to address these health plan pain points? Most would suggest a focus on scheduling efficiencies, coordinating care to serve consumers holistically at the right time and right place, and leveraging technology to improve consumer access and engagement.

Care At The Right Time

The first step to mitigating the access to care problem is to make it easy for consumers to get into care. And simple changes can make a big difference. “Make it easy to schedule appointments, offer to see consumers the day they call, and manage demand so there are no long wait times,” suggested Mr. Duck. He also noted that many provider organizations are offering open access and walk-ins (no appointments), access to blocks of schedule times for health plans, and guaranteed access for urgent needs and emergencies. Consumer “groups” for therapy, support groups, and medication management help more consumers access care at once. Allowing online appointment scheduling (or even Uber-like mobile scheduling), offering initial visits through telehealth to reduce wait times, and allowing consumers to communicate by text and email are some other possibilities, according to Mr. Duck.

Care In The Right Setting

The one fundamental assumption that the pandemic has changed is the assumption of where care needs to be delivered. The forced move to telehealth has shown the services can be delivered virtually and in homes, community centers, and mobile clinics.

Vail Connect is a mobile, short-term service, lasting three months or less where “navigators” from Vail Place meet consumers in the community or their homes and connect them to services and supports—physical and mental health assessments, treatment, resources, education, and community supports. The goal is to stabilize consumers and improve health outcomes in order to connect them to long-term primary and psychiatric care. Vail Connect follows a three-tier approach. Tier one is high-intensity rapid intake to intensive services with a same day turnaround. Tier two includes short-term system navigation services for consumers who don’t qualify for targeted case management but need referrals to other programs. Tier three allows for seamless referrals to different programs and services when a more intensive program isn’t required. The number of emergency room visits dropped by 55% and the number of hospital admissions dropped by 77% for consumers in the program.

Dr. Halligan and Mr. Ashcroft outlined how their IHAT model enables delivery of addiction treatment at home. For starters, they acknowledged that in-home care is not right for every consumer and worked with national payers to identify the population best suited to this type of care. IHAT offers psychiatric evaluation, medication bridges, medication-assisted treatment (MAT), individual and family therapy, medical and behavioral health care coordination by a licensed nurse or social worker, and a customized treatment plan. Central to this in-home approach is the role of a Certified Recovery Advisor that the consumer knows and can relate to. The clinical professionals make sure the home is a safe place and ensure the consumer and his or her family are educated about substance use disorders and how to handle situations that might arise during treatment. During the pandemic, Aware’s specially trained teams continued to go into the home with protective equipment, as needed, but also relied on mail deliveries of medications and remote monitoring by registered nurses and through virtual therapy visits. The program reduced emergency room visits, residential stays, partial hospitalizations, and detox by 90% in 90 days, said Mr. Ashcroft.

Technology For Engagement

And what the past decade has taught the health care field is that offering and providing services is not enough getting the consumer engaged in care pays dividends in both improvement of consumer health status and cost reductions. And transformational consumer engagement involves technology.

Cascade Comprehensive Care serves low-income consumers with complex physical and mental health conditions. Most are in very rural areas and lack broadband. But Ms. Fowler said her team is not waiting for the infrastructure to be built—they are making innovative use of 2-way text messaging to connect with consumers and send motivational messages for behavior change and appointment reminders. Cascade is also piloting a program to use advanced artificial intelligence to connect with and understand consumers. The organization is forming partnerships with community stakeholders to get consumers the technology they need and to improve the care experience and outcomes.

The question for executive teams is whether their organization needs “transformation” and, if so, what type? The transformations that payers and health plans are looking for is a fundamental change in the relationship of the consumer to the provider organization—and a fundamentally different business model. This is going to take more than just a change in clinical models. Plans for a change in organizational sustainability and a change in organizational culture are integral to making the transformation work.

About 55% of Italian adults ages 18 to 87 who recovered from a coronavirus disease 2019 (COVID-19) infection had self-rated in the clinical range for at least one mental disorder, such as post-traumatic stress disorder (PTSD), depression, obsessive compulsive disorder (OCD), or anxiety. According to the analysis, which examined 402 COVID-19 survivors, about 36.8% had two disorders; 20.6% had three disorders, and 10% had four disorders. About 2.9% had suicidal ideation, and 0.8% progressed to making suicide plans. Of the 402 COVID-19 survivors, females had greater incidence of post-COVID-19 psychiatric distress than males; the ratio was 2.9 females with psychiatric distress for each male experiencing mental health problems.

The degree of psychological distress varied with the person’s history of previous psychiatric diagnoses, the treatment setting, and the length of hospitalization. People with longer than average hospitalizations had lower rates of PTSD, anxiety, depression, and OCD than people with longer than average hospitalizations. People whose symptoms were managed at home had higher rates of anxiety and sleep disturbance than those who were hospitalized.

These findings were reported in “Anxiety And Depression In COVID-19 Survivors: Role Of Inflammatory And Clinical Predictors” by Dr. Mario Gennaro Mazzaa, and directed by Professor Francesco Benedetti. The researchers conducted a psychiatric screening of 402 Italian adults ages 18 to 87 who survived COVID-19. Within the group, 265 were male and 137 female; the average age was 57.8 years. Each had visited the emergency department at IRCCS San Raffaele Hospital in Milan. At the emergency department, each underwent clinical evaluation, electro-cardiogram, hemogasanalysis, and hematological analysis (a complete blood cell count including differential white blood cell count, and C-reactive protein).

Of the group, 300 were admitted for severe pneumonia and 102 were managed at home. The hospital stays averaged 15.3 days. The researchers conducted a psychiatric assessment about 31 days post discharge, or for those managed at home, 29 days after the emergency department visit. The screening was followed by a clinical interview and a battery of self-report questionnaires to investigate PTSD, depression, anxiety, insomnia, and OCD symptomatology.

The researchers noted that those with a higher level of systemic inflammation due to immune response had higher scores for depression and anxiety at follow-up. They recommended additional research on inflammatory biomarkers, in order to diagnose and treat emergent psychiatric conditions.

The full text of “Anxiety And Depression In COVID-19 Survivors: Role Of Inflammatory And Clinical Predictors” was published July 30, 2020, by Brain, Behavior & Immunity. An abstract is available online at https://www.sciencedirect.com/science/article/pii/S0889159120316068.

For more information, contact:

  • Mario Gennaro Mazza, Psychiatry & Clinical Psychobiology, Division of Neuroscience, IRCCS Scientific Institute Ospedale San Raffaele, Via Olgettina 60, Milan, Italy 20132; Email: info@hsantalucia.it; Website: https://www.hsantalucia.it/en/irccs.

Remember the famous “shoplifting” scene in Home Alone where 8-year old Kevin McAllister ends up accidentally stealing a toothbrush when he encounters Old Man Marley? The most memorable part is when Kevin actually thinks to ask the store clerk “Is this toothbrush approved by the American Dental Association?” The value of certification or accreditation of some sort for all the products and services we buy—and institutions we do business with—is gaining increasing importance in a world of growing competition and choices where transparency and trust are at a premium. The “Good Housekeeping Seal” concept may have evolved, but it hasn’t gone away even in this age of consumer reviews and social media endorsements. Health care, which is becoming increasingly consumer driven, is no exception.

“There is huge and growing competition for health care dollars. Everyone is monitoring their spend—payers and consumers—and accreditation may give them a reason to choose your organization over another,” says Jacqueline Gacek, RN, MS, Director of Quality, Streamline Healthcare Services. Ms. Gacek was presenting the session, Accreditation—A Path To Success, at The 2020 OPEN MINDS Management Best Practices Institute. Her point is that accreditation should be considered as part of an organization’s marketing strategy—to gain preferred relationships with health plans and other payers.

“A lot of payers are starting to require accreditation to be part of their preferred networks and some states require organizations to be accredited for licensure,” said Ms. Gacek. There are four main accrediting bodies for specialty provider organizations recognized by payers—Joint Commission, DNV GL Healthcare, Commission on Accreditation of Rehabilitation Facilities (CARF), and Council on Accreditation (COA). The Joint Commission alone evaluates and accredits more than 22,000 health care organizations and programs in the U.S.; CARF accredits 8,000 provider organizations; DNV GL accredits 600-plus hospitals; and COA accredits approximately 1,600 provider organizations. The standards of the four accrediting bodies meet or exceed the conditions of participation for Medicare and Medicaid, and many commercial payers.

But accreditation is far from static. While accreditation surveys paused initially during the pandemic, accrediting organizations are now moving ahead. DNV GL was the first accrediting organization to move ahead in May. They launched remote surveys, and a plan to resume full onsite surveys “when it is safe to do so.” The Joint Commission soon followed in June. Their revised procedures include use of personal protective equipment (PPE) and physical distancing practices by surveyors, limiting, limiting the numbers of individuals in group sessions, and increasing the use of audio or video conference calls.

There are also changes happening among the accrediting organizations. The Joint Commission updated their child welfare standards in July. And in an unexpected decision, the Centers for Medicare and Medicaid Services (CMS) extended the Joint Commission’s approval for hospital accreditation programs through July 2022—a 2-year extension as opposed to the typical six years. The reason? CMS’ “concerns” related to Joint Commission surveyor performance and comparability of the Joint Commission’s survey process to CMS. COA just announced that it is exploring a potential merger with the Alliance for Strong Families and Communities.

OPEN MINDS Senior Associate, Sharon Hicks, points out that “Even if health plans don’t require accreditation, they definitely give extra credit on the quality side for having accreditation. For example, a provider organization that is accredited may be exempt from reporting specific incidents to their insurance company.”

OPEN MINDS Senior Associate, Cathy Gilbert, concurs, “Health plans do look for accreditation for provider organizations contracting for full program type services. If they waive the accreditation requirement, they would require a site visit with a review process that covers pretty much the same things as an accreditation—and this can delay the contracting and credentialing process.” She says that some health plans also make concessions around credentialing if a provider organization is accredited. They may not have to credential all the licensed clinical professionals as they do with a group practice. As an organization, they would still have to submit rosters of their licensed staff with license information but would not have to go through a full credentialing process.

The question of accreditation—what programs and what accrediting body—is about more than mandates. By understanding the position of your current (and future) payers and health plan customers on accreditation, the market-oriented executive team can make an investment in accrediting with a tangible return.

Two separate studies corroborate that over a third of older adults will struggle with telehealth visits if they require the use of a video-call. The first study found that approximately 26.3% of Medicare beneficiaries are unable to access telehealth visits. Contributing to this is a lack of computers with high-speed internet (41.1% of beneficiaries) and a lack of smartphones equipped with wireless data plans (40.9% of beneficiaries). An additional study found that an estimated 13 million seniors, or approximately 38.0% of all older adults in the U.S., were “unready” for video visits at all, mostly due to inexperience with technology. Even if they have a child in the household, or two or more people in their social network that can help with access, about 32.0% are still unready to access video visits.

Telemedicine” is defined as the use of communications technology to deliver health care to patients at a distance. The second study defined “telemedicine” as direct-to-consumer video visits. “Unreadiness” is defined as meeting any of the following criteria:

  1. Difficulty hearing well enough to use a telephone (even with hearing aids)
  2. Problems speaking or making oneself understood
  3. Possible or probable dementia
  4. Difficulty seeing well enough to watch television or read a newspaper (even with glasses)
  5. Owning no internet-enabled devices or being unaware of how to use them
  6. No use of email, texting, or internet in the past month

Of those unready to use video visits for telemedicine purposes, approximately 30% have any inexperience with technology (no internet-enabled devices; do not know how to use internet-enabled devices; have not emailed, texted, or gone online in a month or more; or have no telephone). Approximately 20.0% of these individuals have at least one physical disability that prevents them from using telemedicine technology (difficulty hearing, difficulty communicating, difficulty seeing, or having probable or possible dementia).

In both studies, the researchers concluded there is a need to address disparities in digital access among older adults. One study suggests expanding the Lifeline program (a Federal Communications Commission program that provides reduced-cost phone or internet service to families with incomes 135% or more below the federal poverty level), but that will not assist with costs of needed devices to access the internet. The second study suggested that telecommunication devices should be covered by the Federal Government as a medical necessity for older adults, and that accessibility accommodations (such as closed captioning for those with hearing difficulty) should be offered for virtual visits.

These findings were presented in “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine,” by Eric T. Roberts, Ph.D.; and Ateev Mehrotra, M.D., MPH. For this research letter, the researchers analyzed public use respondent- and household-level data files from the 2018 American Community Survey (ACS), a nationally representative survey of the U.S. population. They selected ACS respondents who lived in the community (excluding those in nursing homes) and indicated that they were Medicare beneficiaries at the time of the survey. They assessed the proportion who did not have a desktop or laptop computer with a high-speed internet subscription, did not have a smartphone with a wireless data plan, or did not have either means of digital access. The study sample consisted of 638,830 surveyed individuals; equaling a representation of 54,749,082 when weighted. The goal was to examine disparities in digital access (i.e., access at home to technology that enables video telemedicine visits) among Medicare beneficiaries by socioeconomic and demographic characteristics.

The findings were also presented in “Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic,” by Kenneth Lam, M.D.; Amy D. Lu, M.D.; Ying Shi, Ph.D.; Kenneth E. Covinsky, M.D., MPH. The researchers analyzed 2018 data from the National Health and Aging Trends Study, which is a cross-sectional study of community-dwelling Medicare beneficiaries aged 65 or older. They determined telemedicine unreadiness under 4 scenarios: video visits; video visits assuming consumers who have social supports (defined as having a child in the household or at least two individuals in one’s social network) are telemedicine ready; telephone visits; and telephone visits assuming consumers with social supports are telemedicine ready. The goal was to assess the prevalence of telemedicine unreadiness.

The full text of “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine” was published on August 3, 2020 by JAMA Internal Medicine. A copy can be found at https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768772.

The full text of “Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic” was published on April 3, 2020 by JAMA Internal Medicine. A copy can be found at https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768771.

For more information, contact:

  • Eric Roberts, Ph.D., Assistant Professor, Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Room A653, Pittsburgh, Pennsylvania 15261; 412-383-0439; Email: eric.roberts@pitt.edu; Website: https://publichealth.pitt.edu/home/directory/eric-roberts
  • Kenneth Lam, M.D., Clinical Fellow, School of Medicine, University of California at San Francisco, 4150 Clement Street, Building 1, Room 207, San Francisco, California 94121; 415-221-4810; Email: kenneth.lam2@ucsf.edu; Website: https://profiles.ucsf.edu/kenneth.lam

On August 2, 2020, a federal judge struck down Department of Labor (DOL) restrictions on whether health care employees are eligible for the paid sick and family leave program established by provisions of Families First Coronavirus Response Act (FFCRA). The ruling said the DOL rules on the paid leave program unlawfully restricted employee eligibility during the coronavirus disease 2019 (COVID-19) public health crisis. The decision applies nationally. The judge said that the term “health care provider” as used in the FFCRA and defined by the DOL is “vastly overbroad” and includes employees “who are not even arguably necessary or relevant to the health care system’s vitality,” to exempt them from eligibility for the paid sick and family leave. In the wake of the ruling, health care employers must re-examine whether they must provide paid leave to certain employees and take steps to ensure that they have enough caregivers on hand to provide needed care.

The FFCRA was enacted on March 18, 2020. The provisions required job-protected paid sick leave and emergency family leave for employees unable to work due to COVID-19. Up to 61 million employees were estimated to be potentially eligible for paid sick leave or emergency family leave under the FFCRA. The provisions provide for the following:

  • Up to 80 hours of paid sick leave at the employee’s regular rate of pay where the employee is unable to work because the employee is quarantined (pursuant to Federal, State, or local government order or advice of a health care provider), and/or experiencing COVID-19 symptoms and seeking a medical diagnosis.
  • Up to 80 hours of paid sick leave at two-thirds the employee’s regular rate of pay because the employee is unable to work because of a bona fide need to care for an individual subject to quarantine, including a child under age 18 whose school or child care placement is closed or unavailable for reasons related to COVID-19.
  • Up to an additional 10 weeks of paid expanded family and medical leave at two-thirds the employee’s regular rate of pay where an employee, who has been employed for at least 30 calendar days, is unable to work due to a bona fide need for leave to care for a child whose school or child care provider is closed or unavailable for reasons related to COVID-19.

The FFCRA provides exemptions for small employers with fewer than 50 employees if the paid leave would leave the company unable to continue operations. It also provides exemptions for health care provider organizations.

On April 1, 2020, the DOL issued temporary regulations on the FFCRA paid leave program. The temporary rule is effective from April 2, 2020 through December 31, 2020. For the FFCRA, the DOL defined a “health care provider” as: anyone employed at any physician’s office, hospital, health care center, clinic, post-secondary educational institution offering health care instruction, medical school, local health department or agency, nursing facility, retirement facility, nursing home, home health care provider, any facility that performs laboratory or medical testing, pharmacy, or any similar institution, Employer, or entity. This includes any permanent or temporary institution, facility, location, or site where medical services are provided that are similar to such institutions, as well as any individual employed by an entity that contracts with any of these institutions described above to provide services or to maintain the operation of the facility where that individual’s services support the operation of the facility, [and] anyone employed by any entity that provides medical services, produces medical products, or is otherwise involved in the making of COVID-19 related medical equipment, tests, drugs, vaccines, diagnostic vehicles, or treatments.”

On April 14, 2020, the New York Attorney General filed State of New York v. United States Department of Labor, et. al to protest the DOL regulations. The Attorney General said the new rule violated the FFCRA in the following ways:

  • Unlawfully denying paid sick leave and emergency family leave to otherwise eligible employees if the employer determines—for any reason—that the employer does not have work for the employee.
  • Enabling the denial of the FFCRA’s paid sick leave and emergency family leave benefits to large classes of otherwise eligible workers by including them in an unlawfully broad definition of “health care provider.”

Additionally, the Attorney General alleged that the DOL exceeded its authority under the FFCRA in the following ways:

  • Prohibiting employees from taking their paid sick leave or emergency family leave intermittently absent their employer’s consent.
  • Conditioning an employee’s eligibility for paid sick leave or emergency family leave on the employee having previously provided documentation to the employer, including such unspecified documentation as may be required by a separate federal agency.

A link to the full text of “United States District Court: Southern District of New York Opinion & Order in State of New York v. United States Department Of Labor, Et. Al” may be found at www.openminds.com/market-intelligence/resources/080220nyvdolopinion.htm.

More information about how the DOL is implementing the FFCRA COVID-19 paid leave provisions is posted at https://www.dol.gov/agencies/whd/ffcra.

PsychU last reported on this topic in “Families First Coronavirus Response Act Signed With $3.47 Billion In Funding & New Mandates,” which published on May 11, 2020. The article is available at https://www.psychu.org/families-first-coronavirus-response-act-signed-with-3-47-billion-in-funding-new-mandates/.

For more information, contact:

  • Wage and Hour Division, National Contact Center, U.S. Department of Labor, 200 Constitution Ave NW, S-1032, Washington, District of Columbia 20210; Email DOL-Info@dol.gov; Website: https://www.dol.gov/agencies/whd/ffcra
  • Edwin Nieves, Media Contact, Wage and Hour Division, U.S. Department of Labor, 200 Constitution Ave NW, S-1032, Washington, District of Columbia 20210; 202-693-4655; Email: Nieves.Edwin@dol.gov; Website: https://www.dol.gov/agencies/whd/ffcra.

Brigham and Women’s Hospital has tapped mental health startup Rose to help support clinicians’ mental health during the COVID-19 pandemic. During the pilot program, emergency health care professionals at Brigham and Women’s Hospital will receive access to the Rose platform, which monitors their levels of well-being and detects changes in real time.

The platform collects data from users in the form of questionnaires and free-response journal entries, which can be completed in as few as 30 seconds, according to the company. Rose uses those data to track mental health, monitor stress levels, identify triggers and get ahead of more extreme events. Rose, which has its roots at Johns Hopkins University, developed a HIPAA-compliant mental health monitoring platform and mobile app platform that is powered by patented artificial intelligence and natural language processing technology, according to the company.

The use of AI enables the platform to identify key indicators and warning markers for the presence or advancement of mental health symptoms in a user’s responses to questions and prompts. The startup also provides each user with a personalized feed of curated content from its library of more than 1,000 articles and videos based on the user’s history, behavior and app inputs.

Brigham and Women’s Hospital is an academic medical center based in Boston, Massachusetts. The Brigham serves individual from New England, across the United States, and from 120 countries around the world and is a major teaching hospital of Harvard Medical School.

Rose was founded under the belief that mental well-being requires individual and provider organizations to be able to communicate and understand each other in a continually adaptive manner. Rose is actively developing an ecosystem to make this possible, with the ultimate goal of making safe and reliable mental health care accessible to all.

For more information, please contact:

  • Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115; 617-732-5500; Website: https://www.brighamandwomens.org/
  • Rose, 3400 Prospect Street NW, Washington, District of Columbia 20009; 833-400-7673; Website: https://www.askrose.com

On August 19, 2020, the boards of the Alliance for Strong Families and Communities (Alliance) and the Council on Accreditation (COA) signed a nonbinding letter of intent to explore a merger. Both organizations are active in the child welfare sector. In 2018, together they had combined revenue of nearly $20 million. Through the rest of 2020, a Joint Negotiation task force will conduct due diligence. If a decision to proceed is made, the new organization will be created in early 2021.

In a joint statement, Susan N. Dreyfus, president and chief executive officer (CEO) of the Alliance and Jody Levison-Johnson, president and CEO of COA, noted: “The merging of our two organizations to create a new organization is a very exciting possibility as it would amplify both of our missions, assets, networks and accelerate our shared vision to achieve greater impact, influence, and foster more rapid innovation. This new organization would be grounded in a deep commitment to equity, diversity, and inclusion that creates better outcomes for people and communities with a strong focus on advocacy at the local, state, and federal levels. We could maximize our joint capacities, credibility, and reputation, and will build upon the excellence of our partner organizations through data and research, best practices, quality standards, policy, and accreditation pathways. Jointly, we would become a multifaceted and larger cross-sector network of partners (beyond existing COA-accredited organizations and current Alliance members) that could strengthen the reach and influence of our respective fields and the social, health, and human services sector as a whole.”

The Alliance is a strategic action network of social sector leaders who through their excellence, distinction, and influence are working to achieve a healthy and equitable society. It aggregates best practices and serves as an incubator for learning and innovation to generate new solutions. The organization seeks to accelerate change through dynamic leadership development and collective actions to ensure policies and systems provide equal access and opportunity.

The COA, founded in 1977, is an international non-profit accreditor of community-based behavioral health care and social service organizations. COA accredits the full continuum of child welfare, behavioral health, and community-based human and social services for children, youth, adults, and families. COA has developed separate accreditation programs for private organizations, public agencies, Canadian organizations, military programs, and child and youth development programs. Currently, COA accredits or is in the process of accrediting over 1,600 organizations or programs that serve more than 10 million individuals and families each year.

For more information, contact:

  • Jennifer Devlin, Spokesperson, Alliance for Strong Families and Communities, 1825 K Street, N.W., Suite 600, Washington, District of Columbia 20006; 703-876-1714; Email: jdevlin@alliance1.org; Website: https://www.alliance1.org.

Alternative payment methods (APMs) for mental health and addiction disorder treatment are associated with lower behavioral health service utilization and lower spending, as well as improvements in process of care outcomes, according to a review of evaluations of 17 APM implementations. Of the 17 APM implementation evaluations, 11 assessed utilization changes and five found lower utilization. Eight evaluations assessed spending, and half found an association with lower spending. Fifteen evaluations assessed process of care, and 12 reported statistically significant improvements due to the APM.

Among the five APM evaluations that assessed clinical outcomes, three reported improvements. Although data on clinical outcomes was scarce in the APM evaluations, pay-for-performance APMs were associated with improved behavioral health outcomes. APMs with shared savings were not.

The 17 APMs spanned three broad types: fee-for-service (FFS) with links to quality and value, APMs built on FFS architecture, and population-based payments. Within each broad type, the implementations could take different approaches and serve different populations. Nine targeted people with addiction disorder, four targeted people with mental health disorders, and the remaining four targeted both mental health and addiction disorder. Eleven of the APM implementations specifically focused on adults, and two specifically targeted children and adolescents.

17 Alternative Payment Methods Focused On Behavioral Health

Implementation Type Population

Outcomes Evaluated

FFS With Link To Quality & Value

Sustaining Healthcare Across Integrated Primary Care Efforts Program Foundational payments for infrastructure and operations Medicare, Medicaid, and individuals with dual eligibility; all ages Mental health and addiction treatment, processes of care and spending
Adolescent Community Reinforcement Approach Pay-for-performance Publicly funded SUD programs; child and adolescent Addiction treatment, processes of care, clinical outcomes, and spending
Spectrum Addiction Services Pay-for-performance Medicaid and uninsured; adult Addiction treatment, processes of care
Outpatient Psychosocial Counseling Treatment Center In Maryland Pay-for-performance Publicly funded addiction treatment programs; adult Addiction treatment, processes of care, clinical outcomes, and adverse selection
Washington State Mental Health Integration Program Pay-for-performance Medicaid; adult Mental health, processes of care, clinical outcomes, and adverse selection
Connecticut’s Behavioral Health Partnership Pay-for-performance Medicaid; child and adolescent Mental health and addiction treatment, process of care

APMs Built On FFS Architecture

Medicare Shared Savings Program Accountable Care Organizations APMs with shared savings Medicare; adult Mental health and addiction treatment; processes of care, clinical outcomes, spending, utilization, and adverse selection
Maine Medicaid Accountable Communities Initiative APMs with shared savings Medicaid; adult Mental health and addiction treatment; processes of care, spending, and utilization
Vermont Medicaid Shared Savings Program APMs with shared savings Medicaid; all ages Mental health and addiction treatment; processes of care, utilization, and adverse selection
Medicare Pioneer Accountable Care Organizations APMs with shared saving and downside risk Medicare; adult Mental health; processes of care, clinical outcomes, spending, utilization, and adverse selection
Minnesota Integrated Health Partnerships Program APMs with shared saving and downside risk Medicaid; all ages Mental health and addiction treatment; processes of care, spending, and utilization

Population-Based Payment

Delaware Division of Substance Abuse and Mental Health–Outpatient Services APM Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; processes of care, utilization, and adverse selection
Delaware Division of Substance Abuse and Mental Health–Detoxification Care Transition APM Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; utilization, and adverse selection
Maine Addiction Treatment System, phase 1 of performance-based contracting Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; clinical outcomes, utilization, and adverse selection
Maine Addiction Treatment System, phase 2 of performance-based contracting Condition-specific population-based payment Publicly funded addiction treatment programs; adult Addiction treatment; process, utilization, and adverse selection
BCBSMA Alternative Quality Contract Comprehensive population-based payment Commercial; adult Mental health; process of care, spending, and utilization
Oregon Coordinated Care Organizations Comprehensive population-based payment Medicaid; adult Addiction treatment; process of care

These findings were reported in “Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders; A Systematic Review” by Andrew D. Carlo, M.D., MPH; Nicole M. Benson, M.D.; Frances Chu, MSN, MLIS; et al. The researchers analyzed 27 articles published from January 1, 1997 to May 17, 2019, on 17 APM implementations in behavioral health care. The goal was to review and summarize the published literature on APMs for people with behavioral health conditions to evaluate the impact of the APM on behavioral health outcomes or changes in service delivery. The articles each assessed at least one mental health or addiction treatment outcome in comparison to a control group. The researchers concluded that their review identified some evidence for APM effectiveness for behavioral health care; however, more research is needed to identify successful program components and associations with clinical outcomes.

The full text of “Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders; A Systematic Review” was published July 23, 2020 by JAMA Network Open. A copy is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768565 (accessed August 17, 2020).

For more information, contact: Andrew D. Carlo, M.D., MPH, Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 446 East Ontario Street, #7-200, Chicago, Illinois 60611; Email: andrew.carlo@nm.org; Website: https://www.uwmedicine.org/school-of-medicine.

People with mental health disorders who received mental health services at specialty behavioral health clinics had a lower likelihood of having a psychiatric inpatient admission, according to a study of utilization in a large health system in New York. The odds of an inpatient admission were higher for those who received mental health or addiction treatment services at a medical clinic with integrated behavioral health services and higher for those who received behavioral health services at a medical clinic. About 59% received all of their mental health care in medical settings and from provider organizations unaffiliated with the health system. About 16% of people with serious mental illness (SMI) also received all their mental health care in medical settings and from unaffiliated provider organizations.

Compared to the odds of inpatient admission among people who received services in a mental health setting, the odds for those who received services in medical only or in integrated medical and mental health settings were as follows:

  • The odds of a mental health admission were 5.57 times higher for those who received services in a medical setting.
  • The odds of a mental health admission were 3.87 times higher for those who received mental health services in a combined medical and mental health setting.
  • The odds of a medical admission were 2.40 times higher for those who received services in a medical setting.
  • The odds of a medical admission were 1.96 times higher for those who received mental health services in a combined medical and mental health setting.
  • The odds of an addiction disorder admission were 4.25 times higher for those who received services in a medical setting.
  • The odds of an addiction disorder admission were 1.28 times higher for those who received mental health services in a combined medical and mental health setting.

These findings were reported in “Treatment of Serious Mental Illness in Medical and Mental Health Settings” by Scott Wetzler, Ph.D.; Bruce Schwartz, M.D.; Sara Wetzler; Urvashi Patel, Ph.D.; and Nathaniel Counts, J.D. The researchers analyzed claims data from the New York State Medicaid Data Warehouse for 8,988 consumers ages 18 to 65 who had received at least one mental health service at Montefiore Medical Center, an urban academic medical center during 2017 at a mental health setting, a medical setting, or both. The goal was to investigate service use by individuals with SMI and non-serious mental illness. The analysis excluded records for consumers who had dual Medicare/Medicaid coverage, or were receiving services covered by the New York State Office for People With Developmental Disabilities, by an HIV special needs plan, or by Supplemental Security Income were excluded, as were patients with commercial insurance coverage.

Of the 8,988 adults, 2,333 had SMI diagnosis: schizophrenia, delusional or other psychotic disorders, and bipolar disorders; and 6,655 had a non-serious diagnosis. The majority of the full group, 5,289 people, had basic Medicaid coverage (59%) and 3,699 (41%) were enrolled in a specialized Medicaid Health and Recovery Plan (HARP). The HARP coverage provides enhanced care management and support services to people with SMI or addiction disorder.

The 8,988 people were grouped by where their mental health services at Montefiore were provided, with 5,342 who received all through a medical clinic, 3,000 who received all through a specialized mental health clinic, and 646 who received services in both medical and mental health settings. The researchers classified the claims as inpatient or outpatient.

  • Inpatient services were divided, based on the principal discharge diagnosis, into general medical, mental health, or addiction episodes of care.
  • Outpatient services were subdivided into general medical provided by the primary care professional, mental health services delivered by the primary care professional, mental health services provided by a mental health specialist in the primary care setting, or mental health services provided by a mental health specialist (i.e., psychiatrist, psychologist, or social worker) in a specialty mental health setting, and specialized medical services.

The full text of “Treatment of Serious Mental Illness in Medical and Mental Health Settings” was published April 23, 2020, by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900392.

For more information, contact:

  • Scott Wetzler, Ph.D., Professor, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461; Website: https://www.einstein.yu.edu/faculty/4865/scott-wetzler/.

Home health care had a mere 3% share of the $3.6 trillion U.S. health care market in 2018. Medicare and Medicaid together made up 75% of home health spending in 2018. Home-based health care today largely comprises face-to-face care covered by Medicare, long-term services and supports funded through Medicaid home and community-based waivers, and wraparound services.

The pandemic has changed this equation. All health care (or most of it) has been home-based— though largely through telehealth. The question for executive teams developing their recovery strategies is how much of that care will remain virtual—and for face-to-face services, what proportion will move to home-based as opposed to returning to traditional office-based services. Kevin Scalia, Executive Vice President, Corporate Development, Netsmart provided some interesting perspectives on this issue of service location in the “next normal” during the session, Home-Based Services—Opportunities In The Post-Pandemic Health & Human Service System, at the recent 2020 OPEN MINDS Management Best Practices Institute.

Netsmart home care customers saw a big decrease in home-based face-to-face services at start of the pandemic, but those service levels have now rebounded. But as he looks ahead, Mr. Scalia sees the reimbursement model adopted for Medicare home care services making its way to behavioral health and other health-related services across all payers. The model, referred to as the Patient Driven Groupings Model (PDGM) is episodic payment for home care, based on diagnosis and incentives driven by outcomes. “I believe this is coming to behavioral health,” Mr. Scalia said.

There are a few reasons why episodic payments are likely to become more common. First, the possibility of “overbilling” for telehealth services is a fundamental payer concern about continuing the liberalized use of virtual care, and episodic payments would partially address that issue. And, episodic payment models can allow payers to pay for “hybrid” service models—combining virtual care, face-to-face in-home services, and face-to-face clinic-based services in a single payment mechanism.

So, what are the opportunities to deliver home-based services for provider organizations that are considering adding that service delivery model? Mr. Scalia had a number of interesting ideas. First, partnerships with existing provider organizations. He said there are twelve clinical groups in PDGM—one of them being behavioral health. PDGM base rates are adjusted for comorbidities, risk, and resource needs, with outcomes closely monitored (skilled nursing facilities have also shifted to a similar model, the Patient Driven Payment Model or PDPM). Mr. Scalia observed that most home care provider organizations don’t have the clinical resources to provide behavioral health services and would be open to partnerships. A second opportunity is for provider organizations to build their own home-based service delivery programs—specializing in particular consumer conditions and needs. Either option would prepare an organization to deliver home-based care and also to manage episodic payment arrangements with incentives based on consumer experience and outcomes.

Mr. Scalia also highlighted the opportunity for provider organizations to expand into virtual and home-based primary care. He pointed to a recent survey that found that consumers want to connect with “their own” physician rather than a “random physician”—the model of many new telehealth services. This is a big opportunity for specialty provider organizations that have relationships with consumers and can protect and extend those relationships by providing primary care services. And it was surprising to learn that this is already happening to a degree. Netsmart’s use of their primary care module by behavioral health organizations has climbed 77% over the pandemic period.

So how to prepare for a future of hybrid services? First there is expansion of the technology platform. Episodic payments require new billing systems. Electronic visit verification, workforce management, route optimization, telehealth, and mobile solutions with enhanced security were other technologies that Mr. Scalia discussed as part of the enhanced functionality needed for adding home-based service delivery to a hybrid service model.

Another surprising piece of our discussion of preparing for this shift to hybrid is the need for provider organizations to “go retail” with marketing. “Provider organizations need to build a brand for Medicare,” Mr. Scalia noted. The consumers must want to come to you. And as health plans change their network model—with a single provider network for all payers—the provider organizations with the best “consumer perception” are going to be the ones selected by payers.

What do the many opportunities in this move to hybrid models—virtual, at home, and in clinic— share? Mr. Scalia closed the session with this thought—the focus of any new provider organization service development should be on health plan partnerships. “Health plans are going to go around the hospitals directly to community-based provider organizations—behavioral health, home care, senior living, and more. They want partnerships with them to coordinate care and keep people out of the hospital.”

As of July 2020, 50% of adults in the United States fear a major health event could lead to bankruptcy, a five-percentage point increase since 2019. This is especially true for “non-white” adults, among which 64% voiced this concern, a 12-point increase since last year.

Approximately 15% of the U.S. population, including 20% of non-White adults, carry long-term medical debt. Those in households earning less than $40,000 per year are more than four times as likely (28%) as those in households earning $100,000 or more (6%) to be carrying long-term medical debt. One-quarter report that they would need to borrow money to pay a $500 medical bill (via credit card, loan from a financial institution, or borrowing from a friend or family member). Another 14% of U.S. adults report using a medical flexible spending or health savings account to pay medical bills.

The researchers concluded the sharp rise in U.S. health care costs has caused an increase in concerns regarding payment for medical care in the U.S. This concern has only increased during challenges presented by the coronavirus disease 2019 (COVID-19) public health emergency. While they did not make recommendations regarding the results of the survey, the researchers noted that the high cost of health care could be a significant issue in decisions made during 2020 elections.

These findings were presented in “50% in U.S. Fear Bankruptcy Due to Major Health Event,” one in a series of polls conducted as part of the West Health-Gallup U.S. Healthcare Study, where 1,007 U.S. adults were interviewed between July 1 and July 24, 2020. The goal was to determine current trends in medical costs and financial concerns in the U.S.

The full text of “50% in U.S. Fear Bankruptcy Due to Major Health Event” was published on September 1, 2020 by West Health and Gallup. A copy of the report can be found at https://www.westhealth.org/press-release/1-in-2-americans-fear-a-major-health-event-could-lead-to-bankruptcy/.

For more information, contact:

Before the start of the pandemic, nearly 570,000 Americans were homeless. And now, as unemployment rolls mount and moratoriums against evictions and foreclosures expire, an additional 30 to 40 million people could be at risk of homelessness in the coming months. Even before the pandemic, leaders in the health care field had started to acknowledge that housing insecure consumers are consumers who use more health care resources.

But the big question remains—what to do about it? How do health plans approach the issue of caring for housing insecure members? That was the focus of the keynote session, Housing Is Health Care: A Post-Pandemic Look At Integrating Social Determinants Of Health, by Andy McMahon, Vice President, Health & Human Services Policy, UnitedHealthcare Community & State, at The 2020 OPEN MINDS Management Best Practices Institute.

Mr. McMahon outlined a concrete plan—described as the “five levers”—to address the issue of housing among their members. The five levers? Data, policy/system reforms, investments, partnerships, and new clinical models. In each of these areas, Mr. McMahon gave an overview of the many UnitedHealthcare initiatives in each area, but a few stood out:

  • Data: Using data to track consumers and intervention outcomes—and integrating data to increase systemwide collaboration.
  • Policy/system reforms: Advocating for changes in Medicaid 1115A waivers to pay for tenancy supports and aligning HUD vouchers to connect with health care.
  • Investments: Making investments to spur affordable housing development with Stewards for Affordable Housing for the Future, pay-for-success initiatives, and low-interest loans for safety net services.
  • Partnerships: Participating in multi-system partnerships to increase Medicaid supports for housing-related services and developing value-based purchasing contracts that embrace these concepts.
  • New clinical models: Delivering intensive wraparound care onsite through the “housing + health” clinical care model with end care management, patient-centered health coaching, and goal planning, addiction recovery support, employment navigation, and non-emergency transportation assistance—transitioning medically stable and financially self-sufficient members to market-rate housing with ongoing support.

So, what are the opportunities for provider organizations in this national initiative by one of the largest health insurers?

Funding streams: Provider organizations should check if payers have special funding streams to support new or expanded health care and social service programs. For example, UnitedHealthcare has a “plan-agnostic” $150 million social impact investment fund which provides low-interest “catalytic capital” for housing and health care projects that connect more consumers to holistic services and supports.

Onsite and hybrid care models: Provider organizations that can offer face-to-face and hybrid services will be in demand, even as virtual care gains increasing traction across the board. “Many homeless people with serious mental illness don’t just have an iPad and even if they can access the technology, the remote communication may be troubling for them. You need to have case managers present with these consumers to support them in person, even if they are visiting with their clinical professional virtually,” explained Mr. McMahon. Provider organizations that can provide onsite face-to-face services at housing project sites will also have new contract opportunities.

Medical respite programs: For provider organizations offering residential services, respite care for the homeless population may present a new service line opportunity. The need for respite care has been exacerbated by the pandemic and payers are looking for care and support options for homeless consumers “who are not sick enough to stay in hospital but not well enough to go back to the streets or a shelter,” said Mr. McMahon.

Holistic health and social services: From tenancy supports to transportation, a spectrum of services is needed to care for the homeless population and Mr. McMahon advised provider organizations to “strive for end-to-end care management.” Payers are seeking provider organizations that are willing to partner across continuums of care and collaborate with other provider organizations (to offer primary care and behavioral health services), public housing authorities, health plans, state housing finance agencies, transportation sources, etc. to build holistic support frameworks for the homeless population. “With value-based payment contracts and alternative payment models, we are looking for other ways to pay for these things provider organizations are doing to help consumers,” said Mr. McMahon.

What is Mr. McMahon’s advice for provider organizations seeking new opportunities in the housing market? “Come knock on the door and ask us how you can partner,” he suggested. Do your research and focus your outreach efforts on specific functions and/or departments of the payer organization such as population health management, community partnerships, and complex care coordination. He cautioned that provider organizations need to come to the table with data on program efficacy and how they will affect outcomes and expenses. “The worst thing for an MCO to hear is that we spent all this money, and nothing happened,” said Mr. McMahon. At the end of the day, payers are looking for partners who will help them understand the “shared population,” build relationships and work across the continuums of care.

Enrollees in low-spending Medicaid managed care organization (MCO) plans used fewer services, including fewer low-cost, high-value services, and fewer high-value drugs. Enrollees auto-assigned to the lowest-spending plan had 30% lower health care spending than if they were enrolled in the highest-spending plan in the market.

Spending varied considerably across Medicaid MCOs despite no difference in cost-sharing. However, there was suggestive evidence that enrollees in low-spending plans were more likely to experience avoidable hospitalizations. They also had lower use of screening and of high-value drugs to treat diabetes, asthma, and severe mental illnesses. Enrollees assigned to low-spending plans were also more likely to switch out of their plan post assignment.

The researchers concluded that low-spending Medicaid MCOs with no cost-sharing cause broad reductions in the use of health care services and ultimately worsen beneficiary satisfaction and health. The effects were driven by differences in quantity across plans, rather than differences in the negotiated provider organization rates.

These findings were presented in “Are All Managed Care Plans Created Equal? Evidence from Random Plan Assignment in Medicaid,” by Michael Geruso, Timothy J. Layton, and Jacob Wallace. The researchers analyzed spending for 65,596 non-elderly adult Medicaid beneficiaries in New York City, who were randomly assigned to one of 10 Medicaid MCO plans, all with no cost-sharing. New York City is the second-largest Medicaid managed care market in the country, as its residents make up about two-thirds of the state’s Medicaid population. In the New York Medicaid program, beneficiaries who miss the deadline to actively choose a plan are auto-assigned to one of the plans in their market. The detailed administrative data was obtained from the New York State Department of Health (NYSDOH) from 2008 to 2012, which contains certain beneficiary-level demographic and enrollment data linked to health care claims for services covered by fee-for-service Medicaid (FFS) and private MCOs. The MCO enrollment data include an indicator for whether a beneficiary made an active plan choice or was auto-assigned. The goal was to determine the extent to which plans can influence spending without differences in cost-sharing and the trade-offs associated with any spending reductions.

The full text of “Are All Managed Care Plans Created Equal? Evidence from Random Plan Assignment in Medicaid” was published in August 2020 by the National Bureau of Economic Research. A copy is available at https://www.nber.org/papers/w27762.

For more information, contact: 

Telehealth visits may be as effective as in-person visits for maintaining continuous medication-assisted treatment (MAT) for at least three months after starting MAT, according to a rapid evidence review. Further, contingency management improved treatment retention when combined with antagonist MAT, but not with agonist forms of MAT. Applicability, however, may be limited due to implementation challenges.

There were no differences in treatment retention for people using extended-release (XR) buprenorphine in either injectable or implant formulations compared with daily buprenorphine. There were conflicting results with XR-naltrexone injection compared with daily buprenorphine. The addition of psychosocial interventions did not appear to improve retention, but many of the comparison studies provided counseling to the control group, which may have masked the evidence of effectiveness. For incarcerated people, starting MAT before release improved retention in treatment after release.

The rapid evidence review included findings from two systematic reviews and 39 primary studies. The researchers observed that most studies of MAT for opioid use disorder (OUD) did not focus on retention as the primary outcome. Additionally, many studies were small and had design flaws.

These findings were reported in “Retention Strategies For Medications For Addiction Treatment In Adults With Opioid Use Disorder,” a comparative effectiveness review commissioned by the federal Agency for Healthcare Research and Quality (AHRQ). The researchers, Brian Chan, M.D., MPH; Emily Gean, Ph.D.; Irina Arkhipova-Jenkins, M.D., MBA; Jennifer Gilbert, M.D., MPH; Jennifer Hilgart, MSc; Celia Fiordalisi, MS; Kimberly Hubbard, BA; Irene Brandt, MA; Elizabeth Stoeger, BS; Robin Paynter, MLIS; P. Todd Korthuis, M.D., MPH; and Jeanne-Marie Guise, M.D., MPH, conducted a targeted literature review of systematic reviews and randomized controlled trials. They summarized evidence for six retention intervention types: care settings/services/logistical support, contingency management, health information technology, extended-release medication-based treatment, psychosocial support, and financial support. The primary outcome was retention, defined as continued medication engagement for at least three months after MAT initiation. Secondary outcomes included mortality and harm.

A link to the full text of “Retention Strategies For Medications For Addiction Treatment In Adults With Opioid Use Disorder” may be found at www.openminds.com/market-intelligence/resources/082120ahrqecmatretention.htm.

For more information, contact:

  • Farah Englert, Media Contact, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Floor 7, Rockville, Maryland 20857; 301-427-1865; Email: farah.englert@ahrq.hhs.gov; Website: https://www.ahrq.gov/

On August 27, 2020, Arkansas Governor Asa Hutchinson announced that the Arkansas Department of Human Services (DHS) will add 700 slots to the state’s Community and Employment Supports (CES) Waiver program for people with intellectual and developmental disabilities (I/DD). The CES waiver covers Medicaid home- and community-based services (HCBS), supported living, adaptive equipment, specialized medical supplies, and supported employment. It currently serves 4,800 people.

Pending approval by the state legislature, and Centers for Medicare & Medicaid Services (CMS), the new slots will be available beginning December 1, 2020. They will be offered to people on the CES waiver waiting list who have been waiting the longest for services. Currently, there are more than 3,500 people on the waiting list; the average wait lasts 10 years. Individuals on the waiting list are determined eligible at the time of their initial request and their continued eligibility is confirmed prior to the awarding of a slot.

The new slots are funded through a new premium tax in the Provider-Led Arkansas Shared Savings Entity (PASSE) program. To date, this tax has generated about $15 million to fund waiver slots. The PASSE program serves Medicaid beneficiaries with complex behavioral health disorders or I/DD; it currently serves nearly 40,000 people. The PASSE ensures that members have access to all services covered under the Medicaid state plan, the Community Independence Waiver and the CES Waiver.

This is the second time Governor Hutchinson and DHS have expanded the number of people in the program. In 2016, the state’s Tobacco Settlement Fund Commission agreed to allocate unspent funds to cover 500 new slots.

PsychU last reported on this topic in “Arkansas To Reduce Developmental Disability Waiver Wait List By Half Over 3 Years,” which published on February 24, 2017. The article is available at https://www.psychu.org/arkansas-reduce-developmental-disability-waiver-wait-list-half-3-years/.

For more information, contact:

The pandemic has brought the spotlight to many inequities in the health care system. One is the access to treatment (and soon, access to vaccines) for people with disabilities. A few months ago, the shortage of ventilators was a critical issue—causing states to look at their standards for crisis care plans. As these plans were published, disability rights groups saw some states put out policies that either overtly discriminated against people with disabilities or at best, were ambiguous about protections for people with disabilities. Add to this no-visitor policy for people with disabilities admitted to hospitals and unable to communicate on their own, and instances of inaccessible COVID testing, and a troubling picture emerges.

The media reports that Washington state officials were discussing the possibility of rationing care in the event of a shortage of medical equipment and personnel caused the Arc and other disability rights groups to send a letter in March to the U.S. Department of Health and Human Services Office for Civil Rights (HHS-OCR), to ensure that any government decisions to ration treatment would be made without discriminating based on disability, according to Shira Wakschlag, Director For Legal Advocacy, Arc. But shortly thereafter, some states announced policies that the groups found to be discriminatory. They filed four complaints with HHS-OCR about disability discrimination and treatment rationing plans in Washington, Alabama, Tennessee, and Kansas. Later complaints were filed against discriminatory rationing policies announced in Utah, Oklahoma, North Carolina, Oregon, Arizona, and North Texas.

The complaints addressed a range of issues. These included categorical exclusions from treatment on the basis of disability diagnosis, quality of life assessments in place of objective medical evidence, long-term survival speculation beyond the prognosis for COVID-19 treatment, failure to provide for reasonable modifications in receiving treatment including allowing for longer time on a ventilator, reallocation of the ventilators for people with chronic conditions, and overall failure to provide for a reviews of each consumer to avoid decisions based on diagnoses and stereotypes.

In response to the complaints, the U.S. Department of Health & Human Services Office of Civil Rights (HHS-OCR) issued a bulletin in March advising entities covered by civil rights authorities keep in mind their obligations to avoid unlawful discrimination against people with disabilities when making decisions about their treatment during the COVID-19 health care emergency. HHS-OCR also conducted compliance reviews and complaint investigations. Subsequently, Alabama, Connecticut, Tennessee, Pennsylvania, Utah, and North Texas withdrew or amended their discriminatory ventilator rationing policies and instructed hospitals across the state that they cannot discriminate against people with disabilities in accessing treatment.

In Connecticut, disability rights groups filed a complaint against the state for not allowing reasonable exceptions to hospital no-visitor policies for persons with disabilities hospitalized with COVID. This denies consumers the ability to communicate, make informed decisions, and provide informed consent, the groups stated. In Nebraska, the local disability rights group complained to the state for failing to make reasonable modifications to TestNebraska, the COVID-19 testing program. The prescreening required Internet access and being tested required driving to the test site and waiting. The complaint noted that “Many people with disabilities, including people who have intellectual and developmental disabilities (I/DD), are blind, or are in institutional or congregate facilities like nursing homes and assisted living, are unable to drive and lack access to other transportation, and thus are unable to participate in TestNebraska.”

“There is a risk that decisions about rationing essential medical supplies will not be made only on the basis of how well consumers are going to respond to treatment, but may also include a judgment about which lives are more valuable than others that doesn’t have a place in a medical decision-making process,” said Ms. Wakschlag. She noted that the Arc and other groups will continue to work with hospitals and others to ensure that crisis standard of care plans take individuals with disabilities into account. Overcoming categorical exclusions from care, eliminating policies that allow for the reallocation of personal ventilators, and prohibiting long-term survivability not related to the emergent condition as a factor in care decisions will be the priorities.

On August 28, 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) began distributing the first-year funds of its two-year State Opioid Response (SOR) and Tribal Opioid Response (TOR) grant programs. The two programs ultimately will award nearly $3 billion over two years to help states and tribes provide community-level resources for people in need of prevention, treatment, and recovery support services. The awards ranged in size from $4,001,239 for South Dakota to $105,864,578 for California.

Through these existing funding streams, states, and tribes have been able to develop and utilize integral systems of comprehensive care to address their jurisdictions’ individual needs. Through SOR, states across the country are funded to develop tailored approaches to prevention, treatment, and recovery from opioid use disorders and/or stimulant use disorders. The program provides access to evidence-based medication to treat opioid use disorders, along with psychosocial services and community supports. The TOR program enables the development of these same comprehensive approaches among tribal communities.

The awards for each state and tribe are posted at https://www.samhsa.gov/sites/default/files/sor-tor-fy2020-awards.pdf.

The Substance Abuse and Mental Health Services Administration is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. Their mission is to reduce the impact of addiction and mental illness on America’s communities.

For more information, please contact:

  • Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, Maryland 20857; 877-726-4727; Website: https://www.samhsa.gov/newsroom/press-announcements/202008270530.

In this companion piece to the PsychU April 23, 2020 webinar, “Substance Use & The Novel Coronavirus Pandemic: A Conversation With The Experts,” Dr. Roueen Rafeyan discusses patients who believe substances of abuse help them cope better with stress than prescribed psychiatric medications.

Roueen Rafeyan, MD, is the Chief Medical Officer for Gateway Foundation Addiction Treatment Centers and an Assistant Professor of Psychiatry at the Feinberg School of Medicine, Northwestern University. Dr. Rafeyan was identified as the Top Psychiatrist in the Nation by Consumer Reports in 2007. He is also a Distinguished Fellow of the American Psychological Association (APA) and American Society of Addiction. Dr. Rafeyan earned his MD at Istanbul University in Turkey and completed his residency at the University of Illinois at Chicago.

Rachel Self, PhD, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

Mark Tacelosky, PharmD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

 

 

Roueen Rafeyan, MD, is a paid consultant to Otsuka Pharmaceutical Development & Commercialization, Inc.

Rachel Self, PhD, and Mark Tacelosky, PharmD, are paid employees for Otsuka Pharmaceutical Development & Commercialization, Inc.

Three Medicaid health plans that partnered with Lyft to provide non-emergency medical transportation (NEMT) reported improved access to care, lower use of emergency care, and more primary care visits among members who used the service. Members using Lyft to travel to medical appointments also reported higher member satisfaction. Lyft reported outcomes for AmeriHealth Caritas DC, Amerigroup TN, and Centene.

AmeriHealth Caritas DC contracted with Access2Care in 2018. Access2Care is a NEMT manager that partners with Lyft, to oversee AmeriHealth’s transportation program. The health plan evaluated the impact of Lyft for 11,400 members who used the service to get to and from routine medical appointments and urgent care between April 2018 and April 2019. The outcomes, based on claims analysis conducted four months before and after the initial ride with Lyft were as follows:

  • 40% decrease in emergency room (ER) utilization
  • 15% decrease in low acuity non-emergent ER utilization
  • 12% decrease in ambulance utilization
  • 45% increase in compliance rate for 42 Healthcare Effectiveness Data and Information Set (HEDIS) measures

Amerigroup TN partnered with Lyft in 2019 to improve access to care for its members. The health plan started with a 12-month pilot in Memphis, and given early successes, quickly moved to scale the service statewide. The outcomes were as follows:

  • 50% decrease in primary care gaps
  • 44% increase in primary care physician visits
  • 90% decrease in transportation-related grievances
  • 92% of rides with 5 out of 5 stars

Centene worked with its transportation managers in 2018 to launch Lyft pilot programs at four subsidiary health plans: Buckeye Health Plan, in Ohio; Sunshine Health Plan, in Florida; Peach State Health Plan, in Georgia; and Superior Health Plan, in Texas. The outcomes were as follows:

  • 66% decrease in member-rider complaints
  • 99% on-time arrival rate
  • 85% of rides with 5 out of 5 stars
  • One-star ratings dropped from 10% to 1%
  • Average wait time decreased from 28 minutes for a traditional NEMT ride to seven minutes for Lyft

Lyft was founded in 2012 and is a large transportation networks in the United States and Canada. In 14 states and the District of Columbia, it provides access to rides for eligible Medicaid patients, supporting up to 29 million people to get to their appointments. In early 2019, Lyft announced its approval as an enrolled Medicaid provider in Arizona, its first state, making Lyft the first national ridesharing company to bring NEMT services to millions of Medicaid patients.

The outcomes were published as a blog post on August 19, 2020. The post is at https://www.lyft.com/blog/posts/research-improving-access-to-care-medicaid.

For more information, contact:

 

In this companion piece to the PsychU April 23, 2020 webinar, “Substance Use & The Novel Coronavirus Pandemic: A Conversation With The Experts,” Drs. Robin Nelson and Roueen Rafeyan share the strategies they have implemented during the novel coronavirus pandemic to maintain their own wellness.

Robin Nelson, MD, is the PsychU Major Depressive Disorder Section Advisor, a psychiatrist at DGR Comprehensive Behavioral Health LLC in Wyomissing, PA, and an attending psychiatrist at the Caron Foundation Treatment Center in Wernersville, PA. Dr. Nelson received his MD from Duke University’s School of Medicine. He completed his residency in Duke University’s Psychiatric Residency Education Program. Dr. Nelson is board certified by the American Board of Psychiatry and Neurology.

Roueen Rafeyan, MD, is the Chief Medical Officer for Gateway Foundation Addiction Treatment Centers and an Assistant Professor of Psychiatry at the Feinberg School of Medicine, Northwestern University. Dr. Rafeyan was identified as the Top Psychiatrist in the Nation by Consumer Reports in 2007. He is also a Distinguished Fellow of the American Psychological Association (APA) and American Society of Addiction. Dr. Rafeyan earned his MD at Istanbul University in Turkey and completed his residency at the University of Illinois at Chicago.

Rachel Self, PhD, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

Mark Tacelosky, PharmD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

 

 

Robin Nelson, MD, and Roueen Rafeyan, MD, are paid consultants to Otsuka Pharmaceutical Development & Commercialization, Inc.

Rachel Self, PhD, and Mark Tacelosky, PharmD, are paid employees for Otsuka Pharmaceutical Development & Commercialization, Inc.

On August 17, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a new policy to clarify that a 20% Medicare add on payment for services provided to beneficiaries with presumed or diagnosed coronavirus disease 2019 (COVID-19) can only be paid if the beneficiary had a positive COVID-19 test. The goal of this new guidance is to combat fraudulent add-on payment claims.

The details were presented in “New COVID-19 Policies For Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), & Inpatient Rehabilitation Facilities (IRFs) Due To Provisions Of The CARES Act.” Providers must use a viral test such as a molecular or antigen test that is consistent with Centers for Disease Control and Prevention guidelines. The test can be performed either at the hospital, or by another entity, such as a local health department. A viral test performed within 14 days of the beneficiary’s admission can be manually entered into their medical record to satisfy this requirement. If a test is performed more than 14 days prior to a hospital admission, CMS will consider if there are medical factors in addition to that test result to determine if the documentation requirement has been fulfilled.

A link to the full text of “New COVID-19 Policies For Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), & Inpatient Rehabilitation Facilities (IRFs) Due To Provisions Of The CARES Act” may be found at www.openminds.com/market-intelligence/resources/081720cmscovidpolicyhosps.htm.

PsychU last reported on this topic in “IRS Says For-Profit Health Care Provider Organizations Must Pay Taxes On CARES Act Provider Relief Fund Payments,” which published on September 14, 2020. The article can be found at https://www.psychu.org/irs-says-for-profit-health-care-provider-organizations-must-pay-taxes-on-cares-act-provider-relief-fund-payments/.

For more information, contact: 

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On August 21, 2020, New Castle County, Delaware selected ChristianaCare to staff the Division of Police’s newly expanded Behavioral Health Unit. The unit provides mental health and addiction disorder outreach to the community. ChristianaCare’s Community Health team will hire a mental health professional, two case managers, a licensed clinical professional, a registered nurse, and a child victim advocate to begin working with the Behavioral Health Unit in the fall of 2020. The program is supported for the next three years by more than $2 million in federal and state grant funding.

The New Castle County Division of Police formed the Behavioral Health Unit in October 2019, with the goal of increasing its capacity to help people with mental illness or addiction avoid police involvement. The unit combines the activities of the Division’s pre-existing Hero Help Addiction Unit and its Mental Health Unit. The Hero Help program refers people to addiction treatment rather than arrest for low-level crimes. It also provides outreach and Narcan for non-fatal overdose victims, and on-going case management to assist with bridging gaps in treatment. The Mental Health Unit pairs a mental health clinical professional with a police officer to respond to certain emergency calls; the goal is to help those in crisis and help individuals connect to care to prevent repeat calls for service.

On December 2019, the county released a procurement (20PP-003) to provide Hero Help Addiction and behavioral health assistance consulting services. The county sought priced proposals from qualified professional consultants to provide two case managers, a nurse, a mental health professional, a licensed clinical professional, and a child victim advocate. Responses were due by January 8, 2020. The county received three bids but has not reported the names of any unsuccessful bidders. The CristianaCare grant contract runs for 36 months, through May 31, 2023.

ChristianaCare is a health care organization based on Wilmington, Delaware. Its network includes outpatient services, home health care, urgent care centers, three hospitals (1,299 beds), a free-standing emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women’s health.

The procurement is available for download at https://www.openminds.com/rfp/delawares-castle-county-seeks-hero-help-addiction-and-behavioral-health-assistance-consulting-services/.

For more information, contact:

Over the past many months, much of health care (along with education, banking, cocktail parties, and more) has moved to telehealth. But, telehealth in and of itself is not an innovation—and adopting telehealth in the midst of a pandemic is not an indicator that your organization has the ability to innovate. An organization that quickly shifted most of their services to telehealth may be flexible and reactive—but not necessarily innovative.

More importantly, most don’t think telehealth is likely to be the end of the evolution of virtual care. The next wave is likely to occur in remote monitoring—active and passive. Remote patient monitoring (RPM) uses digital technologies to collect health data from consumers in one location and electronically transmit that information securely to a different location for assessment. There are many types of technologies for RPM—in-home sensors and cameras, watches, patches, smartphone apps, and more. And there is a wide range of data that can be collected with RPM—vital signs, mood, sleep, weight, blood pressure, blood sugar, blood oxygen levels, heart rate, and electrocardiograms. The strategic importance of RPM technologies is that they harness the power of predictive analytics in a real-time platform in a way that greatly reduces the staff-to-consumer ratio used for keeping tabs on the status of consumer health. This allows provider organizations to deploy their professional staff to actively work on addressing consumer health improvements—and move beyond monitoring.

Health plans have already recognized the potential of remote monitoring tools. Earlier this year, Humana announced it would allow members to connect their wearables, health apps, and in-home medical devices to its Go365 mobile app that tracks wellness and prevention activities and offers rewards (such as gift cards) for those who reach their goals. Consumers do not have to enter any data as their wearables and fitness trackers feed directly into the app.

What does this look like from the delivery system perspective? The emerging use of remote patient monitoring (RPM) tools was the focus a recent 2020 OPEN MINDS Management Best Practices Institute session, Using Remote Patient Monitoring: Improving Outcomes For Consumers With I/DD, featuring Shaleea Shields, I/DD Innovation Manager, Merakey Allegheny Valley School, and Tom Morgan, Chief Information Officer, Merakey. Merakey provides behavioral health, intellectual and developmental disability, and autism and educational services through at about 700 locations in 12 states.

The Merakey Allegheny Village School provides residential services for 1,400 adults with I/DD in a variety of settings, including group and family homes, across five states. Consumers in these facilities are given iPads that support RPM. The RPM portal on the iPad is used to monitor critical health conditions. As one example, a consumer with pneumonia was monitored remotely using a pulse oximeter. The focus is on early intervention, immediately connecting consumers to their primary care professional, avoiding an emergency room visit and hospitalization.

For Merakey, the iPads serve multiple health management functions beyond RPM. The iPads are also used by consumers to contact staff with non-emergency questions and to facilitate telehealth visits. They also facilitate email apps that send appointment reminders, travel apps that help consumers navigate bus routes, and engagement apps that keep them involved in their care. “We leverage our size and expertise to develop innovative solutions and new models of care to meet the needs of individuals, their families, public and private health care funders, and community partner organizations,” said Mr. Morgan. For consumers, RPM means greater connectedness with clinical professionals. “We found that consumers with I/DD enjoy using technology just like the rest of us, as it gives them a sense of independence,” noted Mr. Morgan.

Why isn’t there more use of remote monitoring? There is the reimbursement issue—it was only late last year that the Centers For Medicare And Medicaid (CMS) expanded reimbursement for RPM services. Today, CPT Code 99454 covers the supply and provisioning of devices used for RPM programs. And CPT code 99453 is a one-time practice expense that covers the initial setup of devices, training and education on the use of monitoring equipment, and any services needed to enroll the consumer on-site. And CPT codes 99457 and 99458 allow for reimbursement for time spent on activities related to remote care, such as reviewing patient data. Today, 23 state Medicaid programs and commercial health plans in 13 states are also required to cover RPM services. But not all payers are there yet.

But as reimbursement moves away from fee-for-service, the power of Artificial Intelligence-infused RPM offers great value advantage in terms of consumer convenience, proactive health interventions, and optimal use of clinical team member talent. Even before the pandemic changed the equation in a fundamental way, 88% of health care provider organizations said they had invested or planned to invest in remote patient monitoring solutions to support their transition to value-based care and contain exploding health care costs, manage chronic conditions, and deal with staff shortages.

The challenge is getting started with remote monitoring. There is an amazing array of RPM technologies to choose from. There are wearables that track wellness and vital signs. The new Amazon Halo band (signaling Amazon’s expanding footprint in the health care space) will use artificial intelligence and multiple advanced sensors to provide highly accurate information to help users monitor and improve their health. Who doesn’t want a wearable that incorporates an accelerometer, a temperature sensor, a heart rate monitor, and even microphones that listen to your voice and track your mood! And that tells you how to improve activity, sleep, and body mass index.

Like all technologies, any purchase of RPM technology needs to start with organizational strategy and be evaluated in terms of improving revenues, margins, and/or performance. Evaluating clinical efficacy, technology functionality, and interoperability with current EHR and care coordination platforms are just a few of the factors that determine whether or not particular RPM technologies make sense for a service line.

 

Professional Disability Associates (PDA) launched a new behavioral health claim management service. PDA, a subsidiary of The Advocator Group and Brown & Brown, Inc., provides specialty risk resources and consultative solutions to the disability insurance market. The new service is intended to help disability insurance carriers improve decision making, duration management, resource utilization, and return to work outcomes of people with complex and, often, costly claims.

Utilizing innovative psychometric survey tools and the expertise of behavioral health clinical professionals, PDA will work with its insurance carrier customers to identify behavioral health claims where psychosocial issues may be affecting the claimant’s functional capacity. Claims selected will follow a prescribed process to identify and assess the claimant’s specific behavioral health issues to determine how the behavioral health issues affect the claimant’s ability to work. Claims suited for this service include those with a primary behavioral health diagnosis, co-morbid behavioral health condition, undiagnosed behavioral health, or COVID-19 impacted claims.

PDA’s proprietary process for evaluating these claims includes an evaluation of medical history and a psychometric assessment of the claimant’s ability and mindset about returning to work, combined with an in-depth interview by a seasoned behavioral health clinician. Targeted strategies for future claim management can include a multi-disciplinary discussion, outreach to a treating provider, outreach to an employer, a peer review, an independent medical exam, and/or surveillance. Where possible, the service will also serve to make recommendations as to how to safely and securely return a claimant to work.

Professional Disability Associates (PDA) is an innovative industry leader in providing specialty risk resources, including medical and vocational review services, consultative solutions and industry benchmarking, as well as full-service claim administration capabilities to major disability insurers and self-insured employers. PDA seeks to deliver customized solutions.

For more information, please contact:

The integration of behavioral health care into primary care is one approach to bridging the care continuum and increasing access to mental health treatment. In this webinar, speakers John Kern, MD, and Sloan Manning, MD, review the origins of behavioral health care integration, identify the role of payers, and identify the successes—and challenges—of current integration efforts. Moderated by Roland Larkin, PhD, NP, this webinar closes with an examination of technology’s role in behavioral and primary health care integration going forward.

Featuring: 

  • John Kern, MD
    Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
  • Sloan Manning, MD
    Primary Care Providers Section Advisor, PsychU
    Medical Director, Novant Health Urgent Care & Occupational Medicine
  • Roland Larkin, PhD, NP
    Medical Science Liaison, Otsuka Pharmaceutical Development & Commercialization, Inc.

 

John Kern, MD, serves as a clinical professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine, as well as the University of Washington’s AIMS Center, the acknowledged world leader in the integration of behavioral health care services into primary care.

Sloan Manning, MD, is the PsychU Primary Care Providers Section Advisor. Dr. Manning is the Medical Director of Novant Health Urgent Care & Occupational Medicine.

Roland Larkin, PhD, NP, is a Medical Science Liaison with Otsuka Pharmaceutical Development & Commercialization, Inc.

 

 

John Kern, MD and Sloan Manning, MD are paid consultants of Otsuka Pharmaceutical Development & Commercialization, Inc.


Roland Larkin, PhD, NP, is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

Walmart will now sell health insurance policies directly to its customers, according to a Walmart spokesperson. Walmart lists job openings on its career’s website for “Walmart Insurance Services LLC.” The retailer already has 18 Care Clinics across Texas, Georgia, and South Carolina, providing treatment for chronic and acute illnesses, though the clinics do not currently accept Medicare Advantage plans.

Walmart’s reach across U.S. consumers, including seniors, has the potential to drive up volume for Medicare plans. While Walmart has confirmed the creation of the insurance agency in a statement, they did not share details about the plans it will sell or their pricing.

Last month Walmart acquired the technology platform CareZone, a venture-backed startup that develops apps to help people manage medications and chronic illnesses. The deal was pegged at $200 million. The retail giant has long been seen as a potential major disruptor for the health care industry. It continues to sell a list of generic medications for no more than $4 and is piloting a health-focused store in Georgia.

Walmart operates approximately 11,500 stores under 56 banners in 27 countries and eCommerce websites in 10 countries. They employ approximately 2.2 million associates around the world with 1.5 million in the U.S. alone.

For more information, please contact:

  • Walmart, 702 SW 8th Street, Bentonville, Arkansas 72712; 800-925-6278; Website: https://corporate.walmart.com/

On July 14, 2020, Amazon announced a collaboration with Crossover Health to pilot convenient health centers near Amazon fulfillment centers and operations facilities in Texas. The first “Neighborhood Health Center” location will be available for Amazon employees and their families in the Dallas-Fort Worth area. Additional centers are planned for other states. Through this initial pilot program, Amazon expects to establish 20 health centers in five cities across the United States: Dallas/Fort Worth, Texas; Phoenix, Arizona; Louisville, Kentucky; Detroit, Michigan; and San Bernardino/Moreno Valley, California. If the pilot is successful, Amazon will look to roll out similar facilities in other cities and states.

The pilot health centers will offer a range of primary care services only for Amazon employees and their families. The centers will offer extended hours to accommodate various employee work schedules. The range of services include full-spectrum acute, chronic, and preventive primary care, prescription medications, vaccinations, behavioral health services, physical therapy, chiropractic care, health coaching, and care navigation to specialty referral services. To support families, same-day pediatric services will also be available. Crossover Health’s proprietary technology platform allows individuals to start nearly all of their care online and then transition to in-person care as needed.

Crossover Health, Inc. provides workplace health care services for employers and employees in various organizations. It is a national medical group that works with self-insured employers. Amazon is a large online retailer and service provide. Its services include Customer reviews, 1-Click shopping, personalized recommendations, Prime, Fulfillment by Amazon, AWS, Kindle Direct Publishing, Kindle, Fire tablets, Fire TV, Amazon Echo, and Alexa.

For more information, please contact:

  • Amazon, 410 Terry Avenue North Seattle, Washington 98109-5210; 206-266-1000; Website: www.aboutamazon.com
  • Crossover Health, Inc., 26831 Aliso Creek Road Suite 200, Aliso Viejo, California 92656; (949) 891-0328; Email: press@crossoverhealth.com; Website: www.crossoverhealth.com

We know the pandemic has forced “innovation” (read “telehealth”) in all of health care and especially in behavioral health. However, the reactive move to telehealth in itself is not innovation. The 15- to 20-year lag between the development of a new and effective practice—and its common use at the community level—persists. As we look ahead and look beyond “video visits,” the question is how much and how will the consumer get services? What are the constraining factors? There is one big factor—the technology on both the consumer and organizational sides of the equation.

We got a glimpse into the strides and the gaps in technology in a national survey of more than 1,000 behavioral health care executives and staff conducted by Qualifacts and the National Council For Behavioral Health. The survey confirmed the dramatic spike in telehealth use by most provider organizations that had no other option to keep their doors open. Pre-pandemic, only 2% of organizations were providing 80% or more of their care virtually but today 60% of organizations are providing 80% or more virtual care. Post-pandemic, only 8% of provider organization executives expect their organizations to deliver more than 80% of care virtually, while the majority (43%) say virtual will constitute 40% to 60% of their overall service delivery. It’s also interesting that organizations with fewer than 100 employees tended to adopt virtual care at a higher percentage than larger ones.

These findings reflect the overall health care landscape. Health care provider organizations’ use of telehealth has gone up by 50 to 175 times during the pandemic. In April, nearly half of all Medicare primary care visits were conducted via telehealth (compared to less than 1% pre-pandemic). In May, as in-person visits picked up again, telehealth visits dropped to 30% of visits. Currently, 57% of clinical professionals view telehealth more favorably than they did before while 64% are more comfortable using telehealth.

The consumer challenges

On the consumer side of the equation, consumer use of telehealth rose from 11% in 2019 to 46% during the pandemic and 76% of consumers are “interested” in telehealth moving forward. However, in this new survey, community behavioral health provider organizations reported concerns about consumers not having the right technology and not being able to understand and use the technology even if it is available. Poor connectivity, lack of Internet access, and difficulty understanding technology were rated as the top three consumer challenges, from their perspective.

These concerns about consumer use of technology are not just focused on Medicaid, but across the entire consumer population. Medicaid beneficiaries are not unlike the rest of the general adult U.S. population when it comes to digital technology use. We know that 86% of Medicaid beneficiaries own smartphones and 69% own tablets—compared to 86% and 72% in the general population and 94% and 79% among those with employer insurance.

But the “digital divide” persists. A recent research letter published in JAMA: The Journal of the American Medical Association indicates that about 38% of elderly consumers were not ready for video visits due to inexperience with technology and 72% of those older than 85 were not prepared for virtual health. There is a broader digital divide. More than 21 million people in the United States don’t have Internet access and that includes 30% in rural areas. And 60% of health care facilities outside metropolitan areas lack broadband as do 40% of the nation’s schools.

The provider organization and staff challenges

Only 26% of clinical staff that were surveyed reported that they “preferred” to deliver service virtually. They expressed the need for consumer engagement solutions to enhance care between sessions. And 47% of clinical staff are concerned about maintaining connections with peers and supervisors in a virtual care environment. This is consistent with the overall U.S. workforce. Even pre-pandemic, remote workers said their greatest challenges were collaboration and communication, and loneliness. And six months of lockdowns and isolation have exacerbated the situation.

Complicating the long-term use of virtual care are differences in executives’ and clinical professionals’ views of their technology capabilities and needs. There is agreement on the key requisites—a comprehensive telehealth platform, consumer engagement solutions to enhance care between sessions, telephonic interventions, consumer portals, and staff engagement sessions. But there is a divergence in how they perceive their electronic health record (EHR) system. Managers had a higher level of confidence (64%) in their EHR’s ability to support virtual care. But only 44% of staff felt the same way. Why the disconnect? One possible explanation is that while legacy EHRs are functional—allowing for service delivery, billing, and collections—workflows have not been reengineered for virtual care, resulting in inefficiencies for clinical staff.

As we look ahead, what are the takeaways for the many executives of specialty provider organizations looking to make virtual service delivery an integral part of their long-term recovery strategy? On the consumer side, provider organizations will have to figure out how to assure consumer access to technology and how to engage consumers in a more virtual service landscape.

For those consumers without the tools and bandwidth to participate in virtual care and remote monitoring, it is likely that provider organizations in value-based arrangements (with enough financial risk) will provide that technology. But even with “connection,” the bigger issue is finding the best practice engagement strategies that yield a return on investment. There is no doubt that engaged consumers have better health status and use fewer unnecessary health care resources. The question is how much health plans and their preferred provider organizations should invest in engagement.

On the clinical service side, taking a look at virtual service workflows will be critical. And, assuming organizations will have a greater proportion of staff members being totally remote, supervision practices will need to be enhanced along with models for clinical team collaborations. If we are going to make the shift to virtual service delivery a permanent one, rethinking how work gets done and how it is managed is critical.

Thirty years ago, the adage in the health care field was “all health care is local.” Hospitals were tied to communities, community mental health centers had catchment areas, Blues plans were organized by states, primary care was a local carriage trade—all of that has changed. Hospitals are now organized in multi-state (or at least multi-county) health systems. Community mental health centers have jumped the catchment area concept—pushing across state lines. Former Blues plans are multi-state behemoths. CVS and Walmart are building health clinics across their footprint. And, this was all before the pandemic.

Now, the virtualization of health care services is further blurring the tie between service delivery and geography. Virtual health care provider organizations are experiencing rapid growth—going public at record multiples. Health systems continue their diversification of both geography and service lines. “Franchise like” expansion of specialty health care services continues. Many specialty provider organization executive teams have made the decision, now that they have virtual service capabilities, they might as well “go statewide.”

Within this changing landscape, there are three key strategic questions about geography for most provider organizations. First, is current revenue, market share, and/or margin in your current geographic footprint at risk due to expanding “out of area” and virtual competition? Second, should expanding your geographic footprint be part of your strategic growth plan? Third, if growth of geographic footprint is a consideration, what services and what geographies should be evaluated for feasibility?

With regard to the first question about competition, most would argue that the revenue from most health care services is “at risk” from out of area and virtual competition. One category of competition is from franchise-like competitors—the CVS, Walgreens, and Walmarts of the market. These organizations offer convenient, low cost, standardized sets of services. Another category is the virtual service delivery organizations—Talkspace, Ginger, Doctor On Demand, Heal, and Hims & Hers—that offer any consumer with an internet connection the ability to get a variety of services online through various models. Lastly, the expanding footprint and service offerings of health systems is a major factor. The pandemic, and its effect on hospital revenue, has put some health system expansion initiatives on hold, but they may come back with a vengeance as these systems look to stabilize their margins.

So, the strategic question is whether and how much the current portfolio of services of an organization will be affected by this geographic expansion of competitors—and what is the strategy to mitigate the negative financial effects of this competition. One possible strategy is a geographic expansion of your own. But this leads to two questions that need some significant market research—what services and what geographies?

The answer to what services would be best for expansion is driven by a few factors. Start with a portfolio review to identify a few services with the following criteria—profitability higher growth potential, clear competitive advantage, and manageable capital requirement for replication. Organizations can develop a new service for geographic expansion, but that often requires new expertise, and definitely requires more capital.

With regard to what geographies are the best fit for your strategy, the OPEN MINDS team has developed a structured process for geographic market evaluation. This market evaluation has both a quantitative and qualitative component. There are three key steps in the quantitative analysis. First, set your objectives for any geographic expansion—increase in revenue, diversification, margin improvement, etc. Second, determine the optimal market factors in any new geography—reimbursement rates, regulatory factors, prevailing wage rates, managed care models, etc.—and the relative weight of those factors. Third, gather the market data and rank or rate each geographic area. This quantitative way of looking at the market is the place to start in thinking about geographic expansion. It identifies what regions should be at the top of your list.

But, this metrics-driven market ranking needs to be followed by a qualitative assessment of each market. First, who are the key payers that are relevant to the planned geographic expansion? Do they need the service? How do they pay for the service? Are they satisfied with the current competitors in the service area? And, then there are the competitors themselves. What are the benefits and features of their services, ability to expand, service capacity, and reputation? With a sense of the payers and competitors in each high-priority geography, decisions can be made about priorities for expansion.

Provider organization consolidation was in full force before the pandemic crisis. But the pandemic crisis is likely to fuel more mergers, acquisitions, affiliations, and other weird arrangements. The reason is straightforward. The post-crisis market landscape will likely include more price pressure, more value-based reimbursement, and more technology—all factors that favor larger, well-capitalized provider organizations.

The question for many provider organization executive teams is how to become one of those larger, well-capitalized organizations that will be sustainable in the post-pandemic landscape. There are only a few options—grow by acquiring or merging with another organization, grow by being acquired by a larger organization, or develop a rapid organic growth strategy fueled by capital from a collaboration of some type or from outside investors. Most executive teams would prefer the first option—being the acquirer. But many of those executive teams are going to find themselves in competition with private equity firms for the “best” organizations to acquire.

Over the past decade, the interest of private equity firms in health care has increased. In 2019, global health care investment deals were at $78.9 billion. In the U.S., these deals rose $46.7 billion in 2019, compared with $29.6 billion in 2018. Sixty percent of these investments were related to service providers and about 15% related to health care technology. Funding for digital health initiatives and health information technology worldwide was $8.9 billion in 2019. The number of health services transactions were down in the first half of 2020, but deal volumes and value are expected to rebound in the second half of the year. Deals involving health services organizations were more than 21% lower through the first half of 2020 compared to that period the prior year, while deal value dropped 52%.

But despite the expected overall dip, there are some areas of increase even in the midst of the pandemic. During the first quarter of 2020, $576 million in equity funding worldwide went to mental health startups, rising 400% from $115 million during the last quarter of 2019. There were 44 recorded deals involving mental health startups during the first quarter of 2020, up 18.9% from 37 in the last quarter of 2019. During the first quarter of 2019, there were 42 recorded deals in this sector with a value of $210 million.

Two other areas where investment increased include telehealth/digital health services and health care technology using artificial intelligence. But new reports cite growing investor interest in primary care and hospice. And surprisingly, long-term care investments remained strong despite the very negative coverage of the future of nursing homes.

Private equity investments in health care are changing the sustainability of traditional provider organizations in several ways—with new service offerings, investment capital for technology and marketing, pressure on fees, and the ability to accept value-based reimbursement. Increased competition creates challenges for traditional provider organizations to maintain competitive advantage for their service lines that have a margin. The strategic options are straightforward—develop a plan to compete with their new service offerings or develop a plan to join a larger organization that can.

But there is a new and emerging scenario. The combination of the continued flow of capital into the health and human service market—coupled with the weakened financial state of many provider organizations caused by the pandemic—is likely to produce a different cadence to investments. Like their non-health care counterparts, there will likely be some “surprise” financial failures. And private equity firms and other investment firms will be in a position to react fairly promptly to the opportunities presented by these financial failures.

Executive teams of provider organizations need to be thinking strategically about mergers and acquisitions (M&A) as part of their recovery strategy. In addition to thinking about target M&A organizations for geographic expansion, for market share of currently profitable services, and for diversification and new service lines, it is important to have a preemptive M&A strategy. The key question—which competitor organizations would present an acute market threat if they had more capital? These are organizations where proactive discussions might be in order.

Now is the time for provider organization executive teams to change their M&A strategies from opportunistic to intentional. Rather than limiting the M&A target list to organizations in obvious financial trouble (it may be better to try to acquire their contracts, staff, or specific assets), proactive targeting of potential partners helps with organizational strategy.

However, keeping on top of consolidation in the field is no easy task. There is no “master registry” of mergers and acquisitions in the health and human service field—either on the for-profit or non-profit side. The key is to know the players in your market—competitors and payers—that matter and stay on top of their plans for growth. The adage “be prepared” comes to mind.

Since the start of the pandemic, many have frequently written about the need for innovation in crisis. And our current crisis has certainly spurred or forced considerable innovation in every sector.

Retailers are livestreaming the shopping experience for consumers. Restaurants are offering not just food but meal prep kits and heat-and-eat options for takeout. Friends are in their own homes but watching movies together through creative sharing platforms sans the popcorn. Broadway has come into homes through Disney Plus. And a popular grill in Ocean City, Maryland is requiring consumers to wear giant inflatable “bumper tables” on wheels to maintain social distancing.

But crisis or not, innovation is not a concept that comes naturally to health and social service provider organizations that have been sustained by a steady stream of payer-prescribed fee-for-service and cost-based payments for decades. For many organizations, their innovation infrastructure is rusty. But as we head into a likely economic depression, and a predicted restructuring of the health and human service financing and delivery system, it is unlikely that the historic payer-directed growth model is going to be enough to sustain most organizations. The question is how to align the competing priorities of survival and innovation. How do executives think about new business models and new market segments while keeping the doors open now?

One approach is “The Three Box Solution.” What is it? It is a strategy for allocating organizational assets—executive time, attention, capital and other resources—in three domains or “boxes”—the present, the past, and the future. For the present, manage the current business for optimal operational success and margin. From the past, identify strengths to build on and eliminate the ideas and practices that can inhibit innovation. And for the future, convert breakthrough ideas to be your “next big thing” and anchor of future sustainability. The model—developed by former Harvard Business School professor Vijay Govindarajan—is similar to a “balanced scorecard” of innovation investment.

The three-box concept has even more relevance as executive teams struggle to cope with the financial implications of the pandemic. There is a need to have a plan for survival in the present and a plan for sustainability in the future—both in motion at the same time. But in adding the focus on the past, Dr. Govindarajan acknowledges that it is often history that prevents executive teams from moving ahead. In a recent interview, he spoke of the importance of forgetting and unlearning and letting go. “If you cannot forget, you cannot learn, yet organizations find it extraordinarily difficult to forget.”

Most important to the current situation, the theory of the three-box solution is based on the assumption that the future is now. There is no time to wait to develop a “future strategy” in the future. The job of preparing for the future needs to be done now. But Dr. Govindarajan is quick to point out that the organizations that have been most successful are likely to let go of the past to invest in the future.

What does this look like on the ground? OPEN MINDS Senior Associate, George Braunstein, and the former CEO of two health care organizations discusses how to achieve the balance between present operations and future investments. His first piece of advice—look at your executive team and your performance data. “If as CEO, you’re spending more than 10% of time on operations, you’re not doing your job,” he says. And he emphasized that data for continuous performance improvement is essential to identify and address the causes of poor performance.

Change management—the letting go of the old for the new—takes a different set of executive skills in Mr. Braunstein’s experience. He recounted a time his organization was trying to introduce same day consumer access. But at the time, clinical professionals controlled their own schedules and were reluctant to give that up. The solution was a bit of barter—providing the new EHR technology they wanted in exchange for a new scheduling model. “I told them we could get a new EHR and they could help pick it but in return they had to agree to centralized scheduling.”

Finally, there are the challenges of innovating for the future in a clinical setting. Mr. Braunstein recommends breaking it down to the basics, “Identify and understand a need (or determine what’s not working), assess what resources you have, and match the two. Then pilot the solutions.” He offered two hands-on examples. The first was changing the service mix for psychiatrists—adding nurse practitioners to the team and having psychiatrists conduct medication groups for consumers who were stable and did not need individual appointments. The two changes freed up many hours of the psychiatrist’s time, improving access to care without hiring additional staff. In another instance, their clinical team found that behavioral health treatment outcomes for homeless consumers were not where they needed to be. The team created new business plans, pursued and blended multiple funding streams, forged new partnerships and invested in a Housing First model—improving outcomes all around. He noted, “Innovation happened because we were addressing a need.” That is good advice for every organization and initiative.

When thinking about how to navigate the next six months, think about how our destinies (both personal and organizational) are a balance between fate and free will. The question posed by Elizabeth Gilbert in Eat, Pray, Love – “which one do I need to stop worrying about because it’s not under my control, and which do I need to steer with concentrated effort?” – is the question addressed by the three-box solution. Many organizations would benefit if their executive teams spent less time thinking about fate (the horse they can’t control) and more time focused on the “basics” of improving current operations and developing new solutions. Or in the words of Louis Pasteur, “Chance favors the prepared mind.”

The pandemic has pushed both the health and human service field and the education field to virtual service models—and most don’t think either field is ready for the challenges. Yes, clinical professionals of provider organizations have made a dramatic pivot to delivering most services online. And, the majority of education services—at all levels—remain in some virtual mode.

But there are two problems. First, from the provider organization perspective, this pivot—with makeshift policies and procedures and patchwork infrastructure—is fine for a stopgap. But many questions remain if this is the long-term solution. Training, supervision, consumer engagement, teamwork, health recordkeeping access, workflow, and reimbursement are just a few of the issues that need to be addressed if virtual is to become the primary means of service delivery.

But the second problem is the broader problem. Do most consumers have the tools and the ability to participate in virtual services? The Federal Communications Commission reported that 21 million Americans—roughly 10% of the 209 million adults—lacked broadband internet. But Microsoft data shows that 162 million people across the United States are not using the internet at broadband speeds—obviously a much higher (and problematic) proportion of the population.

Consumer access to technology is a baseline assumption as we move to more virtual care and a more value-based approach to health services. An article in Lancet Digital Health attributes the digital divide to three causes—lack of access because of inability to pay for technology, lack of motivation, and lack of digital skills and education.

A recent Pew Research Center study found that about 20% of parents with homebound schoolchildren say it is very or somewhat likely their children will not be able complete their schoolwork because they do not have access to a computer at home or don’t have reliable internet at home and have to use public Wi-Fi. That concern is magnified among lower-income groups, where 36% of parents say their children can’t complete schoolwork because they have no computer at home and about 40% report the same likelihood of their child having to use public Wi-Fi to finish schoolwork because there is not a reliable internet connection at home. This survey also covered another key aspect of the digital divide—many Americans are worried about their ability to pay their internet or cellphone bills over the coming months. Over 28% of those who have a high-speed connection worry that they may not be able to pay for this service over the next few months, and 30% of smartphone owners are worried about paying their cellphone bill.

More specifically, a recent report in JAMA Internal Medicine estimates that 13 million older adults (38% of the older adult population) may have trouble using telehealth services. And Medicare beneficiaries without digital access are more likely to be 85 or older, widowed, have a high school education or less, be Black or Hispanic, or have a disability or be covered by Medicaid. For all the enthusiasm for technology and all things virtual (certainly investors love it), the numbers tell a different story. The vision of “mostly virtual” isn’t possible without addressing this digital divide.

What does this look like in the field? In one community, the junior high school parking lot is a “hot spot” where children sit in their parents’ cars and do their daily schoolwork. And a colleague was explaining how her elderly mother who is savvy enough to watch YouTube or Netflix on her tablet or laptop but petrified at the thought of navigating a telehealth visit on her own, getting on camera, and actually talking to a clinical professional remotely.

Joe Dan Beavers, the Chief Executive Officer of Lifeskills, described the steep decline in the volume of services for children provided by his organization—which serves many rural areas—has experienced since schools abruptly closed in March. They have lost contact with most of the children in need of services. A few families have attempted to resume services via smartphone video, because that’s all the technology they have. But some parents have interrupted the children mid-session because they are concerned about the visit “using too much data” or they just need their phone for something else and can’t wait.

So, what are the implications for provider organizations? First, don’t plan on everything remaining virtual in your recovery strategy. You’re going to need some level of in-person or at least hybrid services, depending on your target consumer groups. There are demographic groups that are not going to be well served by telehealth (for many reasons) and developing specialized programs for these consumers is great market positioning.

Second, think about how to connect consumers with technology they don’t have—smartphones, Internet connectivity, etc. Payers and health plans, as well as charitable foundations and large private corporations, may have programs to support bridging this digital divide. For example, Magellan Behavioral Health of Pennsylvania members are eligible to get a free smartphone, data, and minutes each month through the Lifeline federal benefit program. Many other health plans are connecting the Medicaid consumers they serve to the Lifeline benefit as well. And last year, the federal government allowed Otsuka Pharmaceutical Co., Ltd to loan smartphones to people taking Abilify MyCite, a tablet form of the antipsychotic aripiprazole manufactured with an embedded ingestible sensor. Otsuka asked the Office of Inspector General for an opinion on its plans to loan, on a temporary basis, a limited-functionality smartphone to financially needy individuals who do not already have a device that can receive adherence data from the sensor embedded in the medication.

And third, even if the consumers you serve have the tools, think about ways to engage those consumers in using online services. One approach adopted by MyStrength (now Livongo) was to pair consumers with peers in using technology. This use of peers has been found to be very effective in not only using telehealth but in using asynchronous technologies as well.

Regardless of the post-crisis recovery strategy adopted by any health and human service organization, the effect of telehealth will be part of the equation. How to best adopt these technologies to assure a distinctive competitive advantage is the issue. Inevitably, the digital divide needs to be part of the equation.

Blackstone announced that private equity funds managed by Blackstone have reached a definitive agreement to acquire Ancestry from Silver Lake, GIC, Spectrum Equity, Permira, and other equity holders for a total enterprise value of $4.7 billion. Current Ancestry investor GIC will continue to retain a significant minority stake in the company. This transaction represents the first control acquisition for Blackstone’s eighth vintage of its flagship private equity vehicle.

Ancestry is the global leader in digital family history services, operating in more than 30 countries with more than 3 million paying subscribers across its Ancestry online properties and more than $1 billion in annual revenue. The company harnesses the information found in family trees and historical records to help people gain a new level of understanding about their lives. Ancestry also operates a market-leading consumer genomics business, which informs consumers about their heritage and key health characteristics.

Blackstone is a leading investment firm. Blackstone’s asset management businesses, with $564 billion in assets under management, include investment vehicles focused on private equity, real estate, public debt and equity, growth equity, opportunistic, non-investment grade credit, real assets and secondary funds, all on a global basis.

Ancestry, the global leader in family history and consumer genomics, empowers journeys of personal discovery to enrich lives. Through Ancestry’s collection of 24 billion records and over 18 million people in the AncestryDNA network, customers can discover their family story and gain actionable insights about their health and wellness.

For more information, please contact:

  • Blackstone, 345 Park Avenue, New York, New York 10154; 212-583-5000; Email: pressinquiries@blackstone.com; Website: www.blackstone.com
  • Ancestry, 1300 West Traverse Parkway, Lehi, Utah 84043; 1-800-615-6560; Website: www.ancestry.com

Mental health utilization in Canada is projected to rise due to the stress and anxiety resulting from the combination of the spring lock downs and the subsequent economic downturn during the coronavirus disease 2019 (COVID-19). It is estimated that, once the reactionary effects on life due to COVID-19 subside, visits to a mental health professional will increase to approximately 6.3 million to 10.7 million for the foreseeable future, up from 4.1 million pre-pandemic. This is between a 54% to 163% increase over the number of mental health visits prior to COVID-19. Visits to emergency rooms for stress and anxiety-related disorders are projected to increase 1% to 3%, compared to rates before COVID-19. The COVID-19 mental health impact is projected to make women particularly vulnerable, who account for approximately 68% of the jobs lost as of July 2020, and were more likely than men to self-declare their mental health needs as only partially met or totally unmet, even pre-COVID-19.

The researchers concluded once the COVID-19-induced health and economic crises subside, negative effects resulting from life during COVID-19 will continue, especially for women. They recommended that governments should allocate funds for mental health services and leverage their schools and daycare networks to identify families most at-risk, provider organizations should prepare for the demand in services by considering digital delivery channels, and insurance companies should consider adjusting coverage options to accommodate the public’s needs in the months following COVID-19. They also recommended additional research on how the disruption in education opportunities, and potential increase in addiction during COVID-19 may impact residents.

These findings were presented in “Uncovering the hidden iceberg: Why the human impact of COVID-19 could be a third crisis,” by Deloitte. Researchers for Deloitte based their estimates on an analysis of what transpired in the years following the Fort McMurray wildfire in 2016, which forced a month-long evacuation of 88,000 people; and destroyed more than 2,400 homes in Alberta, Canada. Following this event, visits to mental health professionals, and prescriptions for antidepressants, increased in the months following the May 2016 wildfire and have not returned to levels prior to this event. Estimates were also based on an analysis of the long-term impact on Canadians of the “great recession” of 2008 to 2009, and a review of case studies regarding mental health. The goal was to estimate the potential effects of COVID-19 on mental health in the country.

The full text of “Uncovering the hidden iceberg: Why the human impact of COVID-19 could be a third crisis” was published on June 23, 2020 by Deloitte. A copy can be obtained at https://www2.deloitte.com/ca/en/pages/about-deloitte/articles/crisis-covid-19-human-impacts.html.

For more information, contact:

  • Mathieu Laberge, Senior Manager, Economic Advisory, Deloitte Canada, 1600-100 Queen Street, Ottawa, Ontario, Canada K1P 5T8; 613-751-5452; Email: mlaberge@deloitte.ca; Website: https://www2.deloitte.com/ca/en.html
  • Mario Iacobacci, Ph.D., Partner, Economic Advisory, Deloitte Canada, 1190 Avenue des Canadiens-de-Montréal, Suite 500, Montréal, Quebec, Canada H3B 0M7; 514-393-7101; Email: miacobacci@deloitte.ca; Website: https://www2.deloitte.com/ca/en.html

On August 10, 2020, the federal Department of Health and Human Services (HHS) re-opened the Phase 2 Provider Relief Fund application portal for Medicaid and Children’s Health Insurance Program (CHIP) provider organizations because federal data indicated that only 4% of eligible organizations applied during the earlier application period from June 9 through July 20. This distribution is intended for Medicaid and CHIP provider organizations with no Medicare revenue, including behavioral health provider organizations and those that provide Medicaid home- and community-based services. The portal will be open through August 28, 2020.

After the Medicaid and CHIP targeted application period closed on June 20, HHS realized that the provider organization response rate was unexpectedly low. Executives of many provider organizations told HHS they were confused about their organization’s eligibility and about the application process. On July 31, HHS announced it would re-open the application portal, and would allow it to accept applications from Medicare provider organizations, Medicaid and CHIP provider organizations, and dental provider organizations.

The Provider Relief Fund, created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, is intended to replace about 2% of provider organization revenues. For the Phase 1 Provider Relief Fund general distribution in April, HHS used payment information from the Centers for Medicare and Medicaid Services (CMS) to distribute $30 billion directly to Medicare provider organizations proportionate to their share of 2018 Medicare fee-for-service reimbursements. The Phase 1 general distribution offered provider organizations financial relief payments equal to a maximum of 2% of their annual Medicare service revenues. Provider organizations that are not required to submit comprehensive cost reports to CMS were asked to submit revenue information to a portal to receive the balance of their 2% payment of General Distribution funds via a subsequent $20 billion funding round that ended June 3, 2020.

Among provider organizations that serve Medicaid and CHIP beneficiaries, 62% received the maximum Provider Relief Fund payment to replace 2% of revenue during the Phase 1 General Distribution, and 38% received either no payment or a payment that amounted to less than 2% of service revenue. Many provider organizations with low Medicare revenues and higher Medicaid revenues did not complete their applications by the deadline. A large share of those missing the application deadline receive the bulk of revenue from Medicaid or CHIP plans or are dental provider organizations.

Provider organizations eligible to apply for funding through the re-opened portal include those that bill Medicare, Medicaid, Medicaid managed care, or CHIP who have not already received 2% of their total service revenue from the Provider Relief Fund. In an infographic, “Rules of the Road”, about the expanded portal, the National Council for Behavioral Health clarified that this opportunity can be used by provider organizations with the following circumstances:

  • Received an automatic payment from the Medicare Phase 1 General Distribution Fund, but did not yet receive a second payment.
  • Rejected the initial payment from the Phase 1 General Distribution Fund.
  • Missed the initial June 3 deadline to apply for funds.

Reyna Taylor, National Council’s vice president of public policy said a key problem was confusion around the HHS eligibility FAQs for the Medicaid provider portal even after the Medicare distribution submission deadline closed. Many Medicaid provider organizations thought that they should wait for the Medicaid distribution opportunity, and not accept the much lower Medicare distribution. Others mistakenly thought that receipt of funds through the Paycheck Protection Program excluded them from the Provider Relief Fund, so they did not apply. However, when the Medicaid distribution opened, they learned that one of the requirements to receive funds through the Medicaid distribution was that the provider organizations must not have received funds from the General Distribution or must not have received funds equivalent to 2% of annual service revenue. Ms. Taylor said about 30% of National Council members found themselves ineligible for the Medicaid distribution because they received an initial Medicare direct payment from the General Distribution but were confused about whether to apply to the second round of funds from the General Distribution for Medicare provider organizations or wait for the Medicaid distribution. During June and July, trade organizations, including the National Council and the National Association of State Directors of Developmental Disabilities Services, expressed concern to HHS about the prior lack of clarity and the unintended result.

The “Provider Relief Fund Rules of the Road” infographic was published August 14, 2020, by the National Council. An abstract is available online at https://www.thenationalcouncil.org/wp-content/uploads/2020/08/20_PRF_RulesOfRoad_infographic2.pdf?daf=375ateTbd56.

A link to the full text of “National Council Letter To HHS About Specific Mental Health & Substance Use Health Care Provider Fund Distribution” may be found at www.openminds.com/market-intelligence/resources/061820natcouncilltrhhsremhsacaresactprf.htm.

PsychU reported on various aspects of the CARES Act Provider Relief Fund in the following articles:

For more information, contact:

  • U.S. Department of Health and Human Services, 200 Independence Avenue Southwest, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov; Website: https://www.hhs.gov/
  • Sophia Majlessi, Assistant Vice President, Public Relations, The National Council for Behavioral Health, 1400 K Street Northwest, #400, Washington, District of Columbia 20005; 202-621-1631; Email: SophiaM@TheNationalCouncil.org; Website: https://www.thenationalcouncil.org/

Virginia is the first state to deploy an exposure notification application for coronavirus disease 2019 (COVID-19) that uses an application programming interface (API) jointly created by Apple and Google specifically for COVID-19 contract tracing. COVIDWISE was built by the Virginia Department of Health (VDH) in partnership with development from Spring ML using funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

The free app uses Bluetooth to anonymously detect potential exposures. If the app determines that an individual came into contact with another COVIDWISE user had a positive COVID-19 in the past 14 days, the app notifies the user about the potential exposure. The notification provides guidance from VDH about what to do next and how to minimize the risk of further spread.

The app can be downloaded at https://www.vdh.virginia.gov/covidwise/. It works with Android and iOS smartphones.

For more information, please contact:

  • Virginia Department of Health, Post Office Box 2448, Richmond, Virginia 23218-2448; Website: https://www.vdh.virginia.gov/covidwise/

In the 2021 proposed Medicare Physician Fee Schedule (PFS), the Centers for Medicare & Medicaid Services (CMS) said it intended to finalize expansions to telehealth services that were temporarily expanded in the spring of 2020 during the coronavirus disease 2019 (COVID-19) public health emergency (PHE). The expansions relate to specific services that will be added to the telehealth list either on a permanent or temporary basis, and to the types of professionals that can deliver the services. The proposed rule does not address temporary policy changes during the PHE that expanded access to telehealth to all beneficiaries and allowed them to receive the services at home. Changes to those policies must be enacted by Congress. Normally, telehealth is only available for beneficiaries in rural areas, and to access services they must travel to an approved service site. Unless Congress acts to change these policies, after the PHE ends telehealth access will return to the prior status.

CMS is proposing to add nine services to the Medicare telehealth list on a Category 1 (permanent) basis because they are similar to services already on the telehealth list. Additionally, CMS proposed adding 13 services to the telehealth list on a Category 3 (temporary) basis; these services were added to the Medicare telehealth list during the COVID-19 PHE and will remain on the list through the calendar year in which the PHE ends. CMS seeks comment by October 5, 2020, about services added to the Medicare telehealth list during the PHE for COVID-19 that are not considered to be added permanently or that are proposed to be added temporarily.

CMS is proposing to revise a limitation on telehealth visits for nursing facility residents from one visit every 30 days to one visit every three days. CMS seeks comment on whether it would enhance access to care if the frequency limitations were removed, and how best to ensure that nursing home residents would continue to receive necessary in-person care.

Telehealth Services Proposed For Permanent Addition, From 2021 Proposed Medicare Physician Fee Schedule
Service Type HCPCS Code Long Descriptor
Visit Complexity Associated With Certain Office/Outpatient Evaluation & Management (E/Ms) GPC1X Visit complexity inherent to E&M associated with primary medical care services
Prolonged Services 99XXX Prolonged office or other outpatient E&Ms with or without direct beneficiary contact on the same date as the primary service
Group Psychotherapy 90853 Group psychotherapy (other than of a multiple-family group)
Neurobehavioral Status Exam 96121 Neurobehavioral status exam
Care Planning For Consumers With Cognitive Impairment 99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home.
Domiciliary, Rest Home, Or Custodial Care services 99334 Domiciliary or rest home visit for the E&M of an established consumer, 15 minutes
Domiciliary, Rest Home, Or Custodial Care services 99335 Domiciliary or rest home visit for the E&M of an established consumer, 25 minutes
Home Visits 99347 Home visit for E&M of an established consumer, 15 minutes.
Home Visits 99348 Home visit for E&M of an established consumer, 25 minutes.

Category 3 services are proposed for addition through the end of the calendar year in which the COVID-19 PHE ends. These are temporary additions to the Medicare list of telehealth services.

Telehealth Services Proposed For Addition On A Temporary Basis Through The End Of The COVID-19 PHE, From 2021 Proposed Medicare Physician Fee Schedule
Service Type HCPCS Long Descriptor
Domiciliary, Rest Home, Or Custodial Care Services, Established Consumers 99336 Domiciliary or rest home visit for the E&M of an established consumer, 40 minutes
Domiciliary, Rest Home, Or Custodial Care Services, Established Consumers 99337 Domiciliary or rest home visit for the E&M of an established consumer, 60 minutes
Home Visits, Established Consumers 99349 Home visit for E&M of an established consumer, 40 minutes
Home Visits, Established Consumers 99350 Home visit for E&M of an established consumer, 60 minutes
Emergency Department Visits 99281 Emergency department visit for E&M of a consumer, for a self-limited or minor problem.
Emergency Department Visits 99282 Emergency department visit for E&M of a consumer, for a low to moderate severity problem.
Emergency Department Visits 99283 Emergency department visit for E&M of a consumer, for a moderate severity problem.
Nursing Facilities Discharge Day Management 99315 Nursing facility discharge day management; 30 minutes or less
Nursing Facilities Discharge Day Management 99316 Nursing facility discharge day management; more than 30 minutes
Psychological & Neuropsychological Testing 96130 Psychological testing evaluation services by physician or other qualified health care professional, 60 minutes
Psychological & Neuropsychological Testing 96131 Psychological testing evaluation services each additional hour
Psychological & Neuropsychological Testing 96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, 60 minutes
Psychological & Neuropsychological Testing 96133 Neuropsychological testing evaluation services by physician or other qualified health care professional, each additional hour

CMS clarified that licensed clinical social workers, clinical psychologists, physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) practitioner can furnish the brief online assessment and management services as well as virtual check-ins and remote evaluation services. CMS proposed adding two new HCPCS-G codes to facilitate billing by these professionals for remote evaluation of a consumer-submitted video or image, and virtual check ins. CMS proposed making three temporary policy changes permanent related to professional scope of practice implemented for the COVID-19 PHE. They are as follows:

  • Allow certain non-physician professionals (NPPs) to supervise diagnostic tests: Nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), and certified nurse-midwives (CNMs) can supervise the performance of diagnostic tests in addition to physicians. Prior to the May 1st COVID-19 IFC, these non-physician practitioners were already authorized under Medicare regulations to order and furnish diagnostic tests, while as a basic rule, generally only physicians (medical doctors and doctors of osteopathy) were authorized to supervise the performance of diagnostic tests.
  • Allow pharmacists to provide services incident to physician services: Pharmacists may provide services incident to the services, and under the appropriate level of supervision, of the billing physician or NPP, if payment for the services is not made under the Medicare Part D benefit. This includes providing the services incident to the services of the billing physician or NPP and in accordance with the pharmacist’s state scope of practice and applicable state law.
  • Allow physical and occupational therapy assistants to provide maintenance therapy services: Physical therapists (PT) and occupational therapists (OT) can delegate the performance of maintenance therapy services, as clinically appropriate, to a therapy assistant. This change gives PTs/OTs the same discretion to delegate maintenance services as they have for rehabilitative services. CMS noted that if the PHE ends before January 1, 2021, PTs and OTs would need to personally furnish the maintenance therapy services until the proposed policy change takes effect.

The proposed Physician Fee Schedule addresses payment policies for Medicare Part B outpatient services. Changes are proposed to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute. Additional topics include the following:

  1. Medicare Shared Savings Program requirements
  2. Medicaid Promoting Interoperability Program requirements for Eligible Professional
  3. Updates to the Quality Payment Program
  4. Medicare coverage of opioid use disorder services furnished by opioid treatment programs
  5. Medicare enrollment of opioid treatment program
  6. Payment for office/outpatient evaluation and management services
  7. Requirement for Electronic Prescribing for Controlled Substances for a Covered Part D drug under a prescription drug plan or a Medicare Advantage-Prescription Drug plan
  8. Medicare Diabetes Prevention Program (MDPP) expanded model Emergency Policy

For more information about issues related to telehealth, contact:

  • Emily Yoder, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1734, Post Office Box 8016, Baltimore, Maryland 21244-8016; 410-786-1804
  • Donta Henson, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1734, Post Office Box 8016, Baltimore, Maryland 21244-8016; 410-786-1947
  • Patrick Sartini, Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1734, Post Office Box 8016, Baltimore, Maryland 21244-8016; 410-786-9252.

On July 29, 2020, Anthem reported that the number of telemedicine visits for behavioral health was 56 times higher than usual during the coronavirus disease 2019 (COVID-19) pandemic public health emergency. The increase was mentioned during an investor earnings call. Chief Executive Officer Gail Boudreaux said that its Beacon Health Options behavioral health subsidiary was able to quickly adapt to the increase in demand. She said they “pivoted quickly to help transition care providers to a digital interface, enhance online support and services for consumers and conduct outreach for our most at-risk members to address special care needs.” Anthem acquired Beacon Health Options in late 2019.

During the public health emergency, Anthem increased access to virtual care and waived cost-sharing for telehealth and phone visits, including those for mental health, through September 30, 2020. Ms. Boudreaux said that demand for telehealth for any services rose by 300% compared to before the COVID-19 public health emergency. To date, Anthem has facilitated 475,000 telehealth visits and more than 82,000 online COVID-19 assessments. The Anthem LiveHealth Online telehealth platform reached one million visits in April. She said use of the platform remains high.

For the second quarter of 2020, Anthem reported operating revenue of $29.2 billion. As of June 30, 2020, Anthem had 42.5 million covered lives, about 0.7% (about 1.6 million covered lives) more than in March 2020. The increase was driven by greater Medicaid enrollments and Medicare Advantage enrollment, which together increased enrollment by nearly 600,000 lives. The increase was offset by a drop in commercial and specialty business enrollment, which declined by nearly 300,000 covered lives, reflecting a drop in employer-sponsored coverage as unemployment rates rose.

PsychU last reported on this topic in “Anthem To Acquire Beacon Health Options,” which published on July 1, 2019. The article is available at https://www.psychu.org/anthem-to-acquire-beacon-health-options/.

For more information, contact:

  • Jill Becher, Vice President, Public Relations, Anthem, Inc., 5800 Northampton Boulevard, Norfolk, Virginia 23502; 757-459-8031; Email: jill.becher@anthem.com; Website: https://antheminc.com/index.htm
  • Chris Curran, Brand Strategy, Beacon Health Options, 200 State Street, Boston, Massachusetts 02109; 827-243-0472; Email: Chris.Curran@beaconhealthoptions.com; Website: https://www.beaconhealthoptions.com/

Two separate studies corroborate that over a third of older adults will struggle with telehealth visits if they require the use of a video-call. The first study found that approximately 26.3% of Medicare beneficiaries are unable to access telehealth visits. Contributing to this is a lack of computers with high-speed internet (41.1% of beneficiaries) and a lack of smartphones equipped with wireless data plans (40.9% of beneficiaries). An additional study found that an estimated 13 million seniors, or approximately 38.0% of all older adults in the U.S., were “unready” for video visits at all, mostly due to inexperience with technology. Even if they have a child in the household, or two or more people in their social network that can help with access, about 32.0% are still unready to access video visits.

Telemedicine” is defined as the use of communications technology to deliver health care to patients at a distance. The second study defined “telemedicine” as direct-to-consumer video visits. “Unreadiness” is defined as meeting any of the following criteria:

  1. Difficulty hearing well enough to use a telephone (even with hearing aids)
  2. Problems speaking or making oneself understood
  3. Possible or probable dementia
  4. Difficulty seeing well enough to watch television or read a newspaper (even with glasses)
  5. Owning no internet-enabled devices or being unaware of how to use them
  6. No use of email, texting, or internet in the past month

Of those unready to use video visits for telemedicine purposes, approximately 30% have any inexperience with technology (no internet-enabled devices; do not know how to use internet-enabled devices; have not emailed, texted, or gone online in a month or more; or have no telephone). Approximately 20.0% of these individuals have at least one physical disability that prevents them from using telemedicine technology (difficulty hearing, difficulty communicating, difficulty seeing, or having probable or possible dementia).

In both studies, the researchers concluded there is a need to address disparities in digital access among older adults. One study suggests expanding the Lifeline program (a Federal Communications Commission program that provides reduced-cost phone or internet service to families with incomes 135% or more below the federal poverty level), but that will not assist with costs of needed devices to access the internet. The second study suggested that telecommunication devices should be covered by the Federal Government as a medical necessity for older adults, and that accessibility accommodations (such as closed captioning for those with hearing difficulty) should be offered for virtual visits.

These findings were presented in “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine,” by Eric T. Roberts, Ph.D.; and Ateev Mehrotra, M.D., MPH. For this research letter, the researchers analyzed public use respondent- and household-level data files from the 2018 American Community Survey (ACS), a nationally representative survey of the U.S. population. They selected ACS respondents who lived in the community (excluding those in nursing homes) and indicated that they were Medicare beneficiaries at the time of the survey. They assessed the proportion who did not have a desktop or laptop computer with a high-speed internet subscription, did not have a smartphone with a wireless data plan, or did not have either means of digital access. The study sample consisted of 638,830 surveyed individuals; equaling a representation of 54,749,082 when weighted. The goal was to examine disparities in digital access (i.e., access at home to technology that enables video telemedicine visits) among Medicare beneficiaries by socioeconomic and demographic characteristics.

The findings were also presented in “Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic,” by Kenneth Lam, M.D.; Amy D. Lu, M.D.; Ying Shi, Ph.D.; Kenneth E. Covinsky, M.D., MPH. The researchers analyzed 2018 data from the National Health and Aging Trends Study, which is a cross-sectional study of community-dwelling Medicare beneficiaries aged 65 or older. They determined telemedicine unreadiness under 4 scenarios: video visits; video visits assuming consumers who have social supports (defined as having a child in the household or at least two individuals in one’s social network) are telemedicine ready; telephone visits; and telephone visits assuming consumers with social supports are telemedicine ready. The goal was to assess the prevalence of telemedicine unreadiness.

The full text of “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine” was published on August 3, 2020 by JAMA Internal Medicine. A copy can be found at https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768772.

The full text of “Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic” was published on April 3, 2020 by JAMA Internal Medicine. A copy can be found at https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768771.

For more information, contact:

  • Eric Roberts, Ph.D., Assistant Professor, Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Room A653, Pittsburgh, Pennsylvania 15261; 412-383-0439; Email: eric.roberts@pitt.edu; Website: https://publichealth.pitt.edu/home/directory/eric-roberts
  • Kenneth Lam, M.D., Clinical Fellow, School of Medicine, University of California at San Francisco, 4150 Clement Street, Building 1, Room 207, San Francisco, California 94121; 415-221-4810; Email: kenneth.lam2@ucsf.edu; Website: https://profiles.ucsf.edu/kenneth.lam

About 55% of Italian adults ages 18 to 87 who recovered from a coronavirus disease 2019 (COVID-19) infection had self-rated in the clinical range for at least one mental disorder, such as post-traumatic stress disorder (PTSD), depression, obsessive compulsive disorder (OCD), or anxiety. According to the analysis, which examined 402 COVID-19 survivors, about 36.8% had two disorders; 20.6% had three disorders, and 10% had four disorders. About 2.9% had suicidal ideation, and 0.8% progressed to making suicide plans. Of the 402 COVID-19 survivors, females had greater incidence of post-COVID-19 psychiatric distress than males; the ratio was 2.9 females with psychiatric distress for each male experiencing mental health problems.

The degree of psychological distress varied with the person’s history of previous psychiatric diagnoses, the treatment setting, and the length of hospitalization. People with longer than average hospitalizations had lower rates of PTSD, anxiety, depression, and OCD than people with longer than average hospitalizations. People whose symptoms were managed at home had higher rates of anxiety and sleep disturbance than those who were hospitalized.

These findings were reported in “Anxiety And Depression In COVID-19 Survivors: Role Of Inflammatory And Clinical Predictors” by Dr. Mario Gennaro Mazzaa, and directed by Professor Francesco Benedetti. The researchers conducted a psychiatric screening of 402 Italian adults ages 18 to 87 who survived COVID-19. Within the group, 265 were male and 137 female; the average age was 57.8 years. Each had visited the emergency department at IRCCS San Raffaele Hospital in Milan. At the emergency department, each underwent clinical evaluation, electro-cardiogram, hemogasanalysis, and hematological analysis (a complete blood cell count including differential white blood cell count, and C-reactive protein).

Of the group, 300 were admitted for severe pneumonia and 102 were managed at home. The hospital stays averaged 15.3 days. The researchers conducted a psychiatric assessment about 31 days post discharge, or for those managed at home, 29 days after the emergency department visit. The screening was followed by a clinical interview and a battery of self-report questionnaires to investigate PTSD, depression, anxiety, insomnia, and OCD symptomatology.

The researchers noted that those with a higher level of systemic inflammation due to immune response had higher scores for depression and anxiety at follow-up. They recommended additional research on inflammatory biomarkers, in order to diagnose and treat emergent psychiatric conditions.

The full text of “Anxiety And Depression In COVID-19 Survivors: Role Of Inflammatory And Clinical Predictors” was published July 30, 2020, by Brain, Behavior & Immunity. An abstract is available online at https://www.sciencedirect.com/science/article/pii/S0889159120316068.

For more information, contact:

  • Mario Gennaro Mazza, Psychiatry & Clinical Psychobiology, Division of Neuroscience, IRCCS Scientific Institute Ospedale San Raffaele, Via Olgettina 60, Milan, Italy 20132; Email: info@hsantalucia.it; Website: https://www.hsantalucia.it/en/irccs.

In February 2020, Emory University and the Hazelden Betty Ford Foundation signed a letter of intent to create the “Addiction Alliance of Georgia.” The initiative is intended to reduce addiction rates, improve recovery outcomes, and conduct research. It will work to prevent and treat addiction to alcohol, opioids, and other substances.

The Addiction Alliance of Georgia will seek to align with ongoing public and private efforts. It will partner with diverse stakeholders to provide comprehensive treatment and recovery support to both insured and underserved people in Atlanta and across Georgia.

The non-profit Hazelden Betty Ford Foundation provides comprehensive inpatient and outpatient addiction treatment for adults and youth at 17 locations nationwide. With a legacy that began in 1949 and includes the 1982 founding of the Betty Ford Center, the Foundation today also encompasses a graduate school of addiction studies, a publishing division, an addiction research center, recovery advocacy and thought leadership, professional and medical education programs, school-based prevention resources and a specialized program for children who grow up in families with addiction.

For more information, please contact:

  • Jeremiah Gardner, Director, Communications and Public Affairs, Hazelden Betty Ford Foundation, Post Office Box 11, Center City, Minnesota 55012-0011; 651-213-4231; Email: newsroom@hazeldenbettyford.org; Website: https://www.hazeldenbettyford.org/contact-us

On August 5, 2020, Johnson & Johnson (J&J) announced that its Janssen Pharmaceutical Companies had reached an agreement with the U.S. Department of Health and Human Services (HHS) and Department of Defense (DoD) to supply 100 million doses of an investigational vaccine for coronavirus disease 2019 (COVID-19) for use in the United States. Under the agreement, Janssen will demonstrate large-scale manufacturing and delivery of the company’s COVID-19 vaccine candidate Ad26.COV2.S.

HHS said this manufacturing demonstration project will take place while clinical trials are underway. Working in parallel this way expedites the traditional vaccine development timeline. This step builds toward the U.S. government’s Operation Warp Speed goal to begin delivering millions of doses of safe and effective vaccines to the American people by the end of the year.

The vaccine doses could be used in clinical trials or, if the U.S. Food and Drug Administration (FDA) authorizes use as outlined in agency guidance, the doses would be distributed as part of a COVID-19 vaccination campaign. J&J said the vaccine will be provided at a global non-profit basis for emergency pandemic use. Under a subsequent agreement, the U.S. government may purchase an additional 200 million doses of the vaccine.

J&J has been developing a COVID-19 vaccine under an ongoing research and development collaboration with Biomedical Advanced Research and Development Authority (BARDA), part of the HHS Office of the Assistant Secretary for Preparedness and Response, and under the oversight of the FDA. Based on the positive preclinical data recently published in the peer reviewed journal Nature, the Phase 1/2a first-in-human clinical trial of the vaccine candidate is underway in healthy volunteers in the United States and Belgium. J&J is evaluating one- and two-dose regimens in its clinical program. If the vaccine is found safe and effective, J&J seeks to supply more than on billion doses globally through the course of 2021.

For more information, please contact:

  • Johnson & Johnson, One Johnson & Johnson Plaza, New Brunswick, New Jersey 08933; 732-524-0400; Website: www.jnj.com
  • Biomedical Advanced Research and Development Authority (BARDA), Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. Room 638G, Washington, District of Columbia 20201; Website: https://www.phe.gov/about/BARDA/Pages/default.aspx

People with mental health disorders who received mental health services at specialty behavioral health clinics had a lower likelihood of having a psychiatric inpatient admission, according to a study of utilization in a large health system in New York. The odds of an inpatient admission were higher for those who received mental health or addiction treatment services at a medical clinic with integrated behavioral health services and higher for those who received behavioral health services at a medical clinic. About 59% received all of their mental health care in medical settings and from provider organizations unaffiliated with the health system. About 16% of people with serious mental illness (SMI) also received all their mental health care in medical settings and from unaffiliated provider organizations.

Compared to the odds of inpatient admission among people who received services in a mental health setting, the odds for those who received services in medical only or in integrated medical and mental health settings were as follows:

  • The odds of a mental health admission were 5.57 times higher for those who received services in a medical setting.
  • The odds of a mental health admission were 3.87 times higher for those who received mental health services in a combined medical and mental health setting.
  • The odds of a medical admission were 2.40 times higher for those who received services in a medical setting.
  • The odds of a medical admission were 1.96 times higher for those who received mental health services in a combined medical and mental health setting.
  • The odds of an addiction disorder admission were 4.25 times higher for those who received services in a medical setting.
  • The odds of an addiction disorder admission were 1.28 times higher for those who received mental health services in a combined medical and mental health setting.

These findings were reported in “Treatment of Serious Mental Illness in Medical and Mental Health Settings” by Scott Wetzler, Ph.D.; Bruce Schwartz, M.D.; Sara Wetzler; Urvashi Patel, Ph.D.; and Nathaniel Counts, J.D. The researchers analyzed claims data from the New York State Medicaid Data Warehouse for 8,988 consumers ages 18 to 65 who had received at least one mental health service at Montefiore Medical Center, an urban academic medical center during 2017 at a mental health setting, a medical setting, or both. The goal was to investigate service use by individuals with SMI and non-serious mental illness. The analysis excluded records for consumers who had dual Medicare/Medicaid coverage, or were receiving services covered by the New York State Office for People With Developmental Disabilities, by an HIV special needs plan, or by Supplemental Security Income were excluded, as were patients with commercial insurance coverage.

Of the 8,988 adults, 2,333 had SMI diagnosis: schizophrenia, delusional or other psychotic disorders, and bipolar disorders; and 6,655 had a non-serious diagnosis. The majority of the full group, 5,289 people, had basic Medicaid coverage (59%) and 3,699 (41%) were enrolled in a specialized Medicaid Health and Recovery Plan (HARP). The HARP coverage provides enhanced care management and support services to people with SMI or addiction disorder.

The 8,988 people were grouped by where their mental health services at Montefiore were provided, with 5,342 who received all through a medical clinic, 3,000 who received all through a specialized mental health clinic, and 646 who received services in both medical and mental health settings. The researchers classified the claims as inpatient or outpatient.

  • Inpatient services were divided, based on the principal discharge diagnosis, into general medical, mental health, or addiction episodes of care.
  • Outpatient services were subdivided into general medical provided by the primary care professional, mental health services delivered by the primary care professional, mental health services provided by a mental health specialist in the primary care setting, or mental health services provided by a mental health specialist (i.e., psychiatrist, psychologist, or social worker) in a specialty mental health setting, and specialized medical services.

The full text of “Treatment of Serious Mental Illness in Medical and Mental Health Settings” was published April 23, 2020, by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900392.

For more information, contact:

  • Scott Wetzler, Ph.D., Professor, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461; Website: https://www.einstein.yu.edu/faculty/4865/scott-wetzler/.

Does more virtual services mean we’ll have more home-based care? It looks like that could be one of the outcomes of the pandemic. Certainly, the use of tech-enabled services has gone up—and will continue after the end of the pandemic crisis. But as we talk to provider organization executives about their post-pandemic strategies, it looks like the increase in virtual services (both telehealth and digital remote monitoring tools) could be accompanied by more in-home services. This would allow specialty provider organizations to move to a new hybrid care model while dramatically reducing office space expenses.

Prior to the pandemic, home-based services were largely the province of consumers with disabilities on Medicare. Approximately 3.4 million people received Medicare skilled home health care in 2014, with Medicare providing coverage for up to 60 days. In addition, all Medicaid plans cover some form of home care in standard Medicaid for personal care assistance, and with expanded criteria under home and community-based services (HCBS) waivers and 1115 waivers. For example, for the Medicaid population with intellectual and developmental disabilities, 30.4% were enrolled in an HCBS program in 2016, increasing to 39.5% in 2019. Only 933,084 consumers received home-based services in 2019. And physician house calls were standard practice in 1930, when approximately 40 percent of patient encounters occurred in the patient’s home. However, by 1980, house calls had dropped to one percent, according to the American Academy of Family Physicians.

But the pandemic seems to be changing the home-based services landscape. A recent article highlighted the changing use of home-based services. The Institute for Accountable Care and the National Association of Accountable Care Organizations conducted a survey and found that the current use of home care is for primary care (26%), followed by care coordination (23%), transition from inpatient to home (16%), addressing social needs (14%), and hospital at home (11%). These changes are likely driven by the pandemic and consumer fear of facility-based care. A historical problem remains—traditional financing silos and fee-for-service reimbursement have made continuity and sustainability problematic for programs delivering home-based services. But the potential move to more value-based reimbursement—with more financial risk—in the post-pandemic period is likely to make the reimbursement issue less problematic, and home-based services more common.

Executives of health plans, provider organizations, and investor organizations have taken note. Notably, home care for primary care is on the increase. Humana invested $100 million in Heal, to offer value-based primary care via virtual and in-home encounters. Optum led a group of investors in increasing financing for Dispatch Health, a service delivering home-based urgent care. And health systems are expanding their service line portfolios. For example, New Jersey-based Samaritan Healthcare & Hospice has created a new home primary care service, operating as Samaritan HomeVisit Physician.

There are recent announcements of these hybrid virtual/home-based primary care services— Oscar Health, the Premera NOW health plan on the 98point6 platform, and Doctor On Demand’s Synapse platform are just a few examples.

Acute care home-based services also are getting attention. Mayo Clinic entered into a partnership with Medically Home to launch a new “hospital-at-home” platform, through which Mayo Clinic physicians will direct a suite of services to be delivered by a network of paramedics, nurses, and support team members. This new platform will offer a wide range of services including infusions, skilled nursing, medications, laboratory and imaging services, behavioral health, and rehabilitation services. Other health systems have followed suit – Navicent Health, Atrium Health system’s 36 hospitals in the Carolinas and Georgia, and the Veterans Health Administration which operates 12 hospital-at-home programs.

Like other forms of home-based services, the hospital-at-home model has only been used on a small scale because traditional Medicare and other health plans didn’t cover the model. But during this emergency period of the pandemic, the Centers for Medicare and Medicaid Services (and many health plans) temporarily let hospitals bill for care outside their walls, including in patients’ homes.

This shift to greater use of home-based service models presents both competitive threats and new opportunities for specialty provider organizations. On the threats side, all of these new initiatives are ‘teed up’ to offer services to consumers with complex needs—care coordination, emergency room diversion, readmission prevention, behavioral health, medical monitoring, and more. These hybrid telehealth/home-care models are in a position to offer health plans a capitated reimbursement model for care coordination and an all-inclusive case rate or bundled rate for hospital diversion for acute episodes.

The opportunities for specialty health care provider organizations fall in three domains. The first is to develop working relationships with the home-based service organizations in relevant geographies to offer specialty services, expanding their bandwidth and expertise. The second is to subcontract with a provider of remote/home-based primary care and offer health plans specialty care coordination services for high-needs, complex consumer groups. And lastly, specialty provider organizations could develop their own home-based service platform—creating the same hybrid service for their consumer base and their health plans.

These threats and opportunities in “hybrid” service models would be front and center in every specialty provider organization’s recovery strategy. The questions posed by these shifts in the market are fundamental to service line analysis and portfolio management for the year ahead.

About 11% of people in England and Wales (the United Kingdom) with a diagnosed mental health disorder who died by suicide within 12 months after contact with mental health services did not receive recommended treatment. The diagnoses included bipolar affective disorder, schizophrenia, depression, or an anxiety disorder. Another 13% who died by suicide after contact with the mental health system did not adhere to the prescribed treatment.

Six factors were independently associated with a lower likelihood of receiving treatment, including:

  1. Being under age 40
  2. Unemployment
  3. Living alone
  4. Drug misuse
  5. Medication side effects
  6. Co-morbid personality disorder

These findings were reported in “Treatment Of Mental Illness Prior To Suicide: A National Investigation Of 12,909 Patients, 2001–2016” by Myrsini Gianatsi, MSc; Hannah Burns, MBChB, MRes; Isabelle M. Hunt, Ph.D.; Saied Ibrahim, Ph.D.; Kirsten Windfuhr, Ph.D.; David While, Ph.D.; Louis Appleby, M.D., FRCPsych; and Navneet Kapur, M.D., FRCPsych. The researchers sought to determine the level of undertreatment among consumers with mental health conditions who died by suicide. They analyzed data for 12,909 people in England and Wales who died by suicide within 12 months after contact with mental health services between 2001 and 2016. The researchers further examined records of consumers who at the time of death had not received treatment as recommended by national clinical guidelines. This analysis focused on levels of nonprescription of treatment and nonadherence, as well as the association between the consumers’ clinical and sociodemographic characteristics and treatment receipt.

The full text of “Treatment Of Mental Illness Prior To Suicide: A National Investigation Of 12,909 Patients, 2001–2016” was published April 28, 2020, by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900452.

For more information, contact: 

  • Isabelle M. Hunt, M.D., MPH, Ph.D., Research Fellow, Division of Psychology & Mental Health (L5)Division of Psychology & Mental Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom; Email: isabelle.m.hunt@manchester.ac.uk; Website: https://www.research.manchester.ac.uk/portal/isabelle.m.hunt.html

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

On June 16, 2020, Kentucky Governor Andy Beshear filed a letter of intent to launch a state-based health insurance exchange. The exchange is expected to be able to accept enrollments in fall 2021 for the 2022 plan year.

Between 2010 and 2017, the state operated Kynect, a state-based health insurance exchange for people without employer-sponsored health insurance to find individual plans or sign up for Medicaid. In 2017, former Governor Matt Bevin dismantled Kynect and moved it to the federal healthcare.gov platform. The cost to revive Kynet is estimated to be $5 million plus operating costs, which is lower than the $10 million per year the state now pays to utilize the federal Healthcare.gov Exchange.

The function of the Kentucky Health Benefit Exchange is to oversee the Commonwealth’s implementation of the Affordable Care Act. Through the Exchange, individuals in Kentucky can be connected to HealthCare.gov to shop for health insurance, compare costs and plans, and apply for premium subsidies and tax credits. Individuals can also determine their eligibility for Medicaid and the Kentucky Children’s Health Insurance Program.

For more information, please contact:

  • Kentucky Health Benefit Exchange, Office of Health Data and Analytics, 275 East Main Street, 4-WE, Frankfort, Kentucky 40602; 502-564-7940; Email: KHBE.Questions@ky.gov; Website: https://healthbenefitexchange.ky.gov/Pages/index.aspx

In this interview, Paul Gionfriddo, PsychU Stigma Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Jason Carter, PharmD, Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Gionfriddo’s perspective on the opportunities and challenges that lie ahead.

Paul Gionfriddo, is the PsychU Stigma Section Advisor, as well as the President and Chief Executive Officer of Mental Health America in Alexandria, Virginia.

Jason Carter, PharmD, is a Medical Science Liaison for Otsuka Pharmaceutical Development and Commercialization, Inc.

Dr. Charles Raison is PsychU’s Major Depressive Disorder Section Advisor; Professor, Department of Human Development and Family Studies, School of Human Ecology, University of Wisconsin-Madison, Madison, WI; Professor, Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; Founding Director, Center for Compassion Studies, University of Arizona, Tucson, AZ; Clinician, University Physicians Healthcare, Tucson AZ; and Clinician, University of Wisconsin Healthcare.

How has your practice changed over the past 6 months, as it relates to the COVID pandemic?

I’m primarily a researcher, although I see patients in the hospital with residents at the University of Wisconsin–Madison. For most of the last six months, I have done this via video.  It was, despite some awkwardness, very interesting. I saw telehealth’s potential.

But once COVID rates fell, we returned for the most part to in-person visits.

As for my work as a researcher at Usona Institute, it was upended for a few months. We do studies where each subject is accompanied by two clinicians for six to eight hours; three people in one room is not ideal in terms of COVID risk. So that work was disrupted for a time until we figured out how to do it safely enough to resume.

How do you think you will be seeing your patients in the future? (i.e., in person, virtual, combination)

On medical hospital units, my practice will probably return to what is was, with all in-person visits.

So many people who are stellar psychiatric clinicians tell me that their experience with televisits has been interesting, with some using it exclusively during this time and others using a combination of televisits with in-person visits. They tell me that some patients prefer video—it seems to help. For some people, having a little bit of distance from the clinician is more comfortable. And being in their own home—there’s comfort there, too.

There are a lot of pragmatic reasons as well that people prefer seeing their psychiatrist via video. They have limited time, and some have limited means. Instead of driving 45 minutes to the appointment and paying to park, perhaps missing work, their 15-minute medicine check takes about 15 minutes, as long as they have a workable internet.

Where telehealth falters is where there are more than two people in the session, such as with video group therapy. We’ve all experienced being in a Zoom meeting where people constantly interrupt one another. As humans we have so many subtle signals that cue us as to who is going to speak next. We don’t have those cues with video.

What do you think will be the main driver for the future of health care?

Insurance and reimbursement, of course, but beyond that, access and affordability.

We have so many challenges right now in the U.S. We don’t know how exactly COVID will reshape the future of health care, but it’s important to keep in mind that not all of the changes will be bad by any means.

We have had a century now where infectious diseases in the first world have been held at bay. Just some 150 years ago, half of those born were dead by their teens due to infection. We have built our entire modern world on the presumption that we can all hang out with one another without risking death from infection. What COVID has taught us is that our vista hasn’t been wide enough; we have left out our relationship with the microbial world.

There is a massive change in how we deal with this world.

One gift COVID has bequeathed us is the rapid deployment of resources and new technologies. Just like wars ramp up technological innovation, our war against the coronavirus has fueled innovation and will produce amazing medical developments, such as engineered nanobodies.

As investigators look at immune system response to COVID, some of their innovations may shape the future of cancer treatment—and the future of treatment for mental illness. As we learn more about the immune system, we see more and more its connection to mental health.

What is your biggest concern for the future of health care?

That we won’t get as lucky the next time a pandemic hits. Consider smallpox, where one-third of the afflicted died. What if one-third of those with COVID died? We’d be looking at millions dead.

COVID presents an interesting paradox where mental health is concerned. It is just deadly enough to be terrifying but not so deadly that it is almost a guaranteed death certificate. We have an innate drive to avoid infectious danger, but we also have an innate drive to be with others and socialize. This tension between opposite drives has negative mental health effects.

If COVID had a mortality rate of 10%–15%, no one would leave their home. The economy would collapse.

So COVID is our wake-up call after a century of mostly controlling the microbial world.

How has PsychU helped during this time of uncertainty?

I am just very impressed how PsychU has been operating. As the Major Depressive Disorder Section Advisor, I have found it an intellectual feast. PsychU has sparked my thinking.

How can we continue to improve mental health care… together?

On the immediate level, there is a huge need for increased access to health. We need better ideas, better treatments. I have been thinking about it this way: We have two strategies against bacterial illness. We can prevent it, or we can treat it with antibiotics once it appears.

Vaccines work by putting light stress on the immune system. It is akin to lifting weights—combatting the stressor makes the immune system stronger, just like lifting a weight makes the muscles stronger.

We need to find treatments in mental health that are like vaccines and prevent disease—treatments that stimulate the brain/body continuum to get stronger, that stimulate resistance to depression. On the horizon there are some interesting short-term interventions that provide long-term benefits.

 

On July 16, 2020, a federal appeals court upheld the administration’s plan to implement site-neutral payments for Medicare outpatient services. The ruling was in American Hospital Association, et al., v. Alex M. Azar, II. Based on this appeal ruling, the Centers for Medicare & Medicaid Services (CMS) will be permitted to reduce reimbursement for outpatient physician services provided by an off-campus provider-based hospital department (PBD) to the same rate paid to independent community-based physicians.

On July 17, 2020, the American Hospital Association (AHA) said it was reviewing the decision to determine its next steps. AHA believes that if CMS implements the site-neutral payments, it will reduce beneficiary access to care. In its response to the ruling, AHA said the CMS policy “fails to account for the fundamental differences between hospital outpatient departments and other sites of care. Hospitals are open 24/7, held to higher regulatory standards and are often the only point of access for patients with the most severe chronic conditions, all of whom receive treatment regardless of ability to pay.”

The American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), and several member hospitals filed the complaint on December 4, 2018 to challenge the site-neutral provision. For regulatory purposes, PBDs are considered hospitals. As a result, under the previous Medicare Outpatient Prospective Payment System (OPPS), PBDs received reimbursement rates up to twice as high as the rates paid to a community-based physician performing the same services. The plaintiffs alleged that the site-neutral policy violates Congressional intent to protect hospital outpatient departments. They also alleged that the rule was based on faulty analysis, and that the cuts would adversely affect consumers in rural and vulnerable communities.

The appeals court ruling overturned a district court ruling that found CMS overstepped its legal authority in finalizing the site-neutral payment provisions in the OPPS final rule for 2019. The appeals court concluded that the question was whether CMS can reduce the OPPS reimbursement for a specific service and implement that cut in a non-budget-neutral manner as a method for controlling unnecessary volume increases for the service. The appeals court opinion states, “In our view, Congress did not ‘unambiguously forbid’ the agency from doing so.”

A link to the full text of “Decision: United States Court of Appeals: No. 19-5352 – American Hospital Association, et al., v. Alex M. Azar, II” may be found at www.openminds.com/market-intelligence/resources/071620ahavazardecision.htm.

A link to the full text of “Final Rule, Medicare Program: Changes To Hospital Outpatient Prospective Payment And Ambulatory Surgical Center Payment Systems And Quality Reporting Programs” may be found at www.openminds.com/market-intelligence/resources/112118frmcarehospoppschanges.htm.

For more information, contact:

  • U.S. Department of Health and Human Services, 200 Independence Avenue Southwest, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov; Website: https://www.hhs.gov/

In response to the COVID-19 pandemic, SuperCare Health and Optum collaborated to create a COVID-19 Telemonitoring Program that allows symptomatic individuals to be monitored and to recover in their homes, avoiding unnecessary hospitalizations. According to Curtis Sather, M.D., medical director and pulmonologist at Optum, SuperCare Health was contacted in the early stages of developing the COVID-19 monitoring program, knowing close respiratory monitoring would be vital in setting up alternative care for people who were confirmed for, or potentially had, COVID-19 but didn’t require hospitalization.

Paula Dahl, executive vice president of strategy and business development, emphasized that SuperCare Health is a respiratory disease management company that has specialized in and has developed a variety of programs for people with respiratory conditions for years, so it was a natural progression to adapt these proven clinical models to assist individuals with COVID-19 in this time of crisis. Ms. Dahl credits part of SuperCare Health’s ability to deploy a solution for individuals with COVID-19 to the fact that SuperCare already had the framework established within their iBreathe COPD readmission prevention program™. The clinical pathway included the ability to spot check SpO2 blood oxygen saturation, capture daily health monitoring question responses based on the Borg dyspnea score, and other activities of daily living to the SuperCare Health Clinical electronically. This daily tracking allows SuperCare Health teams to intervene in the individuals’ care promptly and appropriately, work with the Optum teams on escalations and ongoing communication aimed at helping this high-risk individual population get the care they need.

SuperCare Health is a comprehensive high-touch, high-tech, post-acute health care organization that manages chronic care individuals and provides a broad range of therapies including ventilation, oxygen, CPAP/BiPAP, medication optimization, and airway clearance and mobilization. Utilizing mobile technologies combined with clinical services, SuperCare Health has proven cost savings that reduce hospital readmissions and offer shared savings for payers.

Optum, part of the UnitedHealth Group family of businesses, is a health services and innovation company powering modern health care by connecting and serving the whole health system across 150 countries. Optum serves more than 100,000 physicians, practices, and other health care facilities, as well as 127 million individual consumers.

For more information, contact:

  • SuperCare Health, 8345 Firestone Blvd, Suite 210, Downey, California 90241; 888-260-2550; Website: https://supercarehealth.com
  • Optum, Corporate Headquarters, 11000 Optum Circle, Eden Prairie, Minnesota 55344; Website: www.optum.com

On May 18, 2020, Blue Cross and Blue Shield of Minnesota (Blue Cross) announced it was sending its Medicare Advantage members preventive screening kits designed for use at home. These kits are for diabetes A1C and microalbumin tests for in-home chronic disease management, as well as colorectal cancer screening kits.

The goal is to expand access to in-home wellness and preventive services during the coronavirus disease 2019 (COVID-19) public health emergency. To further reduce barriers to care, Blue Cross is waiving member cost-sharing for in-network primary care, mental health, and addiction treatment office visits for the duration of the public health emergency in 2020.

Blue Cross began making member outreach calls in June to tell its Medicare Advantage members about the expanded benefits and to ask about the members’ additional care needs. Organization President and Chief Executive Officer Craig Samitt, M.D., said Blue Cross is working closely with its provider organization network and with community agencies to “support members, keep them safe, and expand needed access to alternative care delivery methods.” Blue Cross previously announced the following coverage changes to support members during the COVID-19 pandemic emergency:

  • Waiving all member costs related to in-network COVID-19 treatment and care, including hospitalization;
  • Increasing access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications and/or encouraging members to use 90-day mail order benefit;
  • Encouraging the use of virtual care to help members maintain social distancing standards and minimize risk of exposure;
  • Waiving costs for Doctor On Demand for members whose benefits include coverage of Doctor On Demand services (an independent company providing telehealth services);
  • Increasing the types of technology that provider organizations can use remotely, including FaceTime and Skype; and
  • Expanding the types of services that can be provided via telehealth channels, including behavioral health; physical, occupational and speech therapies; and medication management.

Blue Cross and Blue Shield of Minnesota has 2.3 million covered lives. It is a non-profit independent licensee of the Blue Cross and Blue Shield Association.

For more information, contact:

  • Jim McManus, Director of Public Relations, Blue Cross and Blue Shield of Minnesota, Inc., 3535 Blue Cross Road, Eagan, Minnesota 55122-1154; 651-662-2882; Email: jim.mcmanus@bluecrossmn.com; Website: https://www.bluecrossmn.com/coronavirus.

On July 31, 2020, Michigan Governor Gretchen Whitmer vetoed Senate Bill (SB) 956, which would have created a new facility type to house people recovering from coronavirus disease 2019 (COVID-19) and prohibit housing them in nursing homes. In her veto notice, she said that the premise behind the legislation was unsupported and that the legislation also failed to address how such facilities would operate. Going forward, people recovering after hospitalization with COVID-19 will continue to be housed in isolation units created within existing facilities.

The veto notice said that SB 956 would not protect nursing home residents. The bill would have forced hospitals and nursing homes to send people who test positive for COVID-19 to the COVID-19-only facilities without any requirement for consent, physician approval, or notification to the individuals or their families. After proposing COVID-19-only facilities, SB 956 failed to explain how such facilities staffed or paid for, or how frail nursing home residents with COVID-19 would be protected “during the potentially traumatic transfer from one facility to another.” The Michigan Senior Advocates Council had asked the governor to veto the legislation.

Initially, Governor Whitmer ordered nursing homes at less than 80% of capacity to create dedicated units for COVID-19-affected residents. The facilities were required to accept new placements, as long as the facility had appropriate personal protection equipment (PPE) for staff. In late May, the order was revised to require nursing homes to make “all reasonable efforts” to create units dedicated to residents with COVID-19; provide appropriate PPE to staff working in those units; and not accept new residents with COVID-19 unless the nursing home had dedicated isolation units.

For more information, contact:

  • Office of Michigan Governor Gretchen Whitmer, Post Office Box 30013, Lansing, Michigan 48909; 517-373-3400; Website: https://www.michigan.gov/whitmer/0,9309,7-387-90498_90663—, 00.html

About 72% of adults in the United States changed their use of traditional in-person health care services, according to a survey conducted in May 2020. The changes were due to consumer concerns about receiving health care services during the coronavirus disease 2019 (COVID-19) pandemic health emergency in 2020. About 41% said they delayed use of health care services, and 38% said they intended to delay future care, treatment, and procedures for at least six months. About 27% said they planned to delay diagnostic procedures or tests in a hospital setting. Only 31% said they felt comfortable visiting their physician’s office. About 28% received some sort of virtual care, such as a telehealth visit; the majority (89%) said they were satisfied with the experience.

Despite concerns about receiving in-person health care services, many of the respondents said they were comfortable visiting a pharmacy to pick up prescriptions or to be tested for COVID-19. About 49% said they were “very comfortable” picking up prescriptions at their local pharmacy and speaking with their pharmacists about their medications. About 39% said they felt comfortable being tested for COVID-19 at a pharmacy. About 9% said they used a local pharmacy’s home delivery service, and 24% said they used a mail-order pharmacy.

Consumers attitudes towards use of standard health care services indicated that a majority felt uncomfortable accessing health care in a variety of settings. About 42% felt uncomfortable going to a hospital for any medical treatment, and 45% felt uncomfortable using an urgent care or walk-in clinic. About 37% of consumers reported that they or someone in their household had chronic health conditions. Within this group, about 60% delayed receiving in-person care.

A majority (64%) said they wanted to be tested for COVID-19, but about 36% were concerned about their ability to access testing and treatment. Of those who want to be tested, 69% said they felt comfortable being tested at their physician’s office, and 18% said they felt comfortable being tested at their workplace.

These findings were reported in “COVID-19 Shifts Consumer Health Care Behavior.” For the report, the Alliance of Community Health Plans (ACHP) and AMCP partnered with Leede Research to survey 1,263 adults aged 18 to 74, online by invitation only, from May 1 to May 6, 2020 to examine changes in health care utilization.

ACHP represents non-profit health plans to improve affordability and outcomes in the health care system. Its member companies are provider-aligned health organizations that provide high-quality coverage and care.

AMCP is a professional organization for managed care pharmacists. Its membership includes pharmacists, physicians, nurses, biopharmaceutical professionals, and other stakeholders. The association’s work focuses on optimizing medication benefit design and population health management to help consumers access cost-effective and safe medications and other drug therapies.

The topline results from “COVID-19 Shifts Consumer Health Care Behavior” were published May 21, 2020, by the Alliance of Community Health Plans. A copy is available online at https://achp.org/release-covid-19-shifts-consumer-behavior-attitudes-toward-healthcare-services/.

For more information, contact:

  • Leah Hunter, Media Contact, Alliance of Community Health Plans, 1825 Eye Street Northwest, Suite 401, Washington, District of Columbia 20006; 202-577-5435; Fax: 202-785-4060; Email: info@achp.org; Website: https://achp.org/
  • Abigail Fredenburg, AMCP, 675 North Washington Street, Suite 220, Alexandria, Virginia 22314; 703-684-2600; Website: https://www.amcp.org/

The American Academy of Family Physicians (AAFP) and National Alliance of Healthcare Purchaser Coalitions (National Alliance) are developing a national primary care model based on a prospective payment system. They are working with regional employer coalitions and physician networks. At this stage of development, the two organizations are focused on developing a roadmap—a common framework—that will set the standard for how purchasers and physicians can work together to deliver meaningful and measurable improvements in how care is paid for and delivered. The AAFP and National Alliance believe this collaboration is the first of its kind between a primary care organization and the employer coalition community.

Michael Thompson, President and CEO of the National Alliance said regional AAFP chapters and regional employer/purchaser coalitions have started discussions. He emphasized the need to move toward the seven principles defined as advanced primary care and noted that the AAFP has been supportive of this direction. Thompson also said the advanced primary care model exists in many parts of the country and the National Alliance has found that when properly structured and reimbursed, the advanced primary care model can help reduce health care costs and improve consumer health.

The advanced primary care model features the following attributes:

  1. Enhanced access through same-day appointments, walk-in hours, virtual access, and removing financial barriers to primary care;
  2. More time with consumers to improve engagement and support, shared decision making, and understanding of the impacts of various social determinants of health;
  3. Realigned payment methods to reward focus on consumer-centered experience and outcomes, quality and efficiency metrics, and de-emphasize visit volume as the basis of payment;
  4. Use of data to support analysis, reporting and communications, and ensure continuous staff training;
  5. Integrated behavioral health screening and coordination of care;
  6. Use of analytics to focus on health improvement through risk stratification and population health management to ensure a systematic approach to reducing gaps in care; and
  7. Referral management to establish more limited, appropriate and high-quality referral practices, coordination, and reintegration of consumer care.

The National Alliance recognizes that there may be a need to have a transitional plan for some groups and some parts of the country. It will support the promotion of advanced primary care practices with regional coalitions and will work with AAFP to educate and transition more practices to an advanced primary care model. A number of employers already use advanced primary care models, and National Alliance is working to educate more employers about the model.

The AAFP is a medical society for primary care professionals. It represents 136,700 physicians and medical students nationwide. The National Alliance is a non-profit network of business coalitions, representing private and public sector, nonprofit, and Taft-Hartley organizations and 45 million Americans, spending more than $300 billion annually on health care.

For more information, contact:

  • Karlene Lucas, Director, Development and Program Management, National Alliance of Healthcare Purchaser Coalitions, 1015 18th Street, NW, Suite 730, Washington, District of Columbia 20036, , 202-775-9300; Email: klucas@nationalalliancehealth.org; Website: https://www.nationalalliancehealth.org/
  • Janelle Davis, Public Relations Strategist, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, Kansas 66211-2680; 913-906-6000; Fax: 913-906-6075; Email: jdavis@aafp.org; Website: https://www.aafp.org/

The pandemic has increased the demand for all things delivered at home. Meals, liquor, mattresses, and more—are all now at people’s literal doorsteps. This is true in the health and human service field too. Telehealth has brought “visits” home. Humana and Blues are sending screening kits to their Medicare members’ homes. There are new services for in-home primary care and in-home hospital services.

Part of this is by mandate—non-emergency health care services have been halted in many states. But it is also a reminder that consumer confidence is just not there—consumers are afraid to get services in places where they will be in contact with the general public and exposed to the virus. This is especially true for consumer perceptions of nursing homes and other congregate care settings. The death rates in nursing homes have exceeded almost every other congregate setting and consumers are looking for alternatives.

A couple states have already responded. Rhode Island announced that it is changing the long-term care system to create more home-based care options. The state plans to invest $25 million for nursing facility supports to expand home-base care options. California is expanding a Medicaid program that allows low-income elderly and disabled people eligible for care in a nursing facility to stay in their own homes instead. By 2021, the Department of Health Care Services (DHCS) plans to expand the Home and Community-Based Alternatives (HCBA) waiver program from just under 4,000 slots to almost 9,000 slots. Currently, 4,688 people are enrolled in the HCBA program, and 836 are on a waiting list. The program covers skilled nursing care, home health aides, personal care services, and case management. DHCS is contracting with nine regional community-based organizations to provide the services.

And importantly for planning, these pandemic-induced moves to provide home-based alternatives to nursing homes are completely consistent with policy changes by many state Medicaid plans to move their long-term services and supports programs (LTSS) to some type of managed care system. Our recent national analyses of Medicaid managed long-term services and supports (MLTSS) programs found 2.8 million consumers are currently covered in those programs, more than doubling (178% increase) since 2010. There are now almost half of state Medicaid plans (24 states) operating some type of MLTSS programs. Four states—Massachusetts, North Carolina, New York, and Texas—are considering expanding MLTSS services to new populations or establishing a more comprehensive model. Three states—Nebraska, Nevada, and Oklahoma—are in the process of adopting a new MLTSS program. Currently, most states select health plans to deliver LTSS services through a competitive bid process.

The strategy question for specialty provider organizations is whether the opportunity posed by this shift in policy and consumer preference presents an opportunity for new service lines and for new relationships with health plans. The U.S. population—including the population with disabilities—is aging and the demand for these support services in on the increase. And right now, about 55% of Medicaid LTSS spending is on institutional long-term care, which includes nursing homes and intermediate care facilities for people with developmental disabilities. Moving even a small amount of nursing home spending to home-based services presents a significant new market opportunity.

We couldn’t wait for lockdowns to end. But now, the challenge of reopening seems almost insurmountable. Most executive teams know where they want to get to but the challenge is getting from lockdown to full opening. In between, there are many additional expenses and, quite likely, several months of financial losses.

In every sector, the costs and risks are looming while the path to business recovery remains fuzzy. Restaurants can’t seat to full capacity and are incurring untold expenses to follow safety guidelines . Airlines have reinstated flights but at 40% or less of former capacity. Colleges are being forced to offer rebates while more than $70 billion is estimated to be added to the budgets of the nation’s 5,000 colleges. Some hair salons and dentist offices are adding a 3% to 5% COVID-19 surcharge to cover the costs of masks, gloves, disinfectants, and plexiglass. In many states, meetings are limited to a maximum of ten people.

For the health care field, data from the Commonwealth Fund found that health care consumer services started to rebound since their plunge in early April but have flattened out. How long this will last is the question. It depends on both legal mandates (which are often specific to just a single city or county) and consumer confidence. We continue to see an uptick in COVID-19 cases and shutdowns. Labor Day activities may lead to increased crowds and consequently, another spike in cases. The reopening of schools presents additional risks of unknown proportions. And come September, we also have to prepare to deal with the double whammy of flu season and COVID-19.

The mounting costs and uncertainties of reopening are keeping most specialty health and social service provider organization executives up at night. Everyone is hearing the same questions over and over again from the field. How do we manage cash flow? Who will pay for increased expenses and infrastructure investments for safety—including new COVID units in residential facilities? How many of our consumers will come back and when? Will our furloughed staff come back? How do we increase access while we are strapped for cash? How long can we sustain the losses from opening and running at lower capacity and lower utilization?

We don’t know all the answers. But simply waiting to see how things shake out, or “hoping it will be fine,” which is all some non-profits are doing—can be fatal. Navigating reopening and the increased turbulence that lies ahead requires a moving forward strategy, which addresses two key buckets—the mechanics and the financials.

The Mechanics

The operational planning for reopening is no small task. A big concern is about safety and about liability risks. There are the COVID-19 safety guidelines to follow. Testing, social distancing, use of personal protective equipment, frequent cleaning, and disinfection of work areas are all procedures that add to costs and require new standard operating procedures even though you can’t function at full capacity. There is the need to plan for social distancing—scheduling consumers to avoid having too many people in waiting areas, spacing out staff in physical spaces, and more.

There are a few challenges here. First, the guidelines from the Centers for Disease Control and Prevention (CDC) miss the point on safety, with little focus on testing and quarantine. Second, compliance with CDC guidelines is expensive. And finally, any perceived lack of compliance with the guidelines—whether intentional or not—could result in legal liability. We’re just starting to see the first of consumer and/or employee lawsuits.

There’s a common theme among managers of organizations with outpatient services—they’re not reopening. One Chief Executive Officer mentioned the possibility of not reopening their outpatient mental health clinic because of the costs of adding increased ventilation capacity in their existing office space. Others are thinking about margins. Is it really worth reopening outpatient clinics when services can be delivered remotely? Staff productivity is higher, and costs of rent are eliminated. But the future of telehealth rates and regulations is still unclear.

And if virtual work is the future, what should you do with office space? Luanne Welch, CEO and President of Easterseals UCP, which offers disability-related and behavioral health services, said they are reconfiguring administrative offices in North Carolina and Virginia because the purpose of office space has moved from daily work and meetings (private offices and conference rooms) to spaces where people connect and collaborate. “We no longer want to pay for real estate to have people come in just to be there. They will come in when they need to be together in person.” Collaborative space is typically less expensive to create on a per employee basis, she explained. They are scaling back on square footage and focusing on the right amount of conference, training and ‘all-hands’ gathering space for face-to-face interaction. “Those who can work from home have typically been more productive doing so, less travel time and less burden on the associated infrastructure. In addition to finding ways to better support working from home, we want to create the best space possible for needed (and missed) in-person connection and collaboration,” she added.

The Financials

The other big issue in reopening is the financial losses that will be incurred for some period of time. Operating a facility at partial capacity with full costs is a formula for red ink. Any reopening plans need detailed financial projections and cash flow estimates for multiple scenarios—pre-pandemic consumer volume, drastically lower volume, somewhat lower volume, etc. The big question is what does the curve to profitability look like? How big will the losses be in the reopening period and how long will it be to breakeven? What is the plan to sustain operations until then?

Even for programs that have been open during the pandemic crisis, the capacity issue is problematic. In a recent discussion with a manager of a residential addiction treatment program, I learned that their maximum capacity—in order to comply with social distancing rules—is now 70%.

Easterseals is using service line portfolio management to plan their recovery strategy. “We evaluate our program portfolio risk and return on both mission sustainability and financial grids. We understand our current state, have drafted a more resilient (more ‘COVID resistant’) future state portfolio, and we are making the necessary changes to move forward,” said Ms. Welch.

Brad Howell, CEO and President of Fidelity House, a Massachusetts provider organization serving people with intellectual and developmental disabilities, provided their organizations’ take on reopening. They reopened their community-based day supports program on August 3, 2020, and plan to open more in-person services in a second wave on August 24. “While the first wave of reopening has worked well and the organization wants to sustain the program which is core to the mission, there are many challenges,” says Mr. Howell.

Fidelity House had to lay off 80% of its day program staff at the start of its new fiscal year on July 1, when Paycheck Protection Program funding ran out. Right now, family members are driving consumers to the day program but when more consumers who rely on public transport are able to come in, social distancing schedules will make commuting much harder. And residents in congregate care facilities don’t want their housemates having too much contact with the outside world.

Another issue is rates. The state (Massachusetts) raised reimbursement rates by 40% during COVID-19 but that is soon scaling back to 25%, and eventually back to pre-pandemic rates. Without the enhanced rates and with the lower service volume, financial sustainability is challenging. “We just can’t cut any more expenses,” said Mr. Howell. He also points out that they need more fluidity and flexibility in how to achieve better outcomes, which their currently rigid contracts don’t allow. “We need to meet with our payers and set a new vision together,” he added.

As part of their move forward strategy, said Mr. Howell, they are engaging in strategic planning right now to “realign their building blocks and mitigate risk.” They are looking at what would happen if certain programs have to be closed. They’re reevaluating office space (as many staff can continue to work virtually) to downsize and cut down on overheads. And they are thinking about how to expand services beyond consumers with disabilities. For example, the increased focus on social determinants of health provides opportunities to extend remote programs to other isolated populations such as the elderly—Fidelity House recently partnered with the local elder services agency to submit a grant proposal. “With virtual services, we are not bound to our current consumers, or our current geographic boundaries,” Mr. Howell pointed out.

It may seem like an oxymoron—spending on marketing at a time when referrals, service volume, profitability, and cash flow are all low. But marketing spend may be the key to navigating the crisis and preparing for recovery.

To determine if marketing spending—and likely virtual marketing spending—should be part of your plans right now requires answering one important question. Do you have service lines where more consumer service volume would generate more margin for your organization? If the answer to this is yes, then a well-planned marketing spend is part of the sustainability solution for your organization. The important issue is treating your marketing spend as an investment—not an expense. You would be right to insist that your marketing plan and all of its associated costs should have a positive net (after all expenses) margin.

Right now, there is more competition for consumers—and variable demand for consumer services. Primary care practices, whose consumer visits dropped to 30% of normal in March and April, have still not seen full recovery, and are at about 80% of normal volume at best. On the other hand, organizations providing home-based health care have seen a spike in demand by more than 30% during the pandemic and expect significant revenue increases this year. And we are seeing more consumers covered by commercial insurance go out of network and incur out-of-pocket costs for behavioral health services, while many insurers have expanded access to behavioral health through telehealth.

At the same time, more marketing dollars are being spent to attract consumers with changing needs and preferences. Hospitals and health systems that collectively spent $542 million on direct-to-consumer advertising in 1997 spent $2.89 billion by 2016. And in 2019, it was estimated that digital advertising for pharmaceuticals and health services would hit $10 billion in 2020. Health care advertising is increasing not only because of increased spend by marketers, but also because of greater interest from consumers. Consumers engage with health content for longer periods of time than with content from other industries. Three out of four consumers are most likely to engage with health advertising when it offers additional information and two out of three would respond to “relevant informative content.”

But marketing has changed. Virtual marketing, which includes leveraging social media, is playing a bigger role. Nine out of 10 consumers buy products and services from companies they follow on social media. Today, 75% of people spend with a brand they follow on social media (an increase of 12% over 2019). Younger consumers are increasingly drawn to social media platforms with video. Generation Z consumers report planning to use Instagram and YouTube more. And 69% of virtual marketers said that boosting brand awareness was their top goal on social media.

For health care organizations with limited budgets, now is a good time to be buying digital advertising (keywords on Google search, social media advertising, etc.). With the pandemic, the big spenders—travel, restaurants, and entertainment venues—have all cut advertising to the bone, driving down the volume, and rates, on digital advertising. Google might actually see a decline in ad revenues for the first time. Facebook and Amazon will continue to grow, but at lower rates than expected.

So, how to put together a virtual marketing plan and determine whether it will deliver the return on investment you need right now? That was the focus of the OPEN MINDS webinar, Is Your Website Designed To Get Referrals, by Tim Snyder, Executive Vice President, OPEN MINDS and Emily Korns, Senior Associate, OPEN MINDS. They offered four key elements for executives to keep in mind while developing a virtual marketing strategy and tactics.

Align to organizational objectives. Your virtual marketing goals must be closely aligned with your overall organizational objectives. If your organizational objective is to grow your consumer base, your marketing strategy should help you identify where those consumers are, what they want, and how you appeal to them. If your organizational objective is to acquire new health plan contracts, your marketing strategy must be shaped around demonstrating outcomes and showcasing your distinctive capabilities. If your objective is to attract and retain new staff, your marketing strategy should highlight why your organization is a great place to work.

Marketing objectives developed in isolation—such as growing the number of website visitors, or getting more Facebook likes—won’t do you any good. It’s imperative that marketing be geared toward the results you need for business recovery and sustainability. In short, you can’t justify the means without the ends.

Know your audience, map the journey. Once you set clear marketing objectives tied into overall organizational strategy, define the target audiences for each objective. Consumers, family members, referral sources, community organizations you can partner with, and payers—each will require a different approach and a different message.

Work to understand every one of these audiences and the typical journey they would take to find the kind of information you offer online. Think about the information they might seek, where they would look for it, and what would help them connect to you as opposed to your competitors.

Provide meaningful content. Effective marketing has always been about breaking through the noise to get people’s attention and you’re competing not only with others who provide the same services that you do but also with all the other distractions and essentials that beckon your consumers when they are online. So, a virtual marketing strategy can succeed only if your content is built on a foundation of clarity, simplicity, and transparency. Content needs to showcase thought leadership, educate, inform, and provide the basics. Tell your audience how your quality of services, and costs, compare to competitors. Let them know what consumers and caregivers are saying about you. Let them know what you are doing to ensure their safety and comfort. Provider organizations have to think like retailers selling online.

And Mr. Snyder warned that all this information will probably exist online in some format—accurate or not—whether or not you control and manage it. So, the best way to suppress any myths and misinformation is to provide accurate information and to make sure these feeds prominently on to the radar of your audiences.

In a ThinkGoogle survey, 82% of consumers said they believed that “the majority of health care providers have the same capabilities and offer similar quality services.” But 91% of those who said that also indicated that on a scale of 1 to 5, they would put forth a level 4 or 5 effort to find a health care provider organization they perceived to be better than the majority. The implication—your online content has to reveal what sets you apart.

Focus on action. In virtual marketing, the focus always has to be on what is called “conversion” or helping your audience take the next step in the journey. So, your audience reads (or watches) your great content but what next? You have to get them before you lose them. Give your online visitors a seamless way to connect more deeply with you—to take a virtual tour, talk to an expert, or best of all—schedule an appointment online. If you have great information to give away (whether that’s a fact sheet, tips for wellness, or questions to ask your clinical professional on your first visit), make sure to collect information about those who download that information. “Don’t give away good content without asking why they are interested in it. Then follow up with information that’s more specific to their needs,” advised Ms. Korns.

How about some social media Jeopardy? It was the first social media network site born in 1997 (hint: It wasn’t Facebook). What is SixDegrees.com? One million users set up profile pages, created lists of connections, and sent messages within networks. The site was shut down after three years but made a comeback and is still around today!

More than two decades later, despite a proliferation of channels that are impossible to keep track of, social media continues to be about connecting. But while many still labor under the myth that connecting is for friends and families—or for celebrities, or for the younger generations—social media has become an essential tool for business—in health care as much as in retail or entertainment.

In a 2017 study, 41% of consumers reported using social media to decide on a health care provider organization. We also know that 90% of consumers in the 18 to 24 year age group use and trust health care information on social media. Surprisingly, it’s not just the young people. Almost 90% of baby boomers and older adults (in their sixties)—a subset of the population at high risk for chronic disease, social isolation, and poor health outcomes—say they use Facebook and Twitter to locate and evaluate health information. And 60% of social media users trust social media posts by clinical professionals over any other group.

The bottom line is that if you, as a health care provider organization, don’t “hang out” where your consumers hang out, then they won’t come to you. It’s all about connecting. You want to use social media to form emotional connections with your potential consumers and stakeholders, to build trust, to establish your expertise, to inform and engage, and ultimately bring them in through your doors (virtual or physical). And the fact that more than 99% of hospitals now have (at least) a Facebook page, implies that your competitors—whether in your community or in cyberspace—are on social media talking to your consumers. Further, the increasing use of virtual services is driving the need for a strong social media presence as the “conversion” from browsing to accessing services can be seamless and instant.

Managing social media has two components. The first is monitoring and responding to the online conversations about your organization and the second is developing a push strategy for messaging. That was the focus of a recent OPEN MINDS Executive Web Forum, Social Media That Puts You In The Community – Virtually, led by OPEN MINDS Executive Vice President, Rob Hickernell. Mr. Hickernell offered best practices for both components.

With regard to monitoring and responding to online conversations, there are a number of external ratings, rankings, and review channels (payer sites, and public platforms like Healthgrades, RateMDs, Yelp, Google, Angie’s List, Nextdoor, and more), as well as reviews that people can post to your social media channels. Monitor the external and owned channels and keep track of what people are saying about you. A great “shortcut” suggested by Mr. Hickernell, is to set up “Google Alerts” for key terms, names, and services so you are notified when you are being mentioned and can respond strategically.

When consumers praise your organization, encourage them to post those comments online. When they give negative reviews, reach out to the unhappy consumer directly, or adjust your internal processes to address the complaint. Ignoring challenging comments, reviews, and ratings only heightens the negative impact they have on your online brand and reacting aggressively makes things worse. As Mr. Hickernell summarized, “You have to make sure that you keep an eye on what people are saying about you and fix any problems that are out there. Get back to people in real time and take the time to comment on both positive and negative comments. It will show that you care about your social media presence and that you care about taking care of any issues that are out there.”

As for the second component, the basics of any other marketing initiative apply to your social media push strategy. Here are five top-of-mind considerations.

Be strategic

Assess the landscape, know your audience, define your goals, form a plan, implement the plan, and measure and monitor.

Your social media goals could be defined in terms of sales, relationships, or engagement with information to a target audience. Ensure that your key performance indicators are not just “vanity metrics” (the number of followers on Facebook, the number of views on YouTube, the number of likes on a LinkedIn post, etc.) but that they encompass engagement (comments, shares, etc.) and especially conversion—seeking appointments, connecting with your experts, and making recommendations.

On a practical level, have and follow a daily schedule of posts across channels, monitor the engagement, and assign someone to respond to all questions and comments in real time.

Be relevant (not trite)

Provide information that matters and that is fresh and compelling. How do you know what matters? Mr. Hickernell emphasized that mountains of consumer data are now available to be anonymized and analyzed to identify trends and patterns that health care provider organizations can capitalize on for marketing.

Have your team take a look at what other specialty health care entities are doing on social media, see what your competition is up to, and mine the vast amounts of demographic data out there (the age of social media is also the age of data) to zero in on your target audience. What age group, gender, or economic class of consumers and family members do you want to reach? Which social media networks are they most likely to be on? What are they looking for? Who are they most likely to respond to? In short, do your homework!

Knowing your audience will help you determine the details of what you want to post, on which channels, how often, and when. And this will help you determine who should be the spokespersons—the executives, the clinical professionals, the frontline staff, consumers, community influencers, or some combination of each key group.

Be consistent with your brand

Your social media presence has to reflect your core brand and position you to showcase your “unique selling proposition.” Consider how you want to distinguish yourself from the competition.

Social media messaging needs to be reviewed and curated like any marketing messaging. The image you want to portray and the key messages you want to reiterate should drive the tone and substance of every post. You can’t be self-serving or “salesy” on social media. Your content must inform, educate, and build trust. Mr. Hickernell suggested the social media “rule of thirds.” A third of your posts could be personal stories to build your brand; a third of posts could promote your business, convert readers, and generate profits; and a third could be ideas from influencers and thought leaders in the industry and your community. The views of your clinical professionals and experts are especially valuable to your target audience.

The pandemic crisis has notably emphasized the value of social media for sharing authoritative health information and thought leader opinions. Anthony Fauci, M.D., director of The National Institute of Allergy and Infectious Diseases, has taken to YouTube to share facts, especially with the younger generation that does not watch cable news.

Be “social”

Keep your social media tone conversational and friendly, and the information you share engaging and in more visual formats. Mr. Hickernell pointed out that having video can increase conversions by as much as 80%. Live social media videos are also growing, with 50% of marketers planning to leverage them in the upcoming year.

And follow the same rules as you do in personal interactions. Acknowledge and thank those who mention you or like or share your posts. Respond to questions and comments. And share content from others that might be relevant and valuable to your audience.

Ask questions or conduct polls to engage those who see your content. And offer the opportunity for consumer or stakeholder groups you can host to allow exchange of views. More than 40% of millennials say they look for health care recommendations and advice from their peers on social media.

Be data-driven

Have a plan for what you do on social media but be prepared to adjust it as you see results. Be prepared to experiment and test. If a planned type of post is not yielding the desired results, or getting as much traction as expected, make the pivot quickly.

Most of all, said Mr. Hickernell, don’t be overwhelmed by social media and don’t try to take it all on at once. Start simple, experiment and monitor, and scale up gradually. And ask your current consumers to follow you—remind them when they come in for visits, during checkout and billing, and at every possible opportunity.

The new age of all things virtual, that has blossomed in the era of lockdowns and social distancing, is imposing new demands on all businesses, and on health care in particular. Social media marketing is at the top of the list. If you’re not on social, you’re not on the radar of your future consumers and stakeholders—and eventually even your current.

On August 3, 2020, WellCare, a Centene Corporation subsidiary, announced that it partnered with Shipt to provide free home grocery delivery for about 200,000 Medicare Advantage members in 23 states for the remainder of 2020. The goal is to help address food insecurity and enhance member safety during the coronavirus disease 2019 (COVID-19) pandemic. Shipt is a same-day delivery service.

WellCare is providing low-income and special needs plan members in select WellCare, WellCare TexanPlus, and ‘Ohana Medicare Advantage plans with free, monthly Shipt memberships for the remainder of 2020. With this benefit, members can have groceries and essentials delivered from a number of retailers directly to their homes through their Shipt account, which not only helps them easily obtain needed essentials, but also helps reduce possible exposure to the virus by eliminating their need to go to the grocery store.

During the COVID-19 pandemic, WellCare’s Community Connections Help Line, a toll-free, nationwide line available to anyone in need, has found increased demand for resources among seniors. The Help Line, which fielded more than 4,000 calls from Medicare members between March 1 and June 30, reports food assistance was the number-one most requested service (34%) accounting for more than one-third of all calls from this demographic. Medication assistance was the second most requested service (26%), followed by transportation (14%).

Shipt is available to more than 80% of U.S. households across 5,000 cities. The user-friendly app works with vetted, reliable Shipt Shoppers to ensure efficiency and user satisfaction. During the COVID-19 pandemic, Shipt has increased support staff, added more shoppers to help with high demand, and provides financial assistance and personal protective equipment to its shoppers.

For more information, contact:

  • Michael Polen, Senior Vice President and Chief Executive Officer of Medicare Solutions, Centene Corporate Communications, 7700 Forsyth Boulevard, St. Louis, Missouri 63105; 314-445-0790; Website: https://www.wellcare.com/
  • Rina Hurst, Chief Business Strategy Officer, Shipt, 17 20th Street N, Suite 100, Birmingham, Alabama 35203; 205-502-2500; Website: https://www.shipt.com/

In this interview, C. Brendan Montano, MD, PsychU Primary Care Provider Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Roland Larkin, PhD, NP, Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Montano’s perspective on the opportunities and challenges that lie ahead.

C. Brendan Montano, MD, is the PsychU Primary Care Provider Section Advisor, as well as the Director and Principal Investigator for Connecticut Clinical Research in Cromwell, Connecticut.

Roland Larkin, PhD, NP, is a Medical Science Liaison for Otsuka Pharmaceutical Development and Commercialization, Inc.

In this interview, Terence Ketter, MD, PsychU Bipolar Disorder Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Dri Wang, PharmD, BCPP, Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Ketter’s perspective on the opportunities and challenges that lie ahead.

Terence Ketter, MD, is the PsychU Bipolar Disorder Section Advisor, as well as the Founder and Founding Chief of the Stanford University Bipolar Disorder Clinic in Stanford, California.

Dri Wang, PharmD, BCPP, is a Medical Science Liaison, Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

In this interview, Sara Jones, PhD, APRN, PMHNP-BC, FAANP, PsychU Nurses Corner Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Kimberly Lonergan, RN, MSN, Senior Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Jones’ perspective on the opportunities and challenges that lie ahead.

Sara Jones, PhD, APRN, PMHNP-BC, FAANP, is the PsychU Nurses Corner Section Advisor, as well as Associate Professor, University of Arkansas for Medical Sciences (UAMS) College of Nursing, and the owner of Journey Wellness Clinic, North Little Rock, Arkansas.

Kimberly Lonergan, RN, MSN, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development and Commercialization, Inc.

In this interview, Alan “Tony” Amberg, MS, MSN, APRN, PMHNP-BC, PsychU Nurses Corner Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Kimberly Lonergan, RN, MSN, Senior Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Amberg’s perspective on the opportunities and challenges that lie ahead.

Alan “Tony” Amberg, MS, MSN, APRN, PMHNP-BC, is the PsychU Nurses Corner Section Advisor, as well as a Psychiatric Consult Liaison Psychiatric Nurse Practitioner at Northwestern Memorial Hospital in Chicago.

Kimberly Lonergan, RN, MSN, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development and Commercialization, Inc.

In this interview, Megan Ehret, PharmD, MS, BCPP, PsychU Pharmacist Corner Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Patricia Rohman, PharmD, MBA, Senior Managed Market Liaison, of Otsuka Medical Affairs. Listen in to hear Ehret’s perspective on the opportunities and challenges that lie ahead.

Megan Ehret, PharmD, MS, BCPP, is the PsychU Pharmacist Corner Section Advisor, as well as the Associate Professor, Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy in Baltimore, Maryland.

Patricia Rohman, PharmD, MBA, is a Senior Managed Market Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

In this interview, Jim Kenney, RPh, PsychU’s Payer Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Jane Guo, PharmD, MBA, Managed Market Liaison for Otsuka Medical Affairs. Listen in to hear Kenney’s perspective on the opportunities and challenges that lie ahead.

James T. Kenney, RPh, MBA, is the PsychU Payer Section Advisor, as well as the President of the Academy of Managed Care Pharmacy, and Founder and President of JTKENNEY, LLC. Mr. Kenney also serves on the Massachusetts Pharmacists Association Government and Legislative Affairs Committee.

Jane Guo, PharmD, MBA, is a Managed Market Liaison for Otsuka Pharmaceutical Development and Commercialization, Inc.

In this interview, Joseph Goldberg, MD, PsychU Bipolar Disorder Section Advisor, discusses the future of health care beyond the COVID-19 pandemic with Fatima Sadat, PharmD, Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Goldberg’s perspective on the opportunities and challenges that lie ahead.

Joseph Goldberg, MD, is the PsychU Bipolar Disorder Section Advisor, as well as a Psychiatry Clinical Professor at Icahn School of Medicine, Mount Sinai, in New York City, New York.

Fatima Sadat, PharmD, is a Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

In this interview, Dwayne Mayes, PsychU Patient and Caregiver Section Co-Advisor, discusses the future of health care beyond the COVID-19 pandemic with Heather Davidson, PhD, Medical Science Liaison, of Otsuka Medical Affairs. Listen in to hear Mayes’ perspective on the opportunities and challenges that lie ahead.

Dwayne Mayes is the PsychU Patient and Caregiver Section Co-Advisor, as well as the Program Director of the Recovery Network and Peer Training Program at the Mental Health Association of Westchester, New York.

Heather Davidson, PhD, is a Medical Science Liaison for Otsuka Pharmaceutical Development and Commercialization, Inc.

In this presentation, the objectives are to:

  • To understand the burden of behavioral health disorders on all stakeholders
  • To define behavioral health quality measures, and how they’re used
  • To describe the growing importance of value-based care in behavioral health care
  • To discuss payer and provider roles in quality improvement including challenges and strategies for success
Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

In this presentation, the objectives are to:

  • Provide a brief overview of Major Depressive Disorder (MDD) and measurement-based care (MBC)
  • Understand the benefits of MBC and commonly used MBC tools
  • Understand why measurement-based tools are underutilized
  • Discuss possible strategies for implementing MBC tools into clinical practice

Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

In this presentation, the objectives are to:

  • Discuss current developments in digital health for psychiatry and consider the advantages and challenges of using digital tools
  • Examine the use of technology in promoting treatment adherence
  • Review shared decision making in psychiatry and the contribution that digital tools can make to its implementation

Request this program for your region or organization today! This live (online or in-person) presentation, and others like it, are available for free for PsychU members. View our complete listing of presentations and programs by visiting our Request A Presentation page.

The U.S. Department of Health and Human Services has extended the coronavirus disease 2019 (COVID-19) public health emergency declaration for an additional 90 days. Secretary Alex Azar endorsed the renewal on July 23, 2020, ahead of its expiration on July 25. With it comes several policy implications for physicians that would have disappeared over the weekend.

Mr. Azar said the administration will continue its whole-of-America response to ensure Americans can get the care they need. A number of organizations have advocated for the extension, citing several ramifications of the renewal, including continuing requirements that payers cover COVID-19 testing without cost-sharing, telehealth waivers, and the 20% add-on Medicare payment for treating coronavirus inpatients.

The mission of the U.S. Department of Health & Human Services is to enhance and protect the health and well-being of all Americans. The department seeks to fulfill that mission by providing for effective health and human services and fostering advances in medicine, public health, and social services.

For more information, please contact:

  • ASPR Press Office, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, District of Columbia 20201; 202-205-8117; Email: asprmedia@hhs.gov; Website: www.hhs.gov

About 67% of adults ages 18 to 64 enrolled in a high deductible health plan (HDHP) have a health savings account, but 55% do not contribute. About one-third of HDHP enrollees do not have a health savings account. Among HDHP enrollees with a health savings account who contributed money to it in the past 12 months, the most frequent level of contribution was $2,000 or more. People with less education and/or low health literacy were less likely to make HSA contributions. As of 2016, about 40% of privately insured adults were enrolled in an HDHP.

An HDHP is defined as a private insurance plan with a deductible of at least $1,300 for an individual or $2,600 for a family in which the plan does not pay out until the deductible is met. HSAs are special savings accounts that allow HDHP enrollees to contribute pre-tax dollars to the HSAs to save for future health care expenses.

Additional findings about the intersection of HDHP enrollment and HSAs were as follows:

  • About 70% of HDHP members who enrolled through a health insurance exchange and 36% of people whose employer offered only one option lacked an HSA.
  • 55% of HDHP members with an HSA had not contributed money to it in the past 12 months.
  • Nearly 32% of those with an HSA said they were unable to afford saving for health care.

These findings were reported in “Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans” by Jeffrey T. Kullgren, M.D., MS, MPH; Elizabeth Q. Cliff, Ph.D.; Christopher Krenz, BA; et al. The researchers analyzed survey responses from 1,637 working-age, English-speaking adults enrolled in an HDHP for at least 12 months. The survey was conducted in August and September 2016. The respondents were asked if they had an HSA, defined in the National Health Interview Survey as “a special account or fund that can be used to pay for medical expenses” that are “sometimes referred to as health savings accounts (HSAs), health reimbursement accounts (HRAs), personal care accounts, personal medical funds, or choice funds, and are different from flexible spending accounts.” The respondents were also asked if they saved for health care expenses in the last 12 months and, if so, which savings vehicles they used and how much they saved. Those who had not saved were asked to state why. Other survey questions health status and source of insurance coverage, as well as factors that could potentially influence health care savings, such as consumer engagement, financial literacy, and health insurance literacy.

The full text of “Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans” was published July 17, 2020, by JAMA Network Open. An abstract is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768350.

For more information, contact:

  • Jeffrey T. Kullgren, M.D., MS, MPH, Assistant Professor, Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Post Office Box 130170, Ann Arbor, Michigan 48113; Email: jkullgre@med.umich.edu; Website: https://ihpi.umich.edu/our-experts/jkullgre

The U.S. has historically “separated” the health of an individual from their social circumstances. “Clinically appropriate” was added to the payment criteria to address level of care—the least restrictive level of care only. But social issues or supports were never in the equation.

That perspective has changed for a couple reasons. Over a decade ago, the fundamentals of health insurance underwriting changed with the Patient Protection and Affordable Care Act. The end of preexisting condition exclusions, the end of annual and lifetime care limits, parity for behavioral health services, and the requirements to accept all applicants eliminated the practice of shifting people with more expensive and complicated health conditions from private health plans to public programs. This situation prompted more investigation about the drivers of use of health care resources. What the research found—health care utilization is driven by a number of factors related to the environment (e.g., poverty), demographics (e.g., gender, insurance status), and mental and physical health (e.g., chronic conditions, serious mental illness, addiction). And the pandemic has and will continue to exacerbate the social needs of the U.S. population—more anxiety and depression, loss of housing, loss of income, interrupted education, and food insecurity.

The social supports/health connection was the focus of a recent web briefing, Population Health: Clinical & Administrative Implications, featuring OPEN MINDS Senior Associates, Sharon Hicks, Paul Duck, and OPEN MINDS Vice President, Richard Louis, III. They discussed how health plan managers have acted on this emerging body of data and are investing in social support services as a tactic for reducing member spend. A just-published survey of social service investments by Medicaid health plans in Texas and California, Comparison Of SDOH-Related Investments By Texas And California Medicaid Health Plans, confirmed this trend, finding that all of the Texas plans addressed food insecurity and transportation, while 71% of plans addressed housing issues. In California, housing instability was addressed by 84% of plans, while lack of transportation and food insecurity were addressed by 79% and 74% of plans, respectively. There are many examples of these health plan initiatives in our recent coverage:

  • Humana has a number of initiatives focused on social supports. They launched a value-based program that pays provider organizations for social determinants of health (SDOH) screenings; documentation of assessment findings; and connecting the member to appropriate resources. They have also continued their “Bold Goal” initiative, launched in 2015, with two additional cities (Cincinnati, Ohio and Detroit, Michigan) announced in May 2020.
  • CVS Health/Aetna launched a collaboration with Unite Us to develop a social determinants of health platform and connect Aetna Medicaid members with a coordinated network of local social service provider organizations.
  • Kaiser Permanente created a three-year initiative with Community Solutions to end chronic homelessness in 15 communities.
  • Horizon Blue Cross Blue Shield of New Jersey announced a demonstration project to assist community health workers in addressing SDOH through an online platform, NowPow.
  • Optum has a new partnership with Wider Circle and Helping Hands Community Partner—“Community Food Circle”—providing Optum beneficiaries in Los Angeles with healthy food amid the COVID-19 pandemic.

And, at a broader level, The Centers for Medicare & Medicaid Services (CMS) has recently allowed payment for services for “social needs” out of Medicare Advantage health plan savings. This is the first time that CMS has broadened the definition of services that can be paid with Medicare funds.

Many traditional specialty provider organizations have a long history of, and great expertise in, addressing the social needs of consumers. How do those organizations meet the emerging market need for connected health and social services and improve their market positioning? My colleagues offered some advice.

Include this expertise in your market positioning—If your organization has expertise in addressing the social support needs of consumers, do health plans managers and other payers know about that expertise? This is a matter of market positioning—understanding whether or not that expertise is a real market differentiator. And, if it is “repositioning,” how you present your organization and your brand—focusing on that expertise and attracting new referrals.

Provide linkages to social support services to all consumers—whether in fee-for-service or value-based initiatives—In your current services, providing referrals and supports for consumers to meet their social support needs is just good business. It results in better consumer outcomes and is a differentiator for health plans. As Ms. Hicks noted, a clinical social worker may not be able to find housing for a consumer, but they can easily arrange a contact with staff at a community-based organization that can. Social needs assessment and social services referrals can be built into standard clinical practices.

Develop targeted approaches to social services for value-based contracts and measure their impact—If your organization has value-based contracts, your management team (like the management teams of health plans) should be thinking about what social support services could improve performance and improve profitability. And any initiative needs a financial analysis of costs and likely returns—and a return-on-investment analysis of whether the predicted financial gains are achieved.

Evaluate the creation of new social support service lines focused on the needs of health plans and other payers—It’s clear health plans and other payers are investing in social services, but what exactly are they looking for? In the OPEN MINDS 2019 survey of health plans, Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System, found that 27% of health plans are investing in initiatives to improve access to affordable housing and 21% are investing in transportation initiatives. Thirteen percent are investing in food insecurity. To decide whether your organization should invest in a new service line focused on social supports requires the same process as developing any other service line- market research to determine specific needs, assessment of the competition, operational and financial feasibility analysis, and a marketing launch plan. The key, as Mr. Louis underscored, is to first understand your organization’s current ability to provide social support programs—then come together with the community to better understand the needs of consumers while aligning the strategic initiative with the goals of the health plan or payer.

An estimated 550 additional veterans in the United States are projected to die by suicide annually for every five-percentage point rise in unemployment, compared to veteran suicide levels prior to the onset of the coronavirus disease 2019 (COVID-19) pandemic. Due to the extended duration of the COVID-19 pandemic, unemployment rates in the general population have increased by nearly 10 percentage points since January 2020, rising from about 3% to more than 13%. According to models based on U.S. state-level data, each additional percentage point increase in the rate of unemployment will result in more than one hundred additional veteran suicide deaths.

At the 13% unemployment rate as of May 2020, an increase of six more percentage points is projected to result in nearly 700 additional veteran suicides due to increases in unemployment. If the unemployment rate were to increase by 20 percentage points, more than 2,500 more veterans could die from suicide annually.

Addiction rates are also projected to rise with the unemployment rate. A five-percentage point increase in the unemployment rate is projected to result in more than 20,000 additional cases of addiction disorder per year in the U.S.

The analysts recommended proactive efforts be implemented to address short-term and long-term needs related to mental health and addiction for veterans before they reach crisis levels. Health systems should enable veterans to employ coping skills learned while in service of the country to mitigate suicidal urges and the threat of developing addiction.

These findings were presented in “Projected COVID-19 MHSUD Impacts, Volume 2: Effects of COVID-Induced Economic Recession (COVID Recession) on Veteran Suicide and Substance Use Disorder (SUD) – June 15, 2020,” by the Meadows Mental Health Policy Institute. Researchers for the Institute partnered with the Cohen Veterans Network (CVN) to analyze U.S. state-level data from 1997 to 2010, which includes the 2007 to 2009 recession, data from the National Survey on Drug Use and Health, and data available from the U.S. Department of Veteran’s Affairs. This data was used in models that applied logarithmic (log) transformation of the suicide rate to permit reporting change in suicide rates as a percentage. An exact percentage change formula was used that is associated with log dependent variables when estimating the effect of a 20-percentage point increase in the unemployment rate on suicide. The goal was to determine how a COVID-19 induced economic recession increases rates of suicide and addiction disorders, with a specific focus on military veterans.

The full text of “Projected COVID-19 MHSUD Impacts, Volume 2: Effects of COVID-Induced Economic Recession (COVID Recession) on Veteran Suicide and Substance Use Disorder (SUD) – June 15, 2020,” was published on June 18, 2020 by the Meadows Mental Health Policy Institute. A copy can be found at: https://www.texasstateofmind.org/uploads/whitepapers/COVIDMHSUDImpactsVeterans.pdf.

For more information, contact:

  • Anthony Guido, Vice President, Communications & Marketing, Cohen Veterans Network, 72 Cummings Point Road, Stamford, Connecticut 06902; 203-569-0284; Email: Anthony.Guido@CohenVeteransNetwork.org; Website: https://www.cohenveteransnetwork.org/

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

The nation’s largest private funder of suicide prevention research, the American Foundation for Suicide Prevention (AFSP) announced the research priority areas for the 2020-2022 grant funding cycles. The new research priorities are suicide prevention within underrepresented racial and ethnic communities and the evaluation of technological tools for suicide prevention. Applications in these areas will be reviewed along with the general pool of grant applications, with priority given to strong grants in the designated fields.

This year’s focus on diversity is a part of AFSP’s larger commitment to addressing the disparity in mental health care access. With the vast array of technological tools for suicide prevention, the second priority area is on evaluation of technology for suicide prevention. The two-year priority period allows for resubmission of unsuccessful applications in the second year. Each application is reviewed multiple times by the top suicide prevention researchers in the world. The research grants are funded mainly through individual donors who attend the AFSP Out of the Darkness Walks and other public education events. Many of the AFSP grantees then go on to receive further funding from the National Institute of Mental Health and other large funding agencies. Last year, AFSP awarded over $5M in research grants for nearly 40 new studies.

The American Foundation for Suicide Prevention is dedicated to saving lives and bringing hope to those affected by suicide. AFSP creates a culture that’s smart about mental health through education and community programs, develops suicide prevention through research and advocacy, and provides support for those affected by suicide. Led by CEO Robert Gebbia and headquartered in New York, AFSP has local chapters in all 50 states with programs and events nationwide.

For more information, please contact:

  • American Foundation for Suicide Prevention, 120 Wall Street, 29th Floor, New York, New York 10005; 212-363-3500; Email: info@afsp.org; Website: www.afsp.org

If you or someone you know is in crisis, please contact the Suicide Prevention Hotline / Lifeline at 1-800-273-TALK (8255), or text the Crisis Text Line at 741-741.

Since the start of the pandemic, 53 million Americans have filed for unemployment, close to 16% of the adult population. For many of these people, the loss of their job also means a loss of health insurance.

Exactly how many Americans will lose their health insurance is not clear. Before the COVID-19 pandemic, 27.9 million non-elderly Americans—8.5% of the adult population—were uninsured. A third of the workers experiencing job loss have insurance through another family member’s job and a quarter have coverage through a Medicaid program prior to the pandemic. Of the estimated 10 million people who will lose employer-sponsored health insurance between April and December 2020, a third will regain employer-sponsored insurance by being added to a family member’s policy, nearly half will be eligible for Medicaid, and 10% will be eligible for marketplace subsidies. The balance will likely be uninsured and faced with either buying individual health insurance policies or remaining uninsured and paying cash for services.

This means an increase in enrollment in Medicaid health plans and commercial health plans. There will also be a likely bump in Medicare beneficiaries, with a group of consumers who will apply for coverage based on disability. And there will be an increase in uninsured, cash-paying consumers. Executive teams of provider organizations should be planning for all of the above.

Regarding Medicaid, it is likely that plans will shift a bit in the months ahead. States with stressed budgets will be looking to trim Medicaid. One way is to enroll more consumers in managed care plans and link more payments (to both health plans and provider organizations) to performance. There is financial assistance to state Medicaid plans through the Families First Coronavirus Response Act (FFCRA), with a temporary increase of Federal Medical Assistance Percentage (FMAP) by 6.2 percentage points, which will last through the end of the federal emergency period. In accepting these funds, states cannot decrease enrollment/eligibility, but can change some benefits and provider organization payments.

Now is the time to assess these likely changes in coverage and their potential impact on organizational competitiveness and sustainability in the “new normal.” It takes planning, time, and money to build a direct-to-consumer practice. And on the health plan front, it takes 18 months to go from health plan outreach to new health plan revenue. Now is the time to get started.

People who have been confirmed with mild to moderate COVID-19 can leave their isolation without receiving a negative test, according to recently revised guidance from the Centers for Disease Control and Prevention. Increasing evidence shows that most people are no longer infectious 10 days after they begin having symptoms of COVID-19. As a result, the CDC is discouraging people from getting tested a second time after they recover.

For people who have tested positive but don’t have symptoms, isolation and other precautions can be discontinued 10 days after the date of their first positive test. There are exceptions for the 10-day guidance, including people with compromised immune systems who may be infectious for a longer period of time.

The Centers for Disease Control and Prevention is the leading national public health institute of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgia.

For more information, please contact:

  • Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia, 30329-4027; 800-232-4636; Website: www.cdc.gov

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), has established a new clinical trials network that aims to enroll thousands of volunteers in large-scale clinical trials. They will be testing a variety of investigational vaccines and monoclonal antibodies intended to protect people from COVID-19.

The COVID-19 Prevention Network (CoVPN) was established by merging four existing NIAID-funded clinical trials networks: the HIV Vaccine Trials Network (HVTN), based in Seattle; the HIV Prevention Trials Network (HPTN), based in Durham, North Carolina.; the Infectious Diseases Clinical Research Consortium (IDCRC) based in Atlanta; and the AIDS Clinical Trials Group based in Los Angeles. Those individual networks will continue to perform clinical trials for HIV vaccine and prevention and other infectious diseases in addition to their new COVID roles.

The network’s vaccine testing will be led by Larry Corey, M.D., of the Fred Hutchinson Cancer Research Center in Seattle, and Kathleen M. Neuzil, M.D., MPH, of the University of Maryland School of Medicine. The network’s monoclonal antibody clinical testing efforts will be led by Myron S. Cohen, M.D., of the University of North Carolina, Chapel Hill, and David S. Stephens, M.D., of Emory University in Atlanta. The HVTN, which is based at the Fred Hutchinson Cancer Research Center, will serve as the CoVPN’s operational center.

NIAID continues to pursue progress in understanding, treating, and preventing infectious and immunologic diseases, it recognizes that new challenges to public health continue to emerge. NIAID will continue its tradition of supporting innovative scientific approaches to address the causes of these diseases and find better ways to prevent, diagnose, and treat them.

For more information, please contact:

  • NIAID Office of Communications, 5601 Fishers Lane, MSC 9806, Bethesda, Maryland 20892-9806; 301-402-1663; Email: NIAIDNews@niaid.nih.gov; Website: www.niaid.nih.gov

Based on an assessment of coronavirus disease 2019 (COVID-19)-related job loss, it is estimated that approximately 10.1 million non-elderly adults in the United States will lose employer-sponsored health insurance as a result of job loss in their household by the end of December 2020. This equals approximately 21% of the estimated 48 million non-elderly people in the United States will be part of a household in which someone loses a job due to COVID-19, overall.

Projections show that approximately 3.3 million individuals who lose employer-related health insurance will regain employer-sponsored insurance by being added to a family member’s policy. About 2.8 million will enroll in Medicaid, and 600,000 people will enroll in the individual market, mainly via the Affordable Care Act’s marketplace. However, this still leaves approximately 3.5 million individuals who will be uninsured after December 2020, due to loss of employer-sponsored health insurance.

The researchers concluded that COVID-19 will widely affect the health insurance status of non-elderly adults in the U.S. This includes 10.1 million who will lose employer-sponsored health insurance, 16.3 million who will lose insurance through a family member’s employment, and almost 12.7 million who will lose health insurance the received through Medicaid or CHIP.

These findings were reported in “Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation,” by J. Banthin, M. Simpson, M Buettgens, L.J. Blumberg, and R. Wang for the Urban Institute. The researchers used projections data from the U.S. Department of Labor’s Health Insurance Policy Simulation Model, a detailed microsimulation model of the health insurance system designed to estimate the cost and coverage effects of proposed health care policy options. This model offers projections data on employment losses by industry, state, and demographic characteristics. The goal was to determine potential job loss related to the COVID-19 pandemic, and subsequent loss of employer-sponsored health insurance.

The full text of “Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation,” was published on July 13, 2020 by the Robert Wood Johnson Foundation. An abstract can be found at https://www.rwjf.org/en/library/research/2020/07/changes-in-health-insurance-coverage-due-to-the-covid-19-recession–preliminary-estimates-using-microsimulation.html.

PsychU last reported on this topic in “Nearly 27 Million Americans May Have Lost Job-Based Health Insurance Due To COVID-19; 42% Likely Eligible For Medicaid,” which published on May 26, 2020. The article can be found at https://www.psychu.org/nearly-27-million-americans-may-have-lost-job-based-health-insurance-due-to-covid-19-42-likely-eligible-for-medicaid/.

For more information, contact: 

  • Melissa Blair, Media Contact, Robert Wood Johnson Foundation, 50 College Road East, Princeton, New Jersey 8540-6614; 609-627-5937; Email: media@rwjf.org; Website: https://www.rwjf.org/

“If we think what we are doing today will serve us tomorrow, then we will not be here tomorrow.” This comment, made at The OPEN MINDS 2020 Strategy & Innovation Institute keynote address, Innovation By Design: Capturing Value In Health Care, by Carl Clark, M.D., Chief Executive Officer, Mental Health Center of Denver (MHCD), are words of wisdom for every executive team member of a specialty provider organization. Innovation is no longer a luxury; it is a strategic survival skill.

The pandemic has sped the need for innovation in service delivery. On one hand, it has changed “customer preference” (both consumers and health plans) for services—more virtual, more home-based, and more data-driven. On the other hand, many organizations have been busy introducing new services designed for these changing times. There are four announcements below, each an example of a game changer for specialty provider organization market positioning:

  • Optum’s purchase of AbleTo. An online behavioral health service delivery system now owned by a major health insuring organization, UnitedHealth Group.
  • Heal’s launch of “Heal Pass.” A program that offers physician house calls and next day shipping of medications for a monthly fee of $49 dollars.
  • Mayo Clinic’s expansion of nationwide acute care services at home. Through a partnership with Medically Home and a new “hospital-at-home” advanced care platform, Mayo Clinic’s physicians can deliver high-intensity services to and remotely monitor consumers at home.
  • Quartet’s arrangement with health plans to support mental health and primary care integration through its virtual care platform and coordinated network of mental health professionals, and to use its technology platform to provide virtual tele-psychiatry and tele-therapy to members.

Certainly, these new service offerings aren’t appropriate for all consumers—many consumers with chronic conditions and complex needs will need another approach. But many will prefer these new options—and will embrace the convenience and value they offer. And more importantly, it is these competitive forces that will reshape the service delivery system and force provider organization managers to change their service line portfolio to remain sustainable. Innovation is the solution to this strategic dilemma. As Dr. Clark says, “Innovation is about figuring out how to get people what they need in a new way, when you can’t do the things the way you usually would.”

But how do you nurture a mindset of innovation? How do you embed it in the way you do business? And how do you scale for success? Dr. Clark described five fundamentals that provider organization executives should think about—strategy, culture, resources, partnerships, and agility.

Innovation is strategic. Innovation must be baked into your strategic planning. Dr. Clark advises that you start by asking the key questions. What is the problem you want to solve? What value does it bring (to the organization, to the community, to the consumers you serve)? Does the innovative solution align with your strategic plan? What resources do you need, and do you have the means to obtain them? What is the tolerance for risk within your organization?

At MHCD, innovation is driven by one key question—how to expand access to care. Only two in five people who need care for mental illness and addictions can access that care, says Dr. Clark. Therefore, they are solving so the three in five can also get care. They are thinking about how to expand the capacity of clinical professionals to see more people through technology supports that act as “force multipliers.”

“We look for conflict and complaints, which are opportunities to do something new and different,” explained Dr. Clark.

Innovation is a culture. A culture of innovation must start from the top but cascade down to every level of staff and those served. Executives at MHCD describe it as human-centered design engaging the people served to develop the solutions, cutting through the red tape to solve at the line level where possible, or escalating the issues quickly to the level where they can be solved. When the pandemic enforced remote work, managers at MHCD found a way to “skip the meetings and solve the problems” through daily huddles where quick decisions could be made.

Innovation also leverages input from consumers and the community. MHCD partnered with one of its local neighborhoods to create the Dahlia Campus for Health & Well-Being to support high risk youth in the community and bought four acres of land with the idea of establishing a 20,000 square foot clinic. But when they asked the community what it needed to thrive; more urgent problems became evident. There was a food desert and food swamps, with mostly junk food. MHCD could not solve for behavioral health issues without addressing the social determinants of health. So, they transformed the area into an urban farm with community gardens, a greenhouse, a teaching kitchen, a pre-school, and a pediatrics clinic. And when the kitchens had to close during the pandemic, they still found ways to get the food out. “Getting in with the community created something we never imagined,” said Dr. Clark.

Innovation needs resources. Initially, MHCD had a whole portfolio of ideas but did not dedicate the resources to nurturing them. “We had our core business and innovation was ‘other duties as assigned.’ It was like oil and water,” said Dr. Clark. It wasn’t until they created an Innovation Lab and dedicated funding and staff that they were able to make innovation happen. Today, MHCD invests 15% of its resources in innovation initiatives.

While not every provider organization might have the ability to scale innovation at the same level, a mindset of innovation will help executives get creative about funding. From talking to payers who are eager to support innovation to “crowdfunding,” the options are many when the solutions are evident.

Innovation thrives on partnerships. The resources to support innovation can come from strategic partnerships. Public-private partnerships have proved beneficial for MHCD and the communities it serves.

In 2016, MHCD set out on an ambitious project to help address the housing crisis in Denver (approximately 400 chronically homeless individuals were costing the city $11 million each year). The city issued social impact bonds to raise funds to build a 60-unit apartment building to house the homeless. And MHCD applied the “Housing First” model principles and offered trauma-informed approach to help design the apartments with personal safety in mind. Today, previously homeless consumers are staying in the apartments and either working or attending school.

Another innovative program that thrives on a public-private partnership is MHCD’s “co-responder” program where licensed clinical social workers (LCSWs) accompany police on a first visit when there are issues involving consumers with behavioral health challenges. This intervention at the first responder level helps get people into care quickly. MHCD piloted the program with six LCSWs and was able to reduce the number of people going to jail from 97% to 7% of encounters.

“Innovation enables us to get people what they need right at the moment they need it,” said Dr. Clark and informed us that once the pilot proved successful, they added 24 LCSWs to scale up the program for impact.

Innovation demands agility. For organizations just getting started on innovation, Dr. Clark recommended a rapid-fire process, “Come up with the idea, prototype it, test it, and figure out what worked well and what didn’t.”

There are two ways of thinking when it comes to innovation. The first is exploitative; taking something you already do and improving it. The second is exploratory; starting from scratch and making broad jumps. Exploration, while it can have a big pay off in the end, is risky. So, start small and leverage the resources you already have. As Dr. Clark suggested, “The innovative solution doesn’t have to be completely thought out before you start. Being agile is key—you can modify based on feedback as you go.” He also advised focusing on “the how” rather than “the what” and developing evidence-based practices right from the get-go.

Executives who support innovation must accept that failure is often part of the process. “In health care, we don’t want to make mistakes. But for an innovative culture to work, we must challenge people to take risks and make it okay if things don’t work out.

On July 6, 2020, the Internal Revenue Service (IRS) clarified that for-profit health care provider organizations must pay taxes on payments from the Provider Relief Fund created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Non-profit health care provider organizations that receive Provider Relief Fund payments are generally exempt from paying taxes on the payment, according to the IRS. However, a non-profit provider organization may be subject to taxes on the payment if the provider organization used the payment to cover expenses or lost revenue attributable to an unrelated trade or business.

The IRS clarified the taxability of Provider Relief Fund payments in responses to frequently asked questions. The IRS also noted that health care provider organizations cannot exclude the payments from gross income as a qualified disaster relief payment, even if the business is a sole proprietorship. The payment must be included in gross income.

The Provider Relief Fund allocations are intended to help health care provider organizations cover lost revenue and increase costs during the public health emergency due to coronavirus disease 2019 (COVID-19). The federal Department of Health and Human Services has been distributing the funds since April 10, 2020. The most recent funding tranche, $15 billion for Medicaid and Children’s Health Insurance Program (CHIP) provider organizations, opened in late June 2020.

The data set of CARES Act Provider Relief Fund payments can be viewed online at https://data.cdc.gov/Administrative/HHS-Provider-Relief-Fund/kh8y-3es6/data.

PsychU last reported on this topic in the following articles:

  • “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured,” which published on May 4, 2020, at https://www.psychu.org/hhs-begins-releasing-100-billion-cares-act-funding-to-provider-organizations-for-relief-assistance-treating-the-uninsured/.
  • “24 Provider Organizations Receive Over $100 Million In CARES Act Provider Relief; New York & Presbyterian Hospital Tops The List,” which published on July 27, 2020, at https://www.psychu.org/24-provider-organizations-receive-over-100-million-in-cares-act-provider-relief-new-york-presbyterian-hospital-tops-the-list/.
  • “$15 Billion HHS Relief Fund For Medicaid & CHIP Provider Organizations Is Open For Applications,” which published on August 10, 2020, at https://www.psychu.org/15-billion-hhs-relief-fund-for-medicaid-chip-provider-organizations-is-open-for-applications/.

For more information, contact:

  • Media Relations Office, Internal Revenue Service, 1111 Constitution Avenue Northwest, Washington, District of Columbia 20224; 202-317-4000; Website: https://www.irs.gov/newsroom/frequently-asked-questions-about-taxation-of-provider-relief-payments.

Shatterproof, a non-profit organization dedicated to reversing the addiction crisis in the United States, announced a free, first-of-its-kind tool to connect those in need with high-quality and appropriate addiction treatment.  ATLAS™, an Addiction Treatment Locator, Assessment, and Standards Platform, will launch in six states.

ATLAS evaluates addiction treatment facilities’ use of evidence-based best practices, allows consumers to see and provide feedback on their experience, and offers an easy-to-use online interface to allow those in need and their loved ones to search for and compare facilities using criteria such as location, services offered, and insurer so they can connect with appropriate treatment. ATLAS is currently available in Delaware, Louisiana, Massachusetts, New York, North Carolina, and West Virginia. The platform lists all of the state’s addiction treatment facilities for any addiction, including opioid use disorder, with more than half voluntarily providing information on services and practices they utilize.

Shatterproof worked with RTI International, an independent research institute with expertise in quality measure development, data collection, and quality reporting, to build ATLAS using a combination of rigorous analytic approaches and data collection innovations. ATLAS was funded by Arnold Ventures, the Robert Wood Johnson Foundation, and a coalition of national health care companies: Aetna, a CVS Health Company, Anthem, Inc., Beacon Health Options, Blue Cross Blue Shield of North Carolina, Cigna, Magellan Health, and UnitedHealth Group.

Shatterproof is a national non-profit organization dedicated to reversing the course of the addiction crisis in America. Shatterproof is focused on ensuring that addiction treatment is based upon proven research and ending the stigma of addiction. The organization advocates for changes to federal and state policy, payer reform, treatment quality assessment, and provides public education through online programs.

For more information, please contact:

  • Shatterproof, 135 West 41st Street, 6th Floor, New York, New York 10036; 800-597-2557; Email: info@shatterproof.org; Website: www.shatterproof.org

Following the 2016 rollout of self-scheduling of video and phone visits at Kaiser Permanente Northern California, 14% of appointments took place via phone or video telemedicine visits during 2016, 2017, and 2018. During these years, an average of 14% of appointments were selected as phone or video visits instead of office visits by health care consumers, and 7% of the telemedicine visits were by video.

Health care consumers were most likely to choose telemedicine or telephonic care if they were aged 18 to 44 years of age: about 49.4% of this demographic scheduled video visits, and 39.8% scheduled telephone visits. Those with an office visit copayment of $35 or more were 1.5 times more likely to choose a video or telephone visit than those with a $0 to $10 copayment. Consumers who were required to pay for parking in a garage structure for their visit were about 1.7 times more likely to choose a video or telephone visit than those who did not. Those who had prior experience with a video visit within the past year were about 11.4 times more likely to choose a video or telephone visit than those who had no prior experience.

The researchers concluded that health care consumers usually chose an in-person visit when scheduling an appointment through the online portal. However, telemedicine may allow health care professionals to reach vulnerable consumer groups, and may improve access for those with transportation, parking, or cost barriers when receiving on-site care.

These findings were reported in “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” by Mary E. Reed, DrPH; Jie Huang, Ph.D.; Ilana Graetz, Ph.D.; et al. The researchers analyzed 2,178,440 primary care appointments scheduled by 1,131,722 health care consumers after the 2016 rollout of self-scheduling for video and phone visits at Kaiser Permanente Northern California. The goal was to determine characteristics associated with those choosing between telemedicine or office visits.

The full text of “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” was published June 17, 2020, by JAMA Network Open. An abstract is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767244.

PsychU last reported on telemedicine in “14% Of Physicians Used Telemedicine Video Visits Weekly Pre-COVID-19,” which published on June 29, 2020. The article is available at https://www.psychu.org/14-of-physicians-used-telemedicine-video-visits-weekly-pre-covid-19/.

For more information, contact: 

  • Mary E. Reed, DrPH, Research Scientist, Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, California 94612; Email: mary.e.reed@kp.org; Website: https://divisionofresearch.kaiserpermanente.org/

Unemployment is projected to increase homelessness by up to 45%, from 568,000 as of January 2020 to more than 800,000 people by the end of 2020, due to the coronavirus disease 2019 (COVID-19) public health emergency. The projection is based on the historic data trend indicating that for every percentage point increase in the unemployment rate, the rate of homelessness per 10,000 people increases by 0.65%.

Before the COVID-19 public health emergency began in mid-March 2020, the national unemployment rate in February was 3.5%. The Bureau of Labor Statistics reported that the unemployment rate rose to 14.6% in April. As of June, the unemployment rate had dropped to 11.1%.

These estimates were reported in “Analysis On Unemployment Projects 40-45% Increase In Homelessness This Year” by Brendan O’Flaherty, Ph.D., for Community Solutions, a non-profit organization focused on reducing homelessness. It leads Built for Zero, a movement of more than 80 cities and counties using data to radically change how they work and the impact they can achieve to reduce homelessness to “functional zero.” Dr. O’Flaherty analyzed data from the Annual Homeless Assessment Report to Congress (AHAR) from January 2019, which provides an annual estimate of people experiencing homelessness in the United States, nationally and by state. That number was used as the baseline for the model projecting the impact of unemployment. The model drew on projections of unemployment published by the Economic Policy Institute, which in early April projected 15.6% unemployment in July 2020 due to the effects of COVID-19. The EPI estimate was similar to the 16% unemployment projected by the Congressional Budget Office for July 2020.

Dr. O’Flaherty used the AHAR homelessness baseline and the Economic Policy Institute unemployment projections as inputs in a calculation of the relationship between unemployment and homelessness. The formula was developed by Kevin Corinth, Ph.D., and published in 2017 in “The impact of permanent supportive housing on homeless populations,” by the Journal of Housing Economics.

The full text of “Analysis On Unemployment Projects 40-45% Increase In Homelessness This Year” was published in May 2020 by Community Solutions. A copy is available online at https://community.solutions/analysis-on-unemployment-projects-40-45-increase-in-homelessness-this-year/.

For more information, contact:

  • Brendan O’Flaherty, Ph.D., Professor, Urban Economics, Columbia University, 420 West 118th Street, 1022 International Affairs Building, Mail Code 3308, New York, New York 10027; 212-854-2449; Email: bo2@columbia.edu; Website: https://econ.columbia.edu/econpeople/brendan-oflaherty/
  • Maya Acharya, Social And Press Coordinator, Community Solutions, 60 Broad Street, Suite 2510A, New York, New York 10004; 646-797-4370; Email: info@community.solutions; Website: https://community.solutions/

As a result of the coronavirus disease 2019 (COVID-19) pandemic, Sigma Mental Health Urgent Care is expanding access to mental health care across the state of Texas through their proprietary, HIPAA complaint platform. Sigma’s platform allows a psychiatrist to conduct an appointment virtually with the same quality and efficiency as a face-to-face appointment.

Sigma will also handle prescriptions remotely through the virtual platform. According to Melissa Deuter, M.D., board-certified psychiatrist and founder of Sigma Mental Health Urgent Care, the response to the new methodology has been exceptionally well received and the transition has been seamless, as the telehealth model allows Sigma clinical professionals to obtain a full view of an individual’s mental health and well-being (e.g., weight loss or gain) for the most effective treatment.

Sigma Mental Health Urgent Care provides mental health evaluations, short-term counseling, psychopharmacological services, and referrals for longer-term care when necessary. The mission of Sigma Mental Health Urgent Care Center is to improve the lives of people living with mental health disorders by providing immediate psychiatric and therapeutic services during moments of crisis as well as creating a continuity of care between our staff members and other mental health provider organizations in the community.

For more information, please contact:

  • Sigma Mental Health Urgent Care, 18587 Sigma Road, Suite 260, San Antonio, Texas 78258; 210-314-4564; ​Email: Sigma@SigmaMHUC.com; Website: www.sigmamhuc.com

Kroger Health, the health care division of The Kroger Co., announced the U.S. Food and Drug Administration (FDA) has granted Emergency Use Authorization for the COVID-19 Test Home Collection Kit. The testing solution combines the safety and convenience of at-home sample collection with the expert guidance of a telehealth consultation to help improve the quality of the collection process.

Kroger Health’s COVID-19 Test Home Collection Kit is available to frontline associates across Kroger’s Family of Companies, based on medical need. In partnership with Gravity Diagnostics, a full-service clinical laboratory located in Covington, Kentucky, Kroger Health plans to rapidly expand the availability of the home collection kits to other companies and organizations in the coming weeks, with a goal of processing up to 60,000 tests per week by the end of July. The Kroger Health COVID-19 Test Home Collection Kit will initially be available in Arizona, Colorado, Georgia, Indiana, Kansas, Kentucky, Michigan, Montana, Nevada, New Mexico, Ohio, Tennessee, Utah, and Virginia. Additional states will be added in the coming weeks. Kroger Health launched public drive-thru and walk-up COVID-19 testing sites in April. Since then, Kroger Health has administered more than 100,000 tests across 19 states.

Kroger Health, the health care division of The Kroger Co., is a retail health care organization with over 2,000 pharmacies and 200 clinics in 35 states serving more than 14 million customers. Kroger Health is comprised of a team of 22,000 health care practitioners including pharmacists, nurse practitioners, dietitians, and technicians.

For more information, please contact:

  • The Kroger Co., 1014 Vine Street, Cincinnati, Ohio 45202-1100; 513-762-4000; Website: www.thekrogerco.com

Center on Addiction has changed its name to Partnership to End Addiction. In tandem, it has launched a new brand identity and redesigned website at drugfree.org. The changes are part of an evolution following the 2019 merger of two distinguished leaders in the addiction space. They also align with the organization’s ongoing efforts to address community needs at a time of increased national uncertainty exacerbating the addiction crisis.

The new website provides critical information for families impacted by addiction, as well as policymakers, researchers, and health care professionals in the addiction space. Family members seeking guidance and information can access the organization’s educational content on treatment, recovery, and prevention in addition to one-on-one support from trained helpline specialists. They can also learn about advocating for policy changes, leading efforts in their own communities, and volunteering with the organization. Professionals in government, research, and health care can engage with the organization’s state- and federal-level policy and advocacy work, professional services, partnership opportunities, and addiction research and science.

Partnership to End Addiction’s updated logo, a combined heart and check, reflects its unique approach to ending addiction with a mix of heart and science, compassion, and expertise. Its new brand design demonstrates the broad spectrum of the non-profit’s activities and its evolution as a combined organization now working on all fronts to solve our nation’s addiction crisis.

Partnership to End Addiction is a national non-profit providing personalized support and resources for families impacted by addiction. With decades of experience in direct services, communications and partnership-building, the organization mobilize families, policymakers, researchers, and health care professionals to more effectively address addiction systemically on a national scale.

For more information, please contact:

  • Partnership to End Addiction, 485 Lexington Avenue, 3rd Floor, New York, New York 10017-6706; 212-841-5200; Email: media@toendaddiction.org; Website: https://drugfree.org

On June 18, 2020, Humana announced that its “Bold Goal” initiative focused on social determinants of health continues to show improvement in population health five years after its introduction. The program works to improve the average number of “Healthy Days” by screening for and addressing members’ upstream social needs like food insecurity (inability to obtain proper nutrition), transportation problems, and loneliness (a discrepancy between an individual’s desired and actual social relationships, whether in their quality or quantity). Under the Bold Goal initiative, Humana has provided more than 2.6 million social determinant screenings. Each member screened had an average of 3.5 health-related social needs.

Humana Medicare Advantage members across all markets improved on the Healthy Days measure between 2015 and 2019. In the seven original Bold Goal communities, Medicare Advantage members reported 2.3% fewer unhealthy days, from an average of 13.58 days per month in 2015 to an average of 13.27 days per month in 2019. In non-Bold Goal communities, the average number of unhealthy days rose by 0.2%, from 13.42 days to 13.45 days. In five of the seven original Bold Goal communities (San Antonio, Texas; Baton Rouge and New Orleans, Louisiana; Tampa, Florida; and Knoxville, Tennessee), Humana Medicare Advantage members experienced fewer unhealthy days in 2019 than in 2015. In two Bold Goal communities (Louisville, Kentucky and Broward County, Florida), the average number of unhealthy days rose, which Humana attributed in part to growth of new membership in higher-risk populations in those markets.

Humana Medicare Advantage Improvement On Healthy Days Metric, 2015 To 2019, In Bold Goal Communities
Area 2015 Average Number Of Unhealthy Days In The Past 30 Days 2019 Average Number Of Unhealthy Days In The Past 30 Days Percent Change
Non-Bold Goal Communities 13.42 13.45 +0.2%
Seven Original Bold Goal Communities 13.58 13.27 -2.3%
San Antonio, Texas 14.69 13.43 -8.6%
Baton Rouge, Louisiana 13.72 13.10 -4.5%
New Orleans, Louisiana 13.38 13.09 -2.2%
Tampa, Florida 12.93 12.44 -3.7%
Knoxville, Tennessee 14.14 13.83 -2.2%
Louisville, Kentucky 12.66 13.60 +7.4%
Broward County, Florida 14.13 14.21 +0.6%

In some Bold Goal communities, Humana monitored the effects on Medicare Advantage members with specific chronic health conditions. Members with chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), depression, congestive heart failure (CHF), and hypertension are experiencing a decrease in unhealthy days compared to the prior year. Humana believes that the decrease is due to integration of procedures to identify and address health-related social needs along with health conditions, both physical and mental, in care management. Between 2015 and 2019, the number of unhealthy days declined as follows:

  • COPD: 1.2% fewer unhealthy days
  • CAD: 1.8% fewer unhealthy days
  • Depression: 2.9% fewer unhealthy days
  • CHF: 3.1% fewer unhealthy days
  • Hypertension: 3.2% fewer unhealthy days

The Bold Goal initiative uses the Centers for Disease Control and Prevention’s (CDC’s) Healthy Days tool to measure population health-related quality of life. The method for estimating unhealthy days is supported by the actual pattern of survey responses to questions regarding self-reported physical health (physical illness and injury) and mental health (stress, depression, and problems with emotions) during the 30 days prior to the survey.

Humana Inc. is a for-profit health insurance company with more than 13 million covered lives in the United States. The “Bold Goal” initiative, which began in 2015, tracks individuals’ unhealthy days for individuals and populations. The goal of the initiative was to target these social determinants of health and, community behavioral health, to help the communities Humana serves become 20% healthier by 2020 and beyond. Having reached that goal for its associates, Humana set a further goal to achieve 500,000 more “healthy days” by the end of 2022.

Since launching the Bold Goal initiative in the seven original communities, Humana has expanded the initiative to 16 total markets. In 2018, it expanded to Chicago, Illinois; Kansas City, Missouri and Kansas; Jacksonville, Florida; and Richmond, Virginia. In 2019, it expanded to Detroit, Michigan; Cincinnati, Ohio; Charlotte, North Carolina; Atlanta, Georgia; and Houston, Texas.

The full text of “2020 Bold Goal Progress Report, Data Trends” was published in June 2020 by Humana. A copy is available online at https://mms.businesswire.com/media/20200618005224/en/799300/1/Humana_BG_data+trends_final+%28002%29.pdf.  An interactive version is posted online at https://populationhealth.humana.com/2020-bold-goal-progress-report/.

PsychU last reported on this topic in “Screening Humana Medicare Advantage Members For Social Determinants Of Health Reduced ‘Unhealthy Days’ By 2.7%,” which published on June 10, 2019. The article is available at https://www.psychu.org/screening-humana-medicare-advantage-members-for-social-determinants-of-health-reduced-unhealthy-days-by-2-7/.

For more information, contact:

  • Alex J. Kepnes, Corporate Media Relations, Humana, 500 West Main Street, Louisville, Kentucky 40202; Email: akepnes@humana.com; Website: https://www.humana.com/

The Centers for Medicare and Medicaid Services (CMS) made big news once again. On June 17, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers. The rule’s definition of VBP is an arrangement intended to align payments to therapeutic or clinical value in a population, such as evidence-based measures. The cost should be linked to existing evidence of the effectiveness and/or outcomes-based measures. Or payment should be linked to the drug’s actual performance in a consumer or a population—such as reduction in medical expenses.

A significant change is that the proposed rule allows medication manufacturers to report multiple “Best Prices” for a medication. The current Federal reporting requirements for medication prices are byzantine in my view and an impediment to rational pricing. In short, under the current Federal reporting requirements, manufacturers must report to CMS their drug’s “Best Price”—the lowest net price a manufacturer offers for the medication in the U.S. after factoring in all rebates and discounts. Manufacturers then pay Medicaid programs a rebate equal to 23.1% of a drug’s “Average Manufacturer Price” if that amount of rebate results in a net price lower than or equal to the Best Price. This is intended to assure that the post-rebate price to Medicaid programs is no more than the Best Price available on the commercial market.

This pricing situation makes manufacturers hesitant to participate in VBP. Under the proposed rule, instead of reporting a Best Price depending on a single outcome, manufactures will be allowed to use “bundled sale” price reporting. This would permit reporting of Best Price as the average net price across all sales prices. This would change Best Price to be the lowest average price that any payer actually pays per unit, including both failures and successes. And CMS is planning an alternative to the bundled sale pricing reporting. The proposed rule would allow commercial health insurers to pay different prices for a medication based on outcomes. The manufacturer would then report the lowest price that any payer negotiates for each outcome as a Best Price, as well as the lowest available price absent a VBP arrangement.

CMS Administrator Seema Verma, in her Health Affairs blog post, CMS’s Proposed Rule On Value-Based Purchasing For Prescription Drugs: New Tools For Negotiating Prices For The Next Generation of Therapies, explained the goals of the proposed rule changes: “Value-based payment in health care involves basing payment on improvements in patient outcomes….However, value-based payment for prescription drugs is still in its infancy….Today, payment for much of health care including pharmaceuticals is based primarily on volume. Volume drives negotiations; the greater the quantity of a manufacturer’s product that a payer sells, the larger the rebate that the payer usually receives from the manufacturer….Today’s proposal would empower commercial plans to negotiate based on value while extending these discounts to Medicaid programs….All Medicaid programs in the country would immediately benefit from these private market deals without having to design the arrangements themselves, as Medicaid programs would only have to pay the lowest price offered for each outcome if they chose to participate.”

With so much happening, this is probably not a top-of-mind issue for most provider organization executives. Some would argue, however, if adopted at scale, there are many implications. Generally, there are concerns that this model of VBP will limit consumer medication choices. There is also the chance that the selected performance measures will “bend” treatment patterns, with preference for certain types of programs.

But most would still add this to the list of new opportunities. For most of these arrangements, “value” will be demonstrated through reduced emergency department use, reduced use of inpatient care, fewer inpatient admissions, cutting inpatient length of stay, and improving (or achieving) particular health status measures—all achieved through the use of the “best” medications, used in the “best” way.

Put it this way—to achieve those performance measures, consumers need to take the medication, take the medication correctly, and integrate the medication into their overall disease management plan. To make that happen, pharmaceutical companies will need provider organization partners with expertise in those disease states, consumer treatment planning and care coordination, and outreach and engagement. As these regulatory changes roll out, VBP for medications will likely open the door to a variety of solutions to achieve these best practices, such as packaging digital technologies, professional services, and support services into programmatic solutions for consumers. The key will be to find these new opportunities—likely through partnerships—to operate in yet another health care market focused on value.

Icertis, an enterprise contract management platform in the cloud, announced Humana selected Icertis as its contract management platform to increase visibility and enterprise-wide efficiency, while reducing cycle time. To meet the demands of the fast-moving, highly-regulated health insurance industry, Humana needed to modernize its manual contract processes with an intelligent, easy-to-use contract management solution that could help it manage intercompany agreements between its insurance group and its health care services, wellness, and care delivery organization business units. Humana will use the Icertis Contract Management (ICM) platform to standardize contract management processes, perform amendments to legacy contracts and create a single source of truth for all intercompany agreements while ensuring compliance with the company’s strict security and data privacy policies.

Health care payers rely on intercompany agreements to manage transfers of assets, liabilities, and risk between subsidiaries and must maintain strict records of these transactions to meet legal audit requirements. Humana selected Icertis due to the contract management leader’s prior experience with leading health care brands like AbbVie, Australian Unity, Johnson & Johnson, Merck and Sanofi and ability to manage all contract types from across its diverse business groups in a central repository.

Icertis is an enterprise contract management platform in the cloud that helps companies unlock the full business value of their contracts to increase revenue, reduce cost, accelerate cash flow, and minimize risk. The adaptable, AI-infused Icertis Contract Management platform quickly turns contracts from static documents into strategic assets.

Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. As of 2014, Humana had over 13 million members in the U.S.

For more information, please contact:

  • Haley Flanagan, Manager of Corporate Communications, Icertis; 14711 NE 29thPlace, Suite 100, Bellevue, Washington 98007; 425-869-7649; Email: CorpComm@icertis.com; Website: www.icertis.com
  • Contact information: Kelley Murphy, Humana Corporate Communications, Humana, Inc., 500 W Main Street, Louisville, Kentucky 40202; 502-224-1755; Email: Kmurphy26@humana.com; Website: www.humana.com

Following the 2016 rollout of self-scheduling of video and phone visits at Kaiser Permanente Northern California, 14% of appointments took place via phone or video telemedicine visits during 2016, 2017, and 2018. During these years, an average of 14% of appointments were selected as phone or video visits instead of office visits by health care consumers, and 7% of the telemedicine visits were by video.

Health care consumers were most likely to choose telemedicine or telephonic care if they were aged 18 to 44 years of age: about 49.4% of this demographic scheduled video visits, and 39.8% scheduled telephone visits. Those with an office visit copayment of $35 or more were 1.5 times more likely to choose a video or telephone visit than those with a $0 to $10 copayment. Consumers who were required to pay for parking in a garage structure for their visit were about 1.7 times more likely to choose a video or telephone visit than those who did not. Those who had prior experience with a video visit within the past year were about 11.4 times more likely to choose a video or telephone visit than those who had no prior experience.

The researchers concluded that health care consumers usually chose an in-person visit when scheduling an appointment through the online portal. However, telemedicine may allow health care professionals to reach vulnerable consumer groups, and may improve access for those with transportation, parking, or cost barriers when receiving on-site care.

These findings were reported in “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” by Mary E. Reed, DrPH; Jie Huang, Ph.D.; Ilana Graetz, Ph.D.; et al. The researchers analyzed 2,178,440 primary care appointments scheduled by 1,131,722 health care consumers after the 2016 rollout of self-scheduling for video and phone visits at Kaiser Permanente Northern California. The goal was to determine characteristics associated with those choosing between telemedicine or office visits.

The full text of “Patient Characteristics Associated With Choosing a Telemedicine Visit vs Office Visit With the Same Primary Care Clinicians” was published June 17, 2020, by JAMA Network Open. An abstract is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767244.

PsychU last reported on telemedicine in “14% Of Physicians Used Telemedicine Video Visits Weekly Pre-COVID-19,” which published on June 29, 2020. The article is available at https://www.psychu.org/14-of-physicians-used-telemedicine-video-visits-weekly-pre-covid-19/.

For more information, contact: 

  • Mary E. Reed, DrPH, Research Scientist, Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, California 94612; Email: mary.e.reed@kp.org; Website: https://divisionofresearch.kaiserpermanente.org/

On June 24, 2020, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) launched Accelerate to Value, a comprehensive program to help independent primary care practices deal with financial challenges related to coronavirus disease 2019 (COVID-19). The program provides financial stabilization payments starting in September 2020 based on the primary care practice’s 2019 revenue. In exchange for receiving the payments, the practice must commit to transitioning to value-based care by the end of 2020. Starting in 2022, the participating practices will be eligible to receive monthly population-based capitated payments, rather than fee-for-service reimbursement.

To participate in the Accelerate to Value program, applications must be submitted by July 31, 2020. Participating practices will have two options:

  • Join an existing accountable care organization through a Blue Premier clinically integrated network.
  • Join Aledade, a company that helps primary care practices move to value-based care.

Accelerate to Value is intended for independently owned and operated primary care practices, including internal medicine, family medicine, pediatrics, geriatrics, multispecialty, and/or OB-GYN. Practices owned by hospitals and health systems are not eligible. Through the duration of the program, participating practices will take steps to improve clinical quality for Blue Cross NC members, including ensuring access to care, adopting and expanding telehealth, using electronic health records, and delivering preventive care and care coordination activities responsive to the COVID-19 pandemic. Practices that meet program requirements will receive a new contract amendment from Blue Cross NC.

Blue Cross NC serves more than 3.8 million covered lives. The organization is an independent licensee of the Blue Cross and Blue Shield Association.

For more information, contact: 

  • Accelerate to Value, Blue Cross and Blue Shield of North Carolina, 1965 Ivy Creek Boulevard, Durham, North Carolina 27707; Email: AcceleratePCP@bcbsnc.com; Website: https://www.bluecrossnc.com/accelerate-value-program

There is a lot of telehealth going on. Medicare has temporarily increased access through the Medicare 1135 waiver, which covers all office visits provided via telehealth in any setting throughout the country, for any physical or mental health service; has suspended enforcement of the “established-relationship” requirement; and added 85 more physician procedure codes. All provider organizations that are eligible to bill Medicare for their professional services can now deliver telehealth.

In Medicaid, most state regulations have been relaxed to provide more telehealth services for beneficiaries, including: the health care professional’s home can serve as a distance site; new consumers (i.e., those not previously receiving telehealth) are able to receive telehealth services; new HIPAA procedures for smart phones and previously non-compliant applications are allowed for telehealth services; verbal consent can be given in lieu of written consent; and telephone-only encounters. In total, 44 states have modified their Medicaid state plans to authorize the coverage of telehealth services for Medicaid beneficiaries.

In a new OPEN MINDS survey, they looked at what has been happening in health plans. What did they find? Approximately 95% of health plans report waiving cost-sharing requirements for beneficiaries. 42% of health plans have contracted with out-of-state or out-of-network provider organizations to deliver telehealth services. They also identified that approximately 22% of health plans are reimbursing provider organizations for telehealth services at the same rate as face-to-face interactions, and 45% of health plans have modified their benefits during the COVID-19 outbreak, including eliminating co-pays, reimbursing the same as in-person, and making treatment related to COVID-19 free.

They also looked at the specialty managed behavioral health organizations (MBHOs)—approximately 46% of MBHOs have reported policy or provision changes since the COVID-19 outbreak. 21% of MBHOs have modified their service delivery to waive cost-sharing requirements and approximately 18% have contracted out-of-state or out-of-network provider organizations to deliver telehealth services. And 18% are reimbursing provider organization for telehealth services at the same rate as face-to-face interactions.

But the big planning question for provider organization management teams is what will happen after the crisis period ends? We have seen health plans set expiration dates on the expanded telehealth benefits, but those dates have been repeatedly moved—for example, Blue Cross Blue Shield of Texas has moved their cut-off date three times. Some states like Colorado and Idaho have made the telehealth expansion permanent. At the federal level, there is still no concrete plan on how long the current benefits will last, but earlier this month, 38 senators released an open letter asking U.S. Secretary of Health and Human Services Alex Azar and Centers for Medicare and Medicaid Services Administrator Seema Verma to provide a plan to make the expanded telehealth access permanent. And as Ms. Verma said earlier in the crisis, “the genie is out of the bottle” and there is no going back.

Yesterday, OPEN MINDS hosted a private roundtable briefing, Telehealth – What Will The Payers Change Post-COVID-19? Let’s Ask Them: An OPEN MINDS Executive Roundtable, for their Elite members of OPEN MINDS Circle on this topic. The faculty—Deborah Adler, Senior Associate at OPEN MINDS; Kathleen Mahieu, Director of Digital Product Innovation and Strategic Partnerships at Aetna Mental Wellbeing; Sean Schreiber, Executive Vice President of Network and Community Health at Alliance Health; Amy Pearlman, Vice President of Clinical Provider Strategy at Beacon Health Options; and Roberta Montemayor, Director of Telemental Health Innovation for Network Strategy Optum Behavioral Health—provided a few key takeaways about what managers can expect in the future.

Payers will continue to offer provisions to encourage telehealth but need to see the value. They need performance measures that demonstrate clinical effectiveness and engagement. They need to know if telehealth services are delivering the same quality and clinical outcomes that face-to-face services can. They need to see if consumers are staying engaged. For example, Mr. Schreiber explained, “We are seeing increased engagement for individuals already involved in care grow over time, but we aren’t seeing as much growth of new members coming into care. The focus needs to be on what the barriers are and how providers are handling bringing new members into care via telehealth, as we see a decrease in new member access and fewer new assessments.”

Payers also noted that the focus on quality and performance will likely expand from the individual-level to a programmatic level, Ms. Pearlman noted that Anthem/Beacon has been asking questions like “How are you being thoughtful in terms of standard operating procedures? How do you handle a crisis?” She noted, “These are the types of programmatic questions that will look different over telehealth than when someone is in the room with you.”

A Coalition of leading addiction and mental health advocacy groups and stakeholder organizations announced the launch of the Recovery Access Coalition to address the barriers to accessing potentially life-saving digital therapeutics authorized by the U.S. Food and Drug Administration (FDA) to treat addiction disorder, like prescription digital therapeutics (PDTs). Members of the Coalition include Advocates for Opioid Recovery, Global Recovery Initiatives Foundation, the Kennedy Forum, the National Council for Behavioral Health, Shatterproof, and Young People in Recovery. Pear Therapeutics, Inc. is a member and sponsor of the initiative.

Digital therapeutics, including PDTs, have a critical role to play for people in recovery. Under current circumstances, the advantages of digital therapeutics to people with addiction treatment needs, and their clinicians, are significant. Digital therapeutics can treat people without physical proximity, extend care over distances, promote deeper connection between people and their care team, and empower people to strengthen their self-assessment skills and better navigate their care. The Recovery Access Coalition is advocating for Medicare coverage of FDA authorized digital therapeutics at the federal level, for Medicaid coverage at the state level, and for broad coverage across the commercial health insurance market. According to the Coalition, policymakers have the rare opportunity to embrace a clinically validated, FDA-authorized therapeutic solution that already exists and is made for the challenges and demands of the moment.

The Recovery Access Coalition aims to eliminate barriers to access for FDA authorized digital therapeutics for addiction disorder. Specifically, the Coalition is seeking policy changes in Medicare, Medicaid, and the commercial insurance market to authorize coverage for digital therapies, including prescription digital therapeutics, for addiction treatment. The goal of the Coalition is to increase policymakers’ awareness of the dire need for digital therapy for substance use disorder, educate policymakers about the value, safety, and efficacy of digital therapeutics in providing needed treatment digitally and promote greater consumer access to and adoption of FDA authorized digital therapeutics for addiction.

For more information, please visit:

  • The Recovery Access Coalition, Website: www.recoveryaccesscoalition.org

On July 17, 2020, the North Carolina Department of Health and Human Services (NCDHHS) announced it has selected 39 vendors, among them health and human service provider organizations, to conduct testing and contact tracing for coronavirus disease 2019 (COVID-19). These organizations represent the state’s initial pool of qualified vendors to support the state’s response to COVID-19. NCDHHS selected the first group of 26 organizations on June 19 and selected 13 more on July 17, 2020.

The state is using a rolling qualification process and vendors will be able to submit a response by the first of every month through December 2020. The goal is to help NCDHHS surge resources such as testing, lab capacity, and contact tracing to respond to the COVID-19 pandemic. Organizations could apply to be qualified for individual or multiple components.

The first areas of work focus on testing all residents and staff of nursing homes and significantly increasing testing for African American/Black, LatinX/Hispanic, Native American, and refugee populations in ZIP codes that lack access to testing sites. Historically marginalized populations are being disproportionately impacted by COVID-19 due to long standing health inequities that NCDHHS is addressing proactively as it responds to the pandemic.

Testing and lab capacity: The state is focusing on supporting historically marginalized populations, testing in congregate living facilities, testing in areas with outbreaks, addressing low-tested counties or communities, and supporting businesses and their workforce. Qualified vendors for testing and laboratory reserve capacity include:

  1. CW Williams Community Health Care Center
  2. EGL Genetic Diagnostics
  3. Laboratory Corporation of America Holding
  4. Omnicare, a CVS Health Company
  5. Orig3n, Inc
  6. United Providers of Health LLC
  7. University Health System of East Carolina

Qualified vendors for testing only include:

  1. Cone Health
  2. Groundwater Solutions
  3. Mako Medical
  4. North Carolina Community Health Center Association
  5. Piedmont Health Services and Sickle Cell Agency
  6. Substance Abuse Treatment Labs
  7. Visit Healthcare

Qualified vendors for lab capacity only include:

  1. Kashi Clinical Laboratories
  2. Mako Medical
  3. Substance Abuse Treatment Labs

Contact tracing: NCDHHS sought vendors who represent the communities and people impacted by COVID-19 to build on the work of local health departments. Contact tracing identifies people who have recently been in close contact with someone who has tested positive for COVID-19. Qualified vendors for contact tracing include:

  1. 22nd Century Technologies
  2. Agile Government Services, Inc.
  3. AM LLC
  4. Arbor/Res-care
  5. Atrium Staffing
  6. Automated Health Systems
  7. BizTechPeople LLC
  8. CW Williams Community Health Care Center
  9. Computer Aid Inc (CAI)
  10. Conduent State Healthcare LLC
  11. Global Contact Services
  12. Grace Federal Solutions LLC
  13. Groundwater Solutions
  14. Intellect Resources
  15. Jennifer Temps, Inc
  16. K4 Solutions Inc
  17. Keystone Peer Review
  18. Maximus Health Services
  19. Medical Edge Recruitment LLC
  20. Piedmont Health Services and Sickle Cell Agency
  21. PRC
  22. Public Consulting Group Inc
  23. ResponsePoint
  24. SouthEastern Healthcare of NC
  25. Spanish Speaking LLC
  26. SWC Group LLP dba Healthcare Solutions
  27. WellSky

From March 1, 2020 through July 20, more than 100,000 North Carolina residents have been diagnosed with COVID-19. There have been 1,642 deaths due to COVID-19. Of the more than 1.4 million tests conducted through July 20, about 7% have been positive for COVID-19.

For more information, contact:

  • Mandy Cohen, Secretary, North Carolina Department of Health and Human Services, 101 Blair Drive, Adams Building, 2001 Mail Service Center, Raleigh, North Carolina 27699-2001; 919-855-4840;  Email: news@dhhs.nc.gov; Website: https://covid19.ncdhhs.gov/.

The Centers for Medicare & Medicaid Services (CMS) is preparing to allow Medicare home health provider organizations to continue using telehealth to provide home health services as they have been under relaxed regulations due to the coronavirus disease 2019 (COVID-19) public health emergency. The goal is to give home health provider organizations predictability in their service delivery options, and to ensure that Medicare beneficiaries continue to have access to the latest treatment technologies.

These proposed changes are among the first flexibilities provided during the COVID-19 public health emergency that CMS is proposing to make a permanent part of the Medicare program. After the public health emergency ends, home health provider organizations will be able to continue to report the costs of telecommunications technology as allowable administrative costs on the home health provider organization cost report.

The telehealth services must be related to the skilled services being furnished, must be outlined in the beneficiary plan of care, and must be tied to a specific goal indicating how such use would facilitate treatment outcomes. Telehealth cannot be used as a substitute for an in-person home visit that is ordered in the plan of care and cannot be considered a visit for the purpose of determining eligibility or payment.

The proposed rule was issued on June 30, 2020, “Medicare and Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Home Infusion Therapy Services Requirements.” Comments will be accepted through August 31, 2020. Additional topics in the proposed rule include the following:

  • Routine, statutorily required updates to the home health payment rates for calendar year 2021. CMS estimates a 2.6% aggregate increase in Medicare payments to home health provider organizations, totaling about $540 million.
  • Updates to the home health wage index including the adoption of revised Office of Management and Budget (OMB) statistical area delineations and limiting any decreases in a geographic area’s wage index value to no more than 5% in calendar year 2021.
  • Implement Medicare enrollment policies for qualified home infusion therapy suppliers and proposes updates to the calendar year 2021 home infusion therapy services payment rates using the calendar year 2021 Physician Fee Schedule amounts.

A link to the full text of “Medicare & Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Home Infusion Therapy Services Requirements” may be found at www.openminds.com/market-intelligence/resources/063020fed42cfr409.htm.

A link to the full text of “Home Health Agencies: CMS Flexibilities To Fight COVID-19” may be found at www.openminds.com/market-intelligence/resources/033020cmshomehealthflexibilitycovid.htm.

PsychU last reported on this topic in the following articles in “Medicare Further Expands Telehealth Access For Long-Term Care, Hospice & Home Health Benefits,” which published on May 18, 2020, at https://www.psychu.org/medicare-further-expands-telehealth-access-for-long-term-care-hospice-home-health-benefits.

For general information about the Home Health PPS, contact:

  • Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; Email: HomehealthPolicy@cms.hhs.gov; Website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index; or Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145;  Fax: 202-260-1462; Website: https://www.cms.gov/.

About 17% of accountable care organizations (ACOs) are developing new home visit programs, according to topline results of a recent survey of 163 ACOs. About 26% of ACOs already have a home visit program. Another 25% conduct home visits, but do not have a formal program. About 32% said they had no plans to start a home visit program.

The majority of ACOs that have or that are developing a home visit program use it to deliver primary care. According to survey responses, other reasons for home visit programs are part of a hospital-at-home model, to support care coordination, or to support transitions from inpatient or residential settings to home care. A minority of programs are intended to address social determinants of health.

The survey was conducted from September 2019 through the start of January 2020 by the Institute for Accountable Care (IAC) and West Health Institute with members of the National Association of ACOs (NAACOS). Responses were received from 163 ACOs. The majority are participating in the Medicare Shared Savings Program; a few are participating in the Next Generation ACO program.

The survey results are being submitted to a peer-reviewed journal. Summary results were reported on July 5, 2020, in “Nearly 70% of ACOs Will Soon Offer Some Type of Home Visits” by Bailey Bryant for Home Health Care News. The article is posted at https://homehealthcarenews.com/2020/07/nearly-70-of-acos-will-soon-offer-some-type-of-home-visits/.

For more information, contact:

  • David Pittman, Health Policy and Communications Advisor, National Association of Accountable Care Organizations, 601 13th Street Northwest, Suite 900 South, Washington, District of Columbia 20005; 202-640-2689; Email: dpittman@naacos.com; Website: https://www.naacos.com/. 

On June 2, 2020, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) announced it had expanded its Horizon Neighbors in Health (HNIH) demonstration project that addresses social determinants of health (SDOH). Horizon BCBSNJ partnered with six health systems to expand the program to members in 70 ZIP Codes across 11 counties (Bergen, Essex, Hudson, Mercer, Monmouth, Morris, Ocean, Passaic, Sussex, Union, and Warren). The health systems are Atlantic Health Systems, Hackensack Meridian Health, RWJ Barnabas Health, the Trenton Health Team, University Hospital, and St. Joseph’s Health. Each health system received grants to hire and train local community health workers; in total 60 will be hired. Over three years, Horizon BCBSNJ anticipates that the health systems will enroll 24,000 members covered by its commercial, Medicaid, or Medicare Advantage plans.

The community health workers use an online platform called NowPow to connect Horizon BCBSNJ members with an array of non-medical services such as food, housing, mental health support, education, or employment opportunities. The program is intended to help Horizon BCBSNJ members connect to services and resources, obtain what they need to improve their health, and maintain the connections independently. Through this program, Horizon BCBSNJ seeks to demonstrate and quantify the impact of using community health workers to help members connect to SDOH on member health and on the total cost of care.

Horizon BCBSNJ is providing $25 million to over three years to fund HNIH. The funding pays for 50% of the community health worker salaries, and half of the salaries for their managers and directors. It will cover 100% of the cost for training and certification for the community health workers, and 100% of the cost of the NowPow data platform. Horizon BCBSNJ makes quarterly payments to its partners based on the number of community health workers and management staff that are predetermined to be hired. The HNIH staffing level varies by partner depending on the number of members the partner seeks to enroll in the program.

Since April 2017, Horizon BCBSNJ has piloted a version of HNIH with Robert Wood Johnson Barnabas Health’s Newark Beth Israel Medical Center. In total, the pilot reached out to assist 1,000 Horizon members living in four ZIP Codes within the medical center’s service area. In early 2019, Horizon BCBSNJ reported that for the participating members, the pilot cut their aggregate total cost of care by 25% as of October 2018. The participants had 20% fewer hospital inpatient admissions and 24% fewer emergency department visits. Their visits to behavioral health professionals increased by 35%. In 2019, Horizon began inviting other health systems across the state to participate to expand HNIH statewide.

To identify potential HNIH participants, Horizon BCBSNJ uses advanced analytics and predictive modeling that consider individual and community factors gleaned from census data, claims data, and other data sources that provide a comprehensive profile on the target population. Using grant funds from Horizon BCBSNJ, the participating health systems hire community health workers from the same communities as the potential participants. Each community health worker is trained by the Penn Center for Community Health Works and, over two weeks, completes the Penn Health IMPaCT Training and Certification Program. After training, the community health workers engage directly with high and at-risk consumers identified by Horizon BCBSNJ. Horizon monitors the progress being made by its partners to ensure that they are achieving enrollment goals.

Due to the coronavirus disease 2019 (COVID-19) pandemic, the HNIH program has been adapted from face-to-face engagement during in-home visits by a community health worker to telephonic engagement. Since the pandemic began, the HNIH community health workers have been helping connect members to SDOH resources and helping the members manage stresses created by the pandemic. In both the face-to-face and telephonic engagement visits, the community health workers use the NowPow online platform to connect HNIH participants to services, track utilization, and document outcomes to ensure that participants are connecting with needed assistance. The NowPow platform maintains an up-to-date inventory of services available from local social, non-profit, and community service organizations.

PsychU last reported on the HNIH pilot outcomes in “New Jersey Horizon Blues Social Determinants Pilot Cut Total Cost Of Care By 25%,” which published on April 25, 2019. The article is available at https://www.psychu.org/new-jersey-horizon-blues-social-determinants-pilot-cut-total-cost-of-care-by-25/.

For more information, contact:

  • Valerie Harr, Director, Community Health, Horizon Blue Cross Blue Shield of New Jersey, 1700 American Boulevard, Pennington, New Jersey 08534;  Email: Valerie_Harr@horizonblue.com; Website: https://www.horizonhealthnews.com/horizon-neighbors-in-health/; and https://www.horizonblue.com/.

In this presentation, Becky Wong, PharmD, MBA, provides an overview of measurement-based care, how measurement-based care may be used to improve quality in psychiatry, shares a fictional case example of measurement-based care in psychiatry, as well as provides additional mental health screening resources.


Becky Wong, PharmD, MBA, is a Senior Medical Science Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

Between March and May 2020, an estimated 1.64 million people employed by non-profit organizations lost their jobs due to the coronavirus disease 2019 (COVID-19) pandemic public health emergency. This equates to more than 13% of those employed by a non-profit organization, and about 8.8% of all job losses during this period. Of the non-profit jobs lost, approximately 35% have been in the health care field.

Across economic sectors, the share of non-profit jobs lost varied. Overall, non-profit job losses accounted for about 71% of all private educational service job losses, about 43% of all private health care job losses, and about 41% of private job losses in the social assistance sector.

Estimated Non-Profit Job Losses By Field, April Thru May 2020, Based On Bureau Of Labor Statistics Overall Private Employment Situation Data
Industry Sector Total Jobs Lost Non-Profit Jobs Lost Non-Profit Share Of Private Jobs Lost
All Private Non-Farm Employment -18.7 million -1.6 million 8.8%
Professional, Scientific & Technical Services -489,200 -14,689 3.0%
Educational Services -455,600 -323,201 70.9%
Health Care -1,322,600 -574,530 43.4%
Ambulatory Health Care Services -1,041,150 -200,942 19.3%
–Offices Of Physicians -229,650 -58,345 25.4%
–Offices Of Dentists -398,100 -4,189 1.1%
–Offices Of Other Health Care Professionals -175,150 -8,552 4.9%
–Outpatient Care Centers -83,600 -37,276 44.6%
Hospitals -26,700 -22,381 83.8%
Nursing & Residential Care Facilities -36,600 -12,883 35.2%
Social Assistance Individual & Family Services -630,150 -259,007 41.1%
Child Day Care Centers -223,900 -79,316 35.4%
Community Food & Housing, Other Relief Services -332,600 -97,568 29.3%
Vocational Rehabilitation Services -8,100 -7,389 91.2%
Arts, Entertainment & Recreation -1.3 million -205,964 15.5%
Performing Arts, Spectator Sports & Similar -226,200 -48,723 21.5%
–Performing Arts Companies -49,100 -42,492 57.0%
Other Services (Except Public Administration) -1.2 million -218,167 18.9%
Religious, Grantmaking, Civic, Professional & Similar -246,050 -147,061 59.8%
Other Fields (Includes: Construction; Manufacturing; Wholesale Trade; Retail Trade; Transportation & Warehousing; Information; Finance & Insurance; And Accommodation & Food Services) -11.4 million -47,570 0.4%

The non-profit sector in 2017 was the third largest employment sector in the United States, with 12.5 million workers. Only the retail sector with 15.8 million workers and the accommodation/food service sector, with 13.6 million workers were larger. The non-profit sector in the United States accounted for more than $670 billion in total annual wages

These findings were presented in the “2020 Nonprofit Employment Report,” by Lester M. Salamon and Chelsea L. Newhouse. The researchers analyzed the latest-available data on non-profit employment and wages generated by the U.S. Bureau of Labor Statistics from the Quarterly Census of Employment and Wages (QCEW), which encompass approximately 97% of non-farm employment. The goal was to determine the current status of non-profit employment, and to estimate the impacts that COVID-19 has had on non-profit employment. They concluded that the U.S. non-profit sector is a larger and more robust economic force than is widely recognized. The significant job losses in the non-profit sector have resulted in increased pressure on the services these organizations have historically provided.

The full text of “2020 Nonprofit Employment Report” was published on June 24, 2020 by the Johns Hopkins Center for Civil Society Studies. A copy of the report can be accessed at http://ccss.jhu.edu/publications-findings/?did=517.

For more information, contact:

  • Chelsea Newhouse, Communications Associate, Johns Hopkins Center for Civil Society Studies, Department of Political Science, Johns Hopkins University, 3100 North Charles Street, Merganthaller Hall 3rd Floor, Baltimore, Maryland, 20218; Email: chelsea.newhouse@jhu.edu; Website: http://ccss.jhu.edu/

Over the 2020 operating year, primary care practices in the United States could lose a total of $15.1 billion in revenue due to coronavirus disease 2019 (COVID-19). This equals a loss of $67,774 in gross revenue per full time physician, from an anticipated base gross revenue of $542,190 per physician had COVID-19 not happened.

The researchers concluded that COVID-19 will cause large, meaningful revenue reductions for primary care practices during 2020. If practices are unable to collect sufficient funding through either fee-for-service or capitated payment mechanisms, these results may threaten practice viability.

These findings were presented in “Primary Care Practice Finances In The United States Amid The COVID-19 Pandemic,” by Sanjay Basu, Russell S. Phillips, Robert Phillips, et. al. The researchers used a microsimulation model incorporating national data on primary care. The goal was to estimate the potential impact of COVID-19 on primary care practice operating expenses and revenues.

The full text of “Primary Care Practice Finances In The United States Amid The COVID-19 Pandemic” was published on June 25, 2020, by Health Affairs. A copy can be found at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00794.

For more information, contact:

  • Sanjay Basu, M.D., Ph.D., Director of Research and Population Health at Collective Health, and Director of Research at Center for Primary Care, Harvard Medical School, 635 Huntington Avenue, Second Floor, Boston, Massachusetts 02115; 617-432-2222; Email: sanjay_basu@hms.harvard.edu; Website: https://primarycare.hms.harvard.edu/faculty-staff/sanjay-basu
  • Sue Ducat, Senior Director of Communications, Health Affairs, 7500 Old Georgetown Road, Suite 600, Bethesda, Maryland 20814; 301-841-9962; Email: sducat@projecthope.org; Website: www.healthaffairs.org/1520_staff.php

The National Committee for Quality Assurance (NCQA) collects information on the performance of health care service delivery from health plans covering more than 191 million people using its proprietary Healthcare Effectiveness Data and Information Set, or HEDIS. One of health care’s most widely used performance improvement tools, HEDIS consists of more than 90 measures over six domains of care. In the behavioral health realm, HEDIS assesses depression screening and follow-up, medication adherence, access, care coordination, opioid overuse, and more. Join NCQA speakers, Junqing Liu, PhD, MSW, and Lyndsey Nguyen, MS, BA, as they provide an update on HEDIS behavioral health measures, the expansion of telehealth inclusion in HEDIS measures, the progress of and learnings from quality improvement projects, and relevant behavioral health programs.

Junqing Liu, PhD, MSW, is a Research Scientist for NCQA. As the measure lead of NCQA’s behavioral health measures, Dr. Liu guides the re-evaluation and updates of HEDIS® behavioral health measures. Dr. Liu’s research focuses on access to mental health services, evidence-based treatment for behavioral health problems, and child welfare services. Dr. Liu was previously a Research Assistant Professor at the University of Maryland School of Social Work and conducted the evaluation of a federally funded research project on the implementation of evidence-based practices in child welfare systems in six states.

Lyndsey Nguyen, MS, BA, currently serves as a Senior Health Care Analyst in the NCQA’s Performance Measurement Department at NCQA. She manages, leads, and coordinates activities related to the development of quality metrics for U.S. health care. Her areas of focus include mental health, substance use, and pain management. Ms. Nguyen holds an MS degree in physiology (complementary and alternative medicine) from Georgetown University and a BA in cognitive science from the University of Virginia.

Hiten Patadia, PharmD, RPh, is a Managed Market Liaison for Otsuka Pharmaceutical Development & Commercialization, Inc.

“You can’t cut your way to prosperity.”

One of the challenges for executive teams in managing to the end of a crisis—especially an extended crisis like this one—is addressing the loss of revenue. In more normal times, the need to replace service line revenue is a gradual one. As service lines age, demand and revenue decrease with new competition. Over time, contracts are lost to competitors. The need to create new sources of revenue is gradual.

But in this pandemic crisis, we’ve seen service lines shuttered with little notice, cost increases that have changed programs from profitable to losing propositions, and a host of new competitors. The economic forecast for the U.S. is not great—and health and human services (at 17% of the country’s gross domestic product) will inevitably be affected by the downturn. The need to find “new revenue” is more pressing.

So where to look? Right now (this could change in a month), we see a few key areas of opportunity for provider organizations serving consumers with chronic conditions and complex needs—each of which we have covered over the past two months.

  1. Expansion of telehealth—Many organizations have (whether willing or not) taken the plunge and are providing virtual care services. But, for many executive teams, the perspective is to serve “current consumers.” This is an area for expansion—new payers, new consumers, new services, and new geographies.
  2. Hybrid service models—Not all services will remain “totally virtual” in the “new normal.” The market advantage will go to the organization offering service lines that combine the depth of face-to-face services with the convenience and cost reductions of virtual care. Think of services that fit into integrated care models with reimbursement based on performance.
  3. Specialty primary care—The pandemic has had a big impact on primary care. Practice revenues are down, and it is likely that many private practices will close. Physician salaries are also down. At the same time, the demand for primary care services for consumers with complex needs has never been greater and health plans are starting to move primary care payments to capitated models.
  4. Intensive home-based services—For good reason, consumers are hesitant to consider any type of residential facility unless necessary. Nursing homes, assisted living facilities, and residential treatment facilities are experiencing falling census and revenue declines as consumers and payers look for alternatives.

5. Housing alternatives—Housing has always been an issue but expect more housing dislocation as the economic outlook sinks and rental support programs decline. Creative approaches to meet the need for stable housing will be in demand.

OPEN MINDS Senior Associate, Paul Duck pointed out that “While most provider organizations are addressing the pandemic by cutting costs, the more progressive organizations are innovating and reinventing their service delivery system and are well positioned for post-pandemic opportunities.” Mr. Duck provided a few tried-and-true tips on increasing revenue in his recent web briefing, Aggressive Business Development Strategies – Adding To The Top Line With Breakthrough Services. The first is to assess whether any of these emerging market opportunities “fit” with your organization’s longer-term vision and recovery plan. The second is to do the vetting work and “due diligence” required to evaluate specific opportunities. The third is to think creatively about expanding a revenue base in a new area. Identify at-risk competitors to form a strategic partnership or enter into new markets.

Despite the significant upset to the health and human service system caused by the pandemic crisis, the move to value-based reimbursement (VBR) seems to be moving along. On June 3, The Centers for Medicare and Medicaid Services (CMS) announced adjustments to 16 value-based care (VBC) models, with goals of accounting for COVID-19-related changes in health care delivery (and the uptick in costs), as well as allowing more time for participating provider organizations to transition to VBC. And, on June 19, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers.

At the health plan level, most recent was the launch of Blue Cross and Blue Shield of North Carolina’s “Accelerate to Value” program to help primary care practices deal with COVID-19-related financial challenges. The program, which requires primary care practices to commit to transitioning to VBC by the end of 2020, provides financial stabilization payments based on the practice’s 2019 revenue.

Over the past few months, we’ve seen similar initiatives emerge from BlueCross BlueShield of Western New York (BCBSWNY), the Pennsylvania Clinical Network with Geisinger Health Plan, and Aetna.

What this means for provider organization recovery strategy depends on the organization’s current market positioning. The likely impact of the impending payer budget crunch (both government and employer) is more managed care and more value-based reimbursement arrangements. But that will vary by specialty, by consumer type, and by geography. Many provider organization executive teams are not waiting to see what comes their way. They are using changing reimbursement as a market positioning advantage for their post-recovery strategy.

For example, Heal announced the launch of a new “health assurance” offering called “Heal Pass”—a monthly subscription of $49 dollars where enrollees receive eight physician house calls, annual physicals, and next-day shipping on medications prescribed by a Heal clinical professional. And, Talkspace has a number of subscription options that consist of unlimited texting, live sessions, or therapy options geared toward specific populations including couples and adolescents—ranging from a rate of $260 per month to $396 per month.

The question for executive teams is to evaluate whether a proposed non-fee-for-service reimbursement model would be better for market positioning—with more revenue and/or greater profitability. To evaluate that question, executive teams need an external perspective—good customer perspectives on what they need and how they prefer to pay for those services. But equally as important, executive teams need to understand the costs of their services, not only by unit of service but by type of consumer over time.

OPEN MINDS Senior Associate, Ken Carr, believes that our traditional view of VBR—reduced costs, focus on value, and consumer outcomes—needs to take on an additional dimension with the advent of models like Heal and Talkspace. Their approach to value is to identify what is important to the consumer—immediate access, price transparency, and consistent payment, with good service and outcomes implied. For provider organization managers, fee-for-service reimbursement has driven business models—filling the schedules of clinical professionals, ensuring required levels of productivity, and shaping consumer access around available office hours. And consumers have no idea how much the service costs until they receive a statement in the mail a month later. In contrast, as Mr. Carr explained, “The new approach to value must focus on ease of access—house calls, phone calls, and virtual services.” The consumer (or the health plan) doesn’t need to worry about the cost—the subscription can be worked into a monthly spending budget like a gym fee or even a Netflix subscription.

Moving to using VBR as a proactive market strategy requires setting aside past structures and creating entirely new approaches. But how do provider organization managers begin to deal with the costs of a consumer-driven access model and set prices for these new models? Identifying the unit cost of a service and the related utilization is a starting point. But building a sustainable model will also require data on how consumers access the service, how often they use the service, and the intensity of their needs. “Provider organizations must create a structure to manage a new payment method that will lower their financial risks while better meeting consumer needs. For that, having timely data, and adjusting resource capacity is critical,” said Mr. Carr.

Mr. Carr had some more pointers for provider organizations gearing up for the shift to value in his seminar, Succeeding With Value-Based Reimbursement: An OPEN MINDS Executive Seminar On Organizational Competencies & Management Best Practices For Value-Based Contracting, at The 2020 OPEN MINDS Strategy & Innovation Institute:

  • Establish yourself as the “preferred provider” with a payer or operate exclusively within a payer system. This means demonstrating outcomes above and beyond what other provider organizations are doing (and having the data to prove it) to gain and maintain a stronger market position.
  • Realign internal operations to manage payer requirements in terms of revenue cycle—an essential process to revisit in an environment where getting paid for the services you provide is critical.
  • Deliver services that are actually valued by payers—using an integrated and holistic approach to care (behavioral health and primary care), care coordination for complex consumer populations, social supports, and medication management.

At the end of the day, VBR is here to stay. As Mr. Carr explained, “Now is the time to start the transition. VBR isn’t going to be set aside or delayed as a result of the pandemic. If anything, it’s going to be adopted as a strategy to keep costs down during a time where budgets are increasingly strained.”

The increased use of virtual therapies during this pandemic crisis will likely make a permanent change in how consumers receive services in the future. But another form of technology, also driven by the staffing challenges presented by the pandemic crisis, is gaining ground in health and human services—the robot.

Before you go to that mental place that says this is too far in the future to worry about, remember that cost pressures, fear of virus transmissions, staffing shortages, and more value-based reimbursement are going to provide market opportunities for organizations with “high value” services. And many “robotic” solutions are available now and can provide unique cost and staffing advantages.

To think about using robots, it is important to remember their simple definition—a mechanical device that can perform a variety of tasks either on command or according to instructions programmed in advance. These devices can be designed in human form (an android) or simply machines designed to perform a task with no regard to their aesthetics. And one note, robots are part of most Americans’ daily lives—Amazon has more than 200,000 mobile robots working in its warehouses, alongside thousands of human workers.

Analysts are predicting an annual growth rate of 12% of health care robots. Of the many types of robots, there are five types that executive teams serving consumers with complex needs should be considering right now.

Companion robots— We’ve covered companion robots before, but the big news, however, is that there is now a window for them to be reimbursed by Medicare. In her session, Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid, at last month’s 2020 OPEN MINDS Strategy & Innovation Institute, Allison Rizer, former Vice President of Strategy and Health Policy at UnitedHealthcare, remarked that new flexibility in the definition of services that can be purchased by Medicare D-SNP plans is now allowing the purchase of services that meet the social needs of dual eligible consumers who often suffer from isolation and diminishing emotional and cognitive function, including companion robots.

Disinfection and cleaning robots—Whether operating a residential or inpatient facility, or reopening outpatient offices, provider organization management teams need more focus on disinfecting workspaces. And there are robots for that! One of these robots is the THOR UVC robot by Finsen Technologies, used for cleaning and disinfection of consumer rooms, emergency departments, perioperative, intensive care units, progressive care units, and transitional care units.

Diagnostic temperature-taking robots—Wondering what staff person is going to take temperatures at the door of your office and who wants that job? There is a robot for that! Zorabots, developed by a Belgian software company, check people’s temperatures and if face masks are worn properly…and all in 53 different languages.

Telepresence treatment robots—Taking virtual care one step further is a whole group of telepresence treatment robots. One example is Ava Robotics’ autonomous telepresence robots, which are allowing health care professionals to treat those with COVID-19 while avoiding infection. Another example comes from OhmniLabs, which announced last month ongoing investments to offer telepresence robots to health care organizations. And in Boston, a dog-like robot named Spot is being used at Brigham and Women’s Hospital and allowing physicians to interact with individuals with COVID-19 via telemedicine. The clinical professionals managing the visit may be remote or avoid contact with the consumer and participate by video but the consumers are onsite and the telepresence robots are performing essential procedures and tests.

Siri, Alexa, and other chatbots—The use of specially programmed voice-enabled tools like Alexa or Siri offer yet another way to leverage the power of “robots” (in this case, artificial intelligence). Last year, Amazon announced the launch of a new Alexa feature that allows consumers to set medication reminders by using their pharmacy prescription information, and to request prescription refills. Another interesting application is “The Patient Is In,” a suite of apps based on Siri and the Apple Watch. With the app, consumers and clinical professionals can stream data both ways, connect in real time, and manage practice logistics and scheduling.

Staffing issues alone may drive the adoption of robotic technologies. We are reminded of the notion of “force multiplier” presented by Carl Clark, M.D., President and Chief Executive Officer of the Mental Health Center of Denver. During his keynote address, Innovation By Design: Capturing Value In Health Care, at our 2020 OPEN MINDS Strategy & Innovation Institute, Dr. Clark suggested that technology can be used as a “force multiplier” to supplement the work of clinical professionals—and the early adopters are making the case.

Imagine the possibilities, Dr. Clark pointed out—one clinical professional on a crisis line can talk to one person on the phone but could text four people at once. And scaling that up, one clinical professional can see 70 consumers a year for depression and provide cognitive behavioral therapy (CBT). But what if we use artificial intelligence to provide the mechanics of CBT—the writing, the assignments, the reviews, and the clinical professional was to talk to the consumers for higher-level interventions. Then one clinical professional can see 700 consumers a year— that’s a 10-times force multiplier! Technology is all about “how we change the way we deliver services to give more people access to care,” said Dr. Clark. Because three out of five people who need care for mental illness or addictions are not receiving that care and we just don’t have an adequate workforce to meet the need.

Passport Health Plan (Passport) announced that Molina Healthcare (Molina), Evolent Health, and Passport have entered into a definitive agreement for Molina to acquire certain assets of Passport Health Plan. Molina agreed to buy certain business lines from Passport Health Plan of Louisville, Kentucky, for $20 million. The agreement helps to provide continuity of care and coverage for Passport members while also preserving hundreds of Kentucky jobs.

The agreement calls for Molina to pay an additional amount beyond the $20 million contingent upon the results of the 2020 open-enrollment period in Kentucky. Molina will also acquire the rights to the Passport Health name. Under the terms of the agreement, which is subject to regulatory approval, Molina intends to acquire the Passport brand, operational and clinical infrastructure, and certain provider organization and vendor agreements. Molina will also offer Passport employees the opportunity to continue employment with Molina. Under a separate agreement, Molina has also agreed to purchase Passport’s real estate in west Louisville.

Passport Health Plan is a community-based health plan administering Medicaid benefits to approximately 315,000 members, as of June 30, 2020. Passport has been contracted with the Commonwealth of Kentucky to administer Medicaid benefits since 1997.

Molina Healthcare, Inc., a FORTUNE 500 company, provides managed health care services under the Medicaid and Medicare programs and through the state insurance marketplaces. Through its locally operated health plans, Molina Healthcare served approximately 3.4 million members as of March 31, 2020.

For more information, please contact:

  • Ben Jackey, Communications Director, Passport Health Plan, 5100 Commerce Crossings Drive, Louisville, Kentucky 40229; 502-457-0381; Email: ben.jackey@passporthealthplan.com; Website: https://passporthealthplan.com
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802​​; 562-951-1588; Email: caroline.zubieta@molinahealthcare.com; Website: www.molinahealthcare.com

The Substance Abuse and Mental Health Services Administration (SAMHSA) announced the adoption of the revised Confidentiality of Substance Use Disorder Patient Records regulation, 42 CFR Part 2. The adoption of this revised rule represents a historic step in expanding care coordination and quality through the Deputy Secretary’s Regulatory Sprint to Coordinated Care.

The new rule advances the integration of health care for individuals with addiction while maintaining critical privacy and confidentiality protections. Under Part 2, a federally assisted substance use disorder program may only disclose consumer identifying information with the individual’s written consent, as part of a court order, or under a few limited exceptions. Health care provider organizations, with an individuals’ consent, will be able to more easily conduct such activities as quality improvement, claims management, individual safety, training, and program integrity efforts.

The ease of sharing information, with consent, among provider organizations will enable better, higher-quality care for those with addiction. This serves as an important milestone in further aligning 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996 (or HIPAA) regulations.

The Substance Abuse and Mental Health Services Administration is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. Their mission is to reduce the impact of addiction and mental illness on America’s communities.

For more information, please contact:

  • Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, Maryland 20857; 800-487-4889; Website: www.samhsa.gov

Federal officials are partnering with several health systems and telehealth companies to develop a nationwide telecritical care network, including a separate telemedicine platform for the Department of Veterans Affairs (VA). The U.S. Defense Department’s Telemedicine & Advanced Technology Research Center (TATRC) and Medical Technology Enterprise Consortium (MTEC) recently launched Phase 1 of National Emergency Telecritical Care Network (NETCCN) Project, aimed at creating a network of “virtual critical care wards” to address the coronavirus pandemic.

TATRC and METC are partnering with Avera Health, the Oregon Health and Science University (OHSU), the Medical University of South Carolina (MUSC), UPMC, Philips, Deloitte Consulting, the Expressions Network, Unissant and the Geneva Foundation on the massive project. Among the projects being developed by this consortium is MUSC’s Portable Remote Operational Wireless Enabled Surge Specialist (PROWESS) ICU, a mobile telehealth platform aimed at offering remote consumer monitoring solutions for individuals who are quarantined and an in-patient telemedicine unit for provider organizations.

In a separate announcement, Philips and the VA announced a 10-year, $100 million contract to create what they’re calling the world’s largest telecritical care program. The partnership between the two longtime collaborators will build upon one of the nation’s largest connected health network, serving close to 9 million veterans a year through mHealth and telehealth platforms and more than 1,700 health care sites.

The United States Department of Veterans Affairs is a federal Cabinet-level agency that provides near-comprehensive health care services to eligible military veterans at medical centers and outpatient clinics located throughout the country. The agency also provides non-health care benefits including disability compensation, vocational rehabilitation, education assistance, home loans, and life insurance.

For more information, please contact:

  • U.S. Department of Veterans Affairs, 810 Vermont Ave NW, Washington, District of Columbia 20420; Website: www.va.gov

Centene Corporation and Quartet Health announced a nationwide expansion of their existing partnership to help members quickly and easily access the behavioral health care they need. The nationwide expansion will enable members to seamlessly access quality behavioral health care from providers located in their areas who serve their unique clinical needs. To support members who want access to care from their homes during the COVID-19 pandemic, all scheduled appointments will be with provider organizations who support virtual care. Centene and Quartet first began their partnership in June 2019, launching in Illinois and Louisiana.

Quartet’s HIPAA-compliant technology platform will integrate with Centene’s population health software, allowing Care Managers and Utilization Managers to refer members to Quartet for behavioral health care, track member progress, and collaborate with the referred behavioral health provider organizations within their existing workflows. Quartet’s national network of care options includes virtual tele-psychiatry and tele-therapy, enabling members to access the care they need safely from their homes during the COVID-19 pandemic.

Centene Corporation, a Fortune 50 company, is a leading multi-national health care enterprise that is committed to helping people live healthier lives. The Company provides fully integrated and cost-effective services to government-sponsored and commercial healthcare programs, focusing on under-insured and uninsured individuals. Centene offers affordable and high-quality products to nearly 1 in 15 individuals across the nation, including Medicaid and Medicare members, as well as individuals and families served by the Health Insurance Marketplace, the TRICARE program, and individuals in correctional facilities.

Quartet Health is a health care technology and services company on a mission to improve the lives of people with mental health conditions. The collaborative technology and range of services bring together physicians, mental health providers, and insurance companies to effectively improve consumer health and drive down health care costs. Quartet is headquartered in New York City and is currently operating in several markets across the United States, including Pennsylvania, Washington, Northern California, New Jersey, North Carolina, Louisiana, and Illinois.

For more information, please contact:

  • Marcela Manjarrez-Hawn, Media Contact, Centene, 7700 Forsyth Boulevard, St. Louis, Missouri 63105; 314-445-0790; Email: mediainquiries@centene.com; Website: www.centene.com
  • Contact information: Quartet Health, Bryant Park, New York, New York 10018; 877-258-4010; Website: www.quartethealth.com

Ridesharing company Uber has rolled out a service to give public health officials quick access to user data to track coronavirus cases. The contact tracing service will be provided for free and is being introduced to public health officials in all countries where Uber operates.

The service provides health departments with data about who used Uber’s services and when and allows health agencies to urge affected drivers and users to quarantine. Uber has a protocol in place that it can disclose user information to public health agencies in an emergency involving danger of death or serious physical injury. Since COVID-19 can be transmitted through close proximity to affected individuals, public health officials have identified contact tracing as a valuable tool to help contain its spread. Uber has seen an increase in contact tracing requests from countries credited for their initial success in containing the virus, such as Australia and New Zealand.

Uber Technologies, Inc. develops, markets, and operates a ridesharing mobile app that allows consumers to submit a trip request, which is routed to crowd-sourced taxi drivers. Its smartphone application connects drivers with consumers who need a ride.

For more information, please contact:

  • Uber Technologies, Inc., 1455 Market Street, Suite 400, San Francisco, California 94103; 415-986-2715; Website: www.uber.com

Most executives are big fans of metrics-based service line analysis and the portfolio management framework that it provides for executive teams. It is one of the best ways for provider organizations to manage their present financial performance and their future market positioning.

However, portfolio management in a crisis is an essential, but completely different exercise. Service line metrics are needed to make crucial decisions. In crisis planning, there are four service line questions. First, given the newly changed environment, what service lines have a positive margin or are at least break even? Second, what service lines have a negative margin and will draw down on available cash? Third, what service lines are critical to success after the crisis and need stabilization and investment? Lastly, when you put these service lines together and look at the entirety of organizational financial performance, if no changes are made, does the organization have enough cash to make it through the crisis period?

If the answer to the last question is “no,” service line portfolio management is the key to crisis recovery strategy. Howard Snyder, Director of Business Development at ActiveDay, a provider organization offering adult day services through more than 115 centers in 12 states, explained their dilemma. As they reopen centers, they find that adhering to social distancing in the facilities and in vehicles providing transportation has limited maximum capacity to approximately 50%. While this may be close to breakeven in larger centers, programs serving 30 or fewer members are unsustainable. Mr. Snyder lamented, “We have already made the terrible decision to permanently close a number of such smaller centers. It’s crushing to walk away from these smaller communities where there are often few alternatives for members.” And he pointed out that most states have provided minimal, if any, support in the form of retainer payments, grants, or fees for remote wellness services. “Allowing vocational rehabilitation provider organizations to suddenly offer in-home care is not a viable pivot, the rates do not support a facility-based infrastructure and a transportation fleet of vehicles,” he noted.

And there is a bigger issue in portfolio management in a crisis. A crisis is the time to invest in the service lines that are key to an organization’s recovery strategy, even if this means increasing the losses in those particular service lines. Executive teams need to assure that their organization is ready to perform in the “new normal” when the crisis period is over (we’re currently using February 2021 as that likely date, based on vaccination availability information). For many organizations, that means new investments. The pain in making this decision is that it may require taking resources from other programs. As we look ahead to the continuing pandemic crisis and (hopefully) an end in the new year, executive teams can use service line analysis and portfolio management to guide their recovery plan.

The American Red Cross is launching a Virtual Family Assistance Center to support families struggling with loss and grief due to the ongoing coronavirus pandemic. People can visit redcross.org/VFAC to access a support hub with virtual programs, information, referrals, and services to support families in need. The hub will also connect people to community resources provided by partners in their area.

The Red Cross has set up a virtual team of specially trained mental health, spiritual care, and health services volunteers who are connecting with families over the phone to offer condolences, support, and access to resources that may be available. They are also providing support for virtual memorial services for families, including connecting with local faith-based community partners. Volunteers are also hosting online classes to foster resilience and facilitate coping skills. They are also sharing information and referrals to state and local agencies as well as other community organizations including legal resources for estate, custody, immigration or other issues. All Family Assistance Center support will be provided virtually and is completely confidential and free.

The American Red Cross shelters, feeds, and provides emotional support to victims of disasters; supplies about 40% of the nation’s blood; teaches skills that save lives; provides international humanitarian aid; and supports military members and their families. The Red Cross is a non-profit organization that depends on volunteers and the generosity of the American public to perform its mission.

For more information, please contact:

  • American Red Cross; 431 18th Street, NW, Washington, District of Columbia 20006; 202-303-4498; Email: media@redcross.org; Website: www.redcross.org

Torchlight, an employee-caregiver support solutions provider organization, announced the release of the first installment of its “Caregiving in Times of Crisis Toolkit.” The Toolkit is designed for organizations, businesses, individuals, parents, and caregivers in need of assistance and information during the Coronavirus/COVID-19 pandemic. With the vast majority of Americans staying at home during the pandemic, many are not only struggling with health concerns and high stress, they are also grappling with eldercare concerns, distance learning, working at home, sudden job losses/furloughs, and the death of loved ones.

The “Caregiving in Times Crisis Toolkit” contains nearly two dozen guides and tools, including articles, podcasts and webinars for eldercare and parent/child resources. Torchlight will continue to add and update resources to the Tool-kit to support individuals and families as the pandemic evolves.

Torchlight’s decision-support tools, caregiving knowledge base, and human expertise combine to reduce stress and enhance outcomes for both families and their sponsoring organizations more cost-effectively than call center or concierge-only solutions. Torchlight’s approach includes a user-friendly digital platform and a team of expert advisors.

For more information, please contact:

  • Torchlight, 25 Corporate Drive, Suite 100, Burlington, Massachusetts 01803; Website: www.torchlight.care

Headspace Inc. has added another nearly $48 million to its offerings during the coronavirus disease 2019 (COVID-19) public health crisis. The new financing was disclosed in a filing with the Securities and Exchange Commission in June 2020 under the issuer name OrangeDot Inc.

With May 27 noted as the date of first sale, Headspace raised the additional funds in the midst of the coronavirus crisis and closed quickly, selling the entire offering amount of $47.7 million and filing the documentation by June 10. Ten investors participated in the new financing. The new funding is an extension of the company’s Series C announced in February, bringing Headspace’s total funding to nearly $216 million.

Founded in 2010, Headspace is a digital meditation app for mindfulness and mental training. Headspace is headquartered in California with offices in San Francisco and London.

For more information, please contact:

  • Headspace Headquarters, 2415 Michigan Avenue, Santa Monica, Los Angeles, California 90404; Email: press@headspace.com; Website: www.headspace.com

The Illinois COVID-19 Response Fund (ICRF) has awarded Chestnut Health Systems $100,000 in its most recent round of funding. In all, ICRF awarded $6.95 million to 42 non-profit organizations around the state to help populations most burdened by the outbreak. The most vulnerable populations in downstate Illinois will be able to get help as a result of the grant award.

Chestnut will use the funding to provide mental health treatment and addiction treatment for people in Illinois impacted by the pandemic. Chestnut operates in Central Illinois, in the St. Louis Metro East area, and in Jefferson County, Missouri.

ICRF is a fund held and processed by The Chicago Community Foundation. It was created to quickly help people all over the state who are in economic, social, and health crisis due to the pandemic.

Chestnut Health Systems is a non-profit organization that has cared since 1973 for persons needing behavioral health services. Chestnut provides addiction treatment, mental health counseling, primary health care, credit counseling, and housing and supportive services. It is a leader in addiction-related research.

For more information, please contact:

  • Lori Laughlin, Director of Marketing and Communications, Chestnut Health Systems, 1003 Martin Luther King Drive, Bloomington, Illinois 61701; 309-820-3814; Email: lnlaughlin@chestnut.org; Website: www.chestnut.org

On July 8, 2020, Walgreens Boots Alliance, Inc. (WBA) and VillageMD entered a $1 billion investment agreement that will result in opening 500 to 700 in-store full-service primary care clinics in more than 30 Walgreens markets over the next five years. Walgreens and VillageMD will open “Village Medical at Walgreens” in Houston and Phoenix markets first. VillageMD will use 80% of the investment to fund the opening of the clinics and build the partnership, including integration with Walgreens digital assets. The investment gives WBA a 30% ownership stake in VillageMD.

WBA and VillageMD tested the concept in a Houston, Texas pilot with five in-store clinics, beginning in November 2019. WBA said the clinics had high consumer satisfaction, with Net Promoter Scores over 90. Tim Barry, chairman and chief executive officer (CEO) for VillageMD said the partnership will allow primary care physicians and pharmacists to work in a coordinated way to enhance the consumer experience.

The new clinics will be staffed with VillageMD primary care professionals and will integrate the Walgreens pharmacist as a key member of a multi-disciplinary team. The clinics will provide a comprehensive range of outpatient services, at-home visits, and 24/7 telehealth services. Clinic size will vary with existing store space. Most of the clinics will be about 3,300 square feet, although some may be as large as 9,000 square feet. The stores will continue to stock a broad range of retail products.

More than half of the new clinics will be located in Health Professional Shortage Areas and Medically Underserved Areas/Populations, as designated by the U.S. Department of Health and Human Services. VillageMD is in the process of recruiting more than 3,600 primary care professionals to staff the clinics. The clinics will accept a wide range of health insurance options and offer comprehensive primary care across a broad range of physician services.

VillageMD and Walgreens also recently announced the availability of Village Medical telehealth provider organizations on Walgreens Find Care™, which is an online platform that connects consumers with a wide range of health services. The rollout advances the WBA strategic priority of “Creating Neighborhood Health Destinations.” WBA runs more than 9,200 stores in the United States.

VillageMD, through its subsidiary Village Medical, provides value-based primary care services to about 600,000 people in nine markets. It partners with more than 2,800 physicians to provide tools, technology, operations, staffing support, and industry relationships. VillageMD manages $4 billion in total medical spend via value-based contracts. The Village Medical brand provides primary care for consumers at traditional free-standing clinics, Village Medical at Walgreens clinics, at home and via virtual visits.

For more information, contact:

  • Walgreens Boots Alliance Inc., 200 Wilmot Road, Deerfield, Illinois 60015; (877) 250-5823; Website: https://www.walgreensbootsalliance.com/; or VillageMD, 125 South Clark Street, Suite 900, Chicago, Illinois 60603; (312) 465-7900; Website: https://www.villagemd.com/.

Mindstrong, a healthcare company dedicated to transforming mental health through innovations in virtual care models and digital measurement, today announced it has secured $100 million in Series C fundraising. Mindstrong’s Series C raise included participation from new and existing investors, including General Catalyst, ARCH Venture Partners, Foresite Capital, 8VC, Optum Ventures, and What If Ventures, among others.

Mindstrong is unlocking an entirely new virtual care model to deliver healthcare to people living with a serious mental illness (SMI). They’re also developing technology for remote patient monitoring and mental health symptom measurement. Their in-house clinical team of therapists, psychiatrists and care coordinators use their technology platform to deliver flexible, efficient, and seamless virtual care to members through a smartphone app. Clinical services are provided by their own team of full-time clinicians on an unlimited basis and at no cost to members, thanks to Mindstrong’s value-based partnerships with national private and public insurance payers.

In addition to Mindstrong’s virtual care model, the member-facing smartphone app allows members to monitor their own mental health symptoms through AI-powered digital biomarker technology that can track changes in mental health symptoms. More importantly, the technology can also trigger alerts to a member’s clinical team when these markers indicate their mental health may be at risk or deteriorating, outside of a therapy or psychiatry session. Therapists use in-app messaging, video, and phone conversations to deliver cognitive-based therapy with members and help coordinate what is oftentimes a complex care plan for an individual living with a serious mental illness. Members can also receive telehealth medication management with a psychiatrist through the Mindstrong app.

Mindstrong is a health care innovation company, dedicated to transforming mental health through innovations in digital measurement, data science, and virtual care models. Mindstrong’s solution and health services help deliver preemptive care and improve outcomes. The company is based in Mountain View, California, and has an office in San Francisco. They are backed by ARCH Venture Partners, General Catalyst, Foresite Capital, Optum Ventures, 8VC, and others

For more information, please contact:

  • Mindstrong, 303 Bryant Street, Mountain View, California 94041; 855-944-0909; Email: info@mindstrong.com; Website: https://mindstrong.com/

Capital District Physicians’ Health Plan, Inc. (CDPHP) announced the expansion of its provider organization network to include tele-mental health services provided by Valera Health. Members can receive care in their homes through Valera’s secure telehealth platform by connecting directly through Valera’s website, or by contacting a representative at the CDPHP Behavioral Health Access Center.

The partnership expansion also addresses the need for better access to mental health services for the 370,000 plus members in the CDPHP service area. CDPHP remains committed to bringing on innovative models that focus on quality, access, and high-performing team-based care.

Established in 1984, Capital District Physicians’ Health Plan, Inc. is a physician-founded, member-focused and community-based non-profit health plan. The company offers high-quality affordable health insurance plans to members in 26 counties throughout New York.

Valera Health is a tele-mental health service company that offers team-based care across the entire spectrum of mental health needs, from behavioral health coaching and therapy, to medication management and psychiatry. Valera also offers a behavioral health engagement platform to payers, provider organizations, and health systems.

For more information, please contact:

  • Ali Skinner, Vice President, Communications Strategy, Capital District Physicians’ Health Plan, Inc., 500 Patroon Creek Boulevard, Albany, New York 12206; 518-641-5035; Email: ali.skinner@cdphp.com; Website: www.cdphp.com
  • Emma Smith, Program Manager, Valera Health, 134 North 4th Street, Brooklyn, New York 11249; Email: esmith@valerahealth.com; Website: https://valerahealth.com

The volume of health care services is down. Since the start of the pandemic, in many states, non-emergency health care services other than virtual care have not been available to consumers. And it is likely that the return to a “typical” health care practice model will be slow. Health care provider organization management teams are struggling with how to reopen. Consumers are trying to weigh the risks of going outside their homes for services of any type. This drop is reflected in the financial performance of both physician practices and hospitals.

A recent Kaiser Family Foundation poll found that almost half of consumers (48%) report that they or their family members have skipped medical care, and only 11% report that the health conditions in question have worsened. PwC’s Health Research Institute (HRI) recently reported that many consumers plan to change their health care habits for medications (11%) and health care visits (16%), with 78% planning to skip at least one visit for care. Many emergency rooms have seen a dramatic drop in use—often 40% or more, and there has been a 50% to 73% drop in vaccinations for measles, mumps, rubella, diphtheria, whooping cough, and HPV. And one interesting note, on a web meeting yesterday, I listened to a health plan manager talk about how consumers were delaying even their virtual visits to primary care professionals, but that virtual visits to mental health professionals have surpassed previous face-to-face volume.

The likely effect of these delays in health services raises big strategic questions that our team considers almost daily. Will there be “pent up demand” for face-to-face services once there is a coronavirus vaccine? Will we see increases in certain conditions at some point in the future? For that reason, a recent op-ed by Sandeep Jauhar, M.D., in The New York Times caught everyone’s attention, “People Have Stopped Going To the Doctor. Most Seem Just Fine.” In his article, he said, “Perhaps Americans don’t require the volume of care that their doctors are used to providing. Most patients, on the other hand, at least those with stable chronic conditions, seem to have done OK. In a recent survey [note: the Kaiser Family Foundation poll], only one in 10 respondents said their health or a family member’s health had worsened as a result of delayed care. Eighty-six percent said their health had stayed about the same.”

One could argue that it is a little too soon to tell if the self-assessment of “health” is accurate. And the early data show that the pandemic crisis is causing excess deaths for conditions other than COVID-19. An analysis of death certificates shows that a fifth of the 24,000 excess deaths that occurred in New York City between March 11th and May 2nd were caused by factors other than COVID-19. Hospitals saw a 38% drop in serious heart-attack cases in March alone, suggesting that even people with acute, life-threatening illnesses have been avoiding medical visits. A nationwide survey conducted in April found that a quarter of individuals with cancer receiving active treatment had delays in care. The effects of delayed health screenings and the postponed management of chronic conditions are not going to be noticed by consumers—or health care professionals—in the short term.

There is a lot of inappropriate use of health care resources. We don’t use health care professionals to the top of their capabilities. We have duplication of testing because of lack of electronic health record interoperability and financial incentives to test too much. Productivity rates of health care professionals are hampered by operational process design and consumer incentives. Emergency rooms are used too often for non-urgent situations. And, our system uses highly trained professionals to do work that could be done by technology.

In the same article, Dr. Jauhar makes the point, “If beneficial routine care dropped during the past few months of the pandemic lockdown, so perhaps did its malignant counterpart, unnecessary care. If so, this has implications for how we should reopen our health care system. Doctors and hospitals will want to ramp up care to make up for lost revenue. But this will not serve our patients’ needs. The start-up should begin with a renewed commitment to promoting beneficial care and eliminating unnecessary care.”

So, what is the big takeaway from this issue for provider organizations serving consumers with chronic conditions? As we look ahead to continued rocky economic times, this pandemic-era period of health care utilization is going to be used to justify reductions in health care spending. Provider organization management teams need to go “long” on developing the ability to demonstrate value using customer-facing metrics—payers and the health plans will be asking.

Addus HomeCare Corporation (Addus), comprehensive home care provider organization, announced the acquisition of A Plus Health Care, Inc. Based in Kalispell, Montana, A Plus Health Care provides home care services, including personal care, private duty nursing, care management, and medical staffing, to approximately 1,200 clients through over 650 employees in seven office locations.

Addus closed the transaction on July 1, 2020, with funding provided by cash on hand. Financial terms of the acquisition were not disclosed. According to Dirk Allison, President and Chief Executive Officer of Addus, the acquisition represents another significant step forward in their strategy to acquire providers that strengthen their presence in their current markets.

Addus HomeCare is a home care services provider organization that primarily includes personal care services that assist with activities of daily living, as well as hospice and home health services for individuals who are at risk of hospitalization or institutionalization. Addus HomeCare’s payor clients include federal, state, and local governmental agencies, managed care organizations, commercial insurers, and private individuals. Addus HomeCare currently provides home care services to approximately 43,000 consumers through 180 locations across 25 states.

A Plus Health Care is a statewide home care and medical staffing agency for Montana with seven regional offices and over 650 employees. With almost 30 years in home care, the company is listed in the top 100 largest companies in Montana.

For more information, please contact:

  • Dru Anderson, Corporate Communications, Addus Homecare, 6801 Gaylord Parkway, Suite 110, Frisco, Texas 75034 ; 615-324-7346, Email: dru.anderson@cci-ir.com; Website: https://addus.com
  • A Plus Health Care, 926 Main Street #16, Billings, Montana 59105; 406-752-3697; Website: http://www.aplushc.com

The National Institutes of Health (NIH) is facilitating a national rapid innovation initiative to speed delivery of accurate, easy-to-use, scalable home or point-of-care tests for coronavirus disease 2019 (COVID-19) before the fall of 2020. The goal is that millions of tests will be available by September 2020, and a pipeline of more COVID-19 tests to be available in advance of the 2020 flu season. Funding of $1.5 billion for this effort was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. NIH launched the Rapid Acceleration of Diagnostics (RADx) initiative on April 29, 2020.

RADx is using a competitive three-phase selection process to identify the most promising at-home or point-of-care tests for COVID-19. The finalists will share $500 million over all phases of development. Each finalist will be matched with technical, business, and manufacturing experts to increase the odds of success. If the selected technologies are relatively far along in development, they will be put into a separate track and immediately advanced to the appropriate step in the commercialization process. Projects will be assessed at each milestone and must demonstrate significant progress to receive continued support.

The NIH National Institute of Biomedical Imaging and Bioengineering (NIBIB) expanded the Point-of-Care Technologies Research Network (POCTRN) to facilitate RADx. The network will use a flexible, rapid process to infuse funding and enhance technology designs at key stages of development, with expertise from technology innovators, entrepreneurs, and business leaders across the country. The network has assembled expert review boards covering scientific, clinical, regulatory, and business domains that will rapidly evaluate technology proposals. To roll-out new products by the end of summer 2020, RADx will use a rapid, parallel process to allow quick project throughput.

Project proposals are being accepted through the online RADx portal on a rolling basis and are reviewed within a week of receipt. Each is reviewed for technical, clinical, regulatory, and commercialization feasibility. Final determinations for advancement to Phase 0 work package development are based on potential for rapid development and commercialization. For proposals advanced to Phase 0, the process is as follows:

  • Phase 0: Work Package Development. Project teams will initiate Phase 0, a “deep dive” with content and commercialization experts that produces a customized one- or two-phase work package. Awards of up to $25,000 will be provided to cover the approximately one-week participation in the RADx deep dive. Based on the results of this deep dive, a subset of projects will be selected for progression to Phase 1. More advanced approaches with higher technology readiness levels will be selected for acceleration directly to Phase 2.
  • Phase 1: Work Package #1. After NIH approves a project for entry into phase 1, funding will be provided immediately to allow work to begin. Depending on the structure of the work package, some funding may be dependent on successful achievement of interim milestones. The awarded budget will be sufficient to address barriers and risks identified in Phase 0 on a maximally accelerated timetable. In-kind support may be provided in technical, clinical, manufacturing, and regulatory domains. Depending on the milestones that must be met, project budgets are expected to range from $500,000 to millions of dollars.
  • Phase 2: Work Package #2. The awarded milestone-driven budget will be sufficient to enable full product deployment on an accelerated timeline. Additional resources will be made available through partnerships established by NIH and in-kind support provided by NIH and RADx. For projects that meet all milestones toward product distribution, budgets of tens of millions of dollars are anticipated. NIH will negotiate cost sharing with for-profit institutions as appropriate.

Project proposals for RADx can be submitted online at https://www.nih.gov/research-training/medical-research-initiatives/radx/radx-programs.

For more information, contact:

  • John T. Burklow, Director, Office of Communications and Public Liaison, National Institutes of Health, 1 Center Drive, MSC 0188, Building 1, Room 344, Bethesda, Maryland 20892-0188; 301-496-5787; Email: nmb@od.nih.gov; Website: https://www.nih.gov/

Health care has always been a stressful profession. Even before the pandemic, we knew that over half of physicians had at least one sign of burnout, including 59% of emergency physicians, 56% of obstetricians, and 55% of family and internal physicians. And burnout hasn’t been limited to physicians. Child welfare workers, nursing home aides, and many other occupational groups in health care suffer from burnout in their increasingly stressful roles.

Then comes the pandemic. The crisis has greatly exacerbated the stress of essential health care workers—the stress from fear of contracting the coronavirus or spreading it to family members; the shortage of essential health care workers during this period; and the stress of high mortality rates in emergency rooms, nursing homes, group homes, and prisons.

A report on health care workers in New York City, conducted by Columbia University Irving Medical Center and New York-Presbyterian, found that right now, half of workers have high levels of acute stress and screened positive for depressive symptoms, while one-third have anxiety. A recent survey of frontline health care workers in China treating individuals with COVID-19 found that 71% were distressed, 50% were depressed, 44% were anxious, and 34% had insomnia. Another study from Italy, currently under review, found 49.38% of health care workers reported symptoms of post-traumatic stress disorder (PTSD).

Add to this the financial instability of provider organizations—something we have reported on over the past three months. The health care sector lost 1.4 million jobs in April. And that is just the tip of the iceberg. Between May and June, dozens of large health systems announced salary reductions and layoffs. Trinity Health announced 1,000 layoffs, in addition to the 2,500 furloughs previously announced. Tower Health has announced layoffs, and Signature HealthCARE has reported layoffs at its corporate headquarters.

What should leaders do to address the growing stress levels in the health care workforce? An initiative with learning sessions with health care professionals found five common concerns—feedback, protection, preparation, support, and additional care. Health care professionals reported that, in this time of crisis, they are looking for clear communication channels and sessions with leadership; personal protection; enhanced and specific training; physical and emotional support services, and care for individuals living apart from their families.

The Royal Ottawa Hospital, in conjunction with the Phoenix Australia Centre for Posttraumatic Mental Health, has developed materials for provider organizations to reduce the impact on those susceptible to so-called moral injury, a type of PTSD. Some of the suggested measures include rotating staff between high- and low-stress roles, establishing policies to guide them through ethically tough decisions, and promoting a supportive culture. It also urges workers, including physicians, nurses, lab technicians, and social workers, to practice self-care through proper nutrition, exercise, and social connection, and to seek professional help when needed.

These issues and potential solutions were discussed by Carl E. Clark II, Chief Executive Officer of Devereux Advanced Behavioral Health, in the session The Crisis Has Changed The Key Staffing Issues For Specialty Services at The 2020 OPEN MINDS Strategy & Innovation Institute. The featured speakers, experienced managers of health care professionals, had some interesting perspectives. Their take is that there are three primary actions that leaders should take—declare crisis leadership; empower first level, direct line supervisors; and practice regular stress debriefing.

Declare crisis leadership—This strategy, like all strategies, must be a top-down endeavor with clear plans, consistent messaging, and regular reinforcement of the plan. The key is to eliminate as many stressors as possible, including any lack of clarity on process and responsibilities, inequitable workloads, or reduced staffing concerns. OPEN MINDS, Senior Associate, Ray Wolfe explained, “Increased visibility of the executive team and the verbal and nonverbal messages they convey will be critical. The leadership should speak clearly, directly, and with one voice about stress in the workplace and assure that it is defined as a community problem so that it can be discussed freely.”

OPEN MINDS, Senior Associate, Sharon Hicks, expanded on this approach, pointing out how important it is for leadership to acknowledge and remove the stigma from the “need” that staff have for support and help. Leadership must normalize the process of asking for help and help reshape how “staff vulnerability” is viewed at their organizations. She explained, “It is important to both SAY that staff should practice self-care while at the same time DOING things, like putting policies in place, that don’t oppose the need for self-care. Understanding your unspoken culture may be the first, and most important thing, that leadership can do to keep frontline staff healthy and productive.”

Empower first level, direct line supervisors—This level of leadership must understand the new strategy, their importance in implementing this strategy, and “carry the ball” when it’s time to roll it out. This will require some level of new training that at the very least requires supervisors to do weekly check-ins with staff on their emotional state and provide more consistent positive reinforcement. It might even, in some situations, require using trauma-informed principles for the benefit of staff. Mr. Wolfe noted, “We empower and provide resources to the supervisors for dealing with these concerns. They are the most trusted leader in an organization and the key to both change efforts and cultural development.”

Practice stress debriefing—The most effective response to stress is regular opportunities to talk, and realistic feedback that empowers a person to take charge of how they respond to stress. The key is to build this around a well-crafted assessment and intervention that creates opportunities for staff group sessions to discuss their concerns. OPEN MINDS, Senior Associate, George Braunstein, advised, “Wherever possible, provide staff a way to take charge of their work environment, such as designing how to maintain safety within the standards for reopening or how to ensure that any lingering organizational racism is addressed. These cannot be one-time events, but ongoing for at least the time where the stressors are still acutely active.”

Ms. Hicks summed up the situation noting, “The level of stress that direct care providers and ancillary staff who are working in hospitals is extraordinary. The stress on clinical staff in ambulatory settings has also been great. And the worst is yet to come. As the overall crisis begins to abate, staff and administrative personnel, outpatient clinics, specialty providers, and direct care staff are going to be vulnerable to experiencing significant psychological issues, including, anxiety, depression, and post-traumatic stress disorder.”

She concluded by emphasizing the importance of ongoing communication and culture building and building an approach that extends true empathy to the stresses staff face. She summarized, “Leaders and culture setters must ask employees what they need and then work to provide that for them. This is about your culture and how you express to your staff that you value them. The key to supporting staff during this unprecedented time is true empathy.”

Cedar Gate Technologies (Cedar Gate), a leading value-based care performance management company, announced its acquisition of Citra Health Solutions (Citra), a capitation management software solutions provider organization. By acquiring Citra, Cedar Gate expands its software and services capabilities across the full spectrum of value-based care. The financial terms of the acquisition were not disclosed.

By combining Cedar Gate’s existing capabilities in risk-based contract performance management, high-performance analytics, bundled payment solutions, and advisory services, the acquisition now adds capitation through Citra’s market-leading EZ-Suite platform. Citra’s EZ-Suite is a comprehensive claims, benefits, and care management software solution that delivers a highly-configurable, scalable, and flexible platform supporting multiple lines of business, including Medicare Advantage, Medicaid, Medi-Cal, carve-out and commercial populations for health plans, Independent Practice Associations (IPAs), and Management Services Organization (MSOs) accepting risk.

Cedar Gate’s enterprise platform includes the ISAAC SaaS performance management system, which enables payers, provider organizations, and self-insured employers to optimize any risk-based contract by identifying improvements in medical loss ratios, capturing lost revenues and enhancing provider network and clinical performance. Cedar Gate’s bundles and capitation administration systems also deliver high-performing, value-based centers-of-excellence programs.

Cedar Gate Technologies is a leading value-based care performance management company founded in 2014. In 2018, Ascension Ventures, a strategic healthcare venture firm, became part of the ownership group.

Citra Health Solutions provides integrated software solutions solving for the administrative, financial and clinical needs of health care payer organizations, with a highly configurable membership, authorization, capitation, claims, payment, and analytics platform. Citra Health Solutions has over 10 million members served by more than 100 Independent Practice Associations, Management Services Organization, health plans, and provider groups managing Medicare, Medicaid/Medi-Cal, specialty care, and commercial populations,

For more information, contact:

  • Julie Callahan, Cedar Gate, One Sound Shore Drive, Suite 300, Greenwich, Connecticut 06830; 469-579-8045; Email: julie.callahan@cedargate.com; Website: www.cedargate.com
  • Citrahealth, 430 Davis Drive, Suite 180, Morrisville, North Carolina 27560; 888-674-7662; Website: www.citrahealth.com

The Paul G. Allen Family Foundation announced the opening of a new housing and homeless services facility in Seattle, Washington. The Gardner House is a community center with 95 family-sized apartments, about half of which are designated as permanent supportive housing for families that need ongoing resources. The other half are rented as affordable housing to tenants experiencing or at risk of homelessness. Two units provide a third function as in-home daycare facilities designed custom for residents who wished to become childcare professionals. Gardner House has already filled 94 of the 95 units.

The Paul G. Allen Family Foundation partnered with Mercy Housing Northwest and the City of Seattle on what they call a “first of its kind” facility. The ground floor houses the Allen Family Center, an 8,000-square-foot community hub offering housing and employment assistance, childcare, other services, and events. The Paul G. Allen Family Foundation provided $30 million to develop and build the Gardner House. The facility received an additional $5 million from the City of Seattle and $10.7 million through a tax credit. Day-to-day operating funds for the resource center will come from Seattle’s Human Services Department. The Gardner House is hosting a virtual tour for its grand opening; the facility worked with local public health officials to establish safety protocols for residents and service professionals.

Founded by philanthropists Jody Allen and the late Paul G. Allen, co-founder of Microsoft, the foundation initially invested in community needs across the Pacific Northwest with a focus on regional arts, under-served populations, and the environment. The foundation supports a global portfolio of frontline partners working to preserve ocean health, protect wildlife, combat climate change, and strengthen communities. The foundation invests in grantees to leverage technology, fill data and science gaps, and drive positive public policy to advance knowledge and enable lasting change.

For more information, please contact:

  • The Paul G. Allen Family Foundation, 505 5th Avenue South, Suite 900, Seattle, WA 98104; 206-342-2000; Email: press@pgafamilyfoundation.com; Website: www.pgafamilyfoundation.org

The Pennsylvania Department of Health and Department Human Services issued updated guidance to ensure a safe return to activities, visitation, and other events for residents in nursing homes, personal care homes, assisted living residences, and private intermediate care facilities. In order to cautiously lift restrictions in long-term care facilities (LTCFs), the departments will now require all LTCFs to meet several prerequisites before proceeding into the official three-step process of reopening.

LTCFs must develop an implementation plan and post that plan to the facility’s website, if the facility has a website that specifies how the reopening and visitation requirements will be met. LTCFs must also administer tests within 24 hours of a resident showing COVID-19 symptoms and complete baseline testing as required in the Secretary’s Orders for skilled nursing facilities issued on June 8 and for personal care homes, assisted living residences, and private intermediate care facilities issued on June 26. They must also develop a plan to allow visitation that includes scheduling and other safety measures and a plan for cohorting or isolating residents diagnosed with COVID-19 in accordance with PA-HAN 509. LTCFs need to establish and adhere to written screening protocols for all staff during each shift, each resident daily, and all persons entering the facility. They must also have adequate staffing and supply of personal protective equipment for all staff and be located in a county that is either in the yellow or green phase of the Governor’s Reopening Plan. Once a facility meets the required prerequisites, the facility can proceed with the three-step process of reopening.

From the date the facility enters step one, a facility must maintain no new COVID-19 cases among staff or residents and have no spread in the facility for 14 consecutive days in order to enter step two. While in step two, facilities are required to maintain no new cases of COVID-19 among staff or residents and have no spread in the facility for 14 consecutive days to progress into the final step. The final step allows LTCFs to operate as outlined for the remainder of the Governor’s COVID-19 Disaster Declaration as long as there are no new COVID-19 cases among staff and residents for 14 consecutive days.

Governor Tom Wolf was sworn in as Pennsylvania’s 47th governor on January 20, 2015. Governor Wolf has been focused on three simple goals since taking office: jobs that pay, schools that teach, and government that works.

For more information, please contact:

  • Office of the Governor, 508 Main Capitol Building, Harrisburg, Pennsylvania 17120; 717-787-2500; www.governor.pa.gov

The PA Clinical Network and Geisinger Health Plan (GHP) announced a new, value-based contract to achieve better health outcomes and lower costs for GHP members. According to Jaan Sidorov, MD, President and Chief Executive Officer of PA Clinical Network, Geisinger Health Plan shares their interest in measurable improvements in quality with lower costs and a better member experience supported by a high performing network.

GHP is excited to partner with the PA Clinical Network to build on the success of their consumer-centered focus on their members’ health. The PA Clinical Network consists of physician-led practices seeking to increase prevention, achieve wellness and reduce avoidable complications from chronic conditions. The network uses information technology and care delivery expertise to drive measurable improvements in care delivery. It is a subsidiary of the Pennsylvania Medical Society, Pennsylvania’s largest physician advocacy organization.

The PA Clinical Network is Pennsylvania’s first and only clinically integrated network (CIN) for independent practices, led by over 150 community-based physicians. The CIN is supported by the Pennsylvania Medical Society and its Care Centered Collaborative.

Geisinger is comprised of 13 hospital campuses, two research centers, a college of medicine, and a nearly 600,000-member health plan serving more than three million residents in central, south-central and northeast Pennsylvania and beyond. Geisinger has approximately 26,500 employees, including over 1,700 employed physicians, all of whom share a commitment to quality healthcare.

For more information, please contact:

  • PA Clinical Network, 777 East Park Drive, Harrisburg, Pennsylvania 17111; 866-441-2392; Website: www.pennsylvaniacin.com
  • Mark Gilger, Media Relations Specialist Marketing and Public Relations, Giesinger Health Plan, 100 North Academy Avenue, Danville, Pennsylvania 17822; 570-214-9026; Email: mcgilger@thehealthplan.com; Website: www.geisinger.org

Health and well-being company Humana Inc. announced a pilot home-testing program that will enable at-home COVID-19 test collection for members, making Humana the first insurer to offer LabCorp’s at-home test-collection kits. Humana also announced an innovative new collaboration with Walmart and Quest Diagnostics to help members more easily get tested, becoming the first health care company to offer its members drive-thru testing at hundreds of Walmart Neighborhood Market drive-thru pharmacy locations across the country. Humana will continue to waive member costs related to COVID-19 diagnostic tests.

To create a seamless experience for members, Humana has developed a coronavirus risk-assessment tool. Members who have symptoms consistent with COVID-19 infection, or those without symptoms who may be been exposed to the virus qualify for testing and will be given the option to request an in-home test or drive-thru testing. This is part of Humana’s ongoing effort to meet members where they are and ensure that they have a wide range of options and choices for COVID-19 diagnostic testing. Humana members with Medicare Advantage, Medicare Supplement, Medicaid, or Employer Group plans through Humana are eligible for the tests, with Humana waiving member costs for the tests.

Humana Inc. is committed to helping their medical and specialty members achieve their best health. Humana’s efforts seek to lead to a better quality of life for people with Medicare, families, individuals, military service personnel, and communities at large.

For more information, please contact:

  • Jim Turner, Corporate Communications, Humana, 500 West Main Street, Louisville, Kentucky 40202; 502-608-2897; Email: jturner2@humana.com; Website: www.humana.com

Kindred Healthcare, LLC (Kindred) announced it has completed its acquisition of the WellBridge Greater Dallas and WellBridge Fort Worth behavioral health hospitals. WellBridge Greater Dallas and WellBridge Fort Worth provide a full continuum of inpatient and outpatient behavioral health services to senior and adult populations in the Dallas-Fort Worth metropolitan area and the greater North Texas region.

Each hospital has 48 licensed beds and both are leaders in behavioral health care, with proven records of providing exceptional behavioral health services and superior clinical outcomes. Kindred plans to continue using the WellBridge name. Through Kindred Behavioral Health (KBH), Kindred is focused on addressing the unmet need for high-quality, specialized and compassionate behavioral health services, including crisis stabilization for acute mental health and addiction disorders; detoxification from alcohol, opiates, cocaine and other drugs; suicidal thoughts or actions, anxiety, depression and post-traumatic stress disorder; and many other behavioral health illnesses. Kindred also recently announced it is now managing Riverside Medical Center’s 64-bed behavioral health unit in Kankakee, Illinois.

Kindred Healthcare, LLC is a health care services company based in Louisville, Kentucky with annual revenues of approximately $3.2 billion. Kindred through its subsidiaries has approximately 31,800 employees providing health care services in 1,731 locations in 46 states, including 64 long-term acute care hospitals, 21 inpatient rehabilitation hospitals, 10 sub-acute units, 95 inpatient rehabilitation units (hospital-based), contract rehabilitation service businesses which served 1,541 non-affiliated sites of service, and behavioral health services.

For more information, contact:

  • Susan E. Moss, Kindred Healthcare, Senior Vice President, Marketing and Communications, Kindred Healthcare, 680 South Fourth Street, Louisville, Kentucky 40202; 502-596-7296; Email: susan.moss@kindred.com; Website: www.kindredhealthcare.com

Summit BHC, an addiction treatment and behavioral health service provider organization, announced the acquisition of Highland Hospital, a 131-bed psychiatric facility in Charleston, West Virginia. This is Summit’s second acquisition in 2020 and its first facility in West Virginia.

According to Jon O’Shaughnessy, chief executive officer of Summit, the addition of Highland Hospital to the Summit family allows them to continue providing quality psychiatric care to their growing population of clients. Mr. O’Shaughnessy also stated Highland Hospital has a history of treating individuals in a state-of-the-art facility for all ages, and also providing specific treatment options for people with drug and alcohol addiction. Highland Hospital has 24 beds dedicated for psychiatric residential treatment with an additional 91 beds for inpatient acute psychiatric needs. Also, part of the acquisition, the Highland Health Center is a 16-bed crisis residential/detox addiction disorder facility licensed as a behavioral health center.

Headquartered in Franklin, Tennessee, and founded in June 2013, Summit was established to develop and operate a network of leading addiction treatment and behavioral health centers throughout the country. The company’s sole focus is on the provision and management of specialty Substance Use Disorder and Mental Health services within a flexible and dynamic continuum of care. The leadership team at Summit is composed of senior executives with decades of combined experience in the behavioral healthcare industry at the national level. The company currently owns and operates 20 freestanding behavioral health and addiction treatment centers in 15 states across the country.

Highland Hospital has been serving the West Virginia community for over sixty years providing quality mental health care, an educated staff, and a safe environment. Highland Hospital’s mission is to provide quality behavioral health care services to children, adolescents, and adults in a caring environment.

For more information, please contact:

  • Daniel Krasner, Executive Vice President of Business Development, Summit BHC, 389 Nichol Mill Lane, Suite 100 & 160, Franklin, Tennessee 37067; 601-906-9024; Email: dkrasner@summitbhc.com; Website: https://summitbhc.com/
  • Highland Hospital, 300 56th Street SE, Charleston, West Virginia 25304; 304-926-1600; Website: https://highlandhosp.com/

Three Medicare Advantage insurers—Highmark, Kaiser, and Humana—received member satisfaction scores higher than the industry average, as ranked by J.D. Power. Across 10 Medicare Advantage plan sponsors, member satisfaction scores averaged 800 of 1,000 possible points; the scores ranged from 773 to 830. WellCare had the lowest score. The three top-ranked plan sponsors received the following scores: Highmark received 830 points; Kaiser Foundation Health Plans received 829; and Humana received 806. Member satisfaction is based on three information and communication performance indicators (clear, helpful, and proactive communication).

Health plans included in the ranking, and their member satisfaction scores, were as follows:

  1. Highmark received a score of 830.
  2. Kaiser Foundation received a score of 829.
  3. Humana received a score of 806.
  4. UnitedHealthcare received a score of 800.
  5. Aetna received a score of 789.
  6. Cigna HealthSpring received a score of 781.
  7. Anthem received a score of 779.
  8. BlueCross BlueShield of Michigan received a score of 779.
  9. Centene received a score of 775.
  10. Wellcare received a score of 773.

More than 40% of Medicare Advantage members utilize digital means when gathering information regarding their health coverage. Overall, information gathering in general is significantly more likely among Medicare Advantage members (87%) than among those who are commercially insured (82%). Interest in telehealth has also increased since the onset of the coronavirus disease 2019 (COVID-19) pandemic, from about 5% of members who had used telehelath prior to March 2020, to 20% of Medicare plan members who say they are interested in receiving information about telehealth after March 2020.

These findings were presented in “J.D. Power 2020 Medicare Advantage Study,” by J.D. Power. The study examined satisfaction among 3,314 members of Medicare Advantage plans across the United States from January 2020 through March 2020. The study measures member satisfaction with Medicare Advantage plans (also called Medicare Part C or Part D) based on six factors: coverage and benefits; provider choice; cost; customer service; information and communication; and billing and payment. Rankings were based on a 1,000-point scale. The average of the satisfaction scores was 800 out of 1,000.

The full text of the top line findings of the 2020 Medicare Advantage Study was published on June 18, 2020, by JD Power. A copy is available online at https://www.jdpower.com/sites/default/files/file/2020-06/2020068%20U.S.%20Medicare%20Advantage%20Study.pdf.

For more information, contact: 

  • Geno Effler, Director, Corporate Communications, J.D. Power, 3200 Park Center Drive, Floor 13, Costa Mesa, California 92626; 714-621-6224; Email: media.relations@jdpa.com; Website: https://www.jdpower.com/business

On May 29, 2020, the Hawaii Department of Human Services (DHS) announced that it intended to rescind the Medicaid Med-QUEST managed care organization (MCO) contracts awarded in January 2020, and the request for proposal (RFP) released August 2019. The new RFP is slated for release in the fall of 2020. Before it is released, DHS intends to issue a request for information (RFI) to better understand the evolving needs of communities and provider organizations due to the coronavirus disease 2019 (COVID-19) public health crisis. Existing contracts with the five incumbent health plans—AlohaCare, Hawaii Medical Service Association (HMSA), UnitedHealthCare Community Plan, Ohana Health Plan/WellCare, and Kaiser—will be extended until the new contract awards are made.

The state’s action is in response to a 7.5% rise in Medicaid enrollment due to unemployment caused by the COVID-19 public health emergency. Since March 4, 2020, Med-QUEST has enrolled over 24,000 additional beneficiaries. As of June 22, 2020, Medicaid enrollment was 358,488, up from 333,321 a year ago. DHS anticipates that the number of Med-QUEST applicants will continue to climb, and that Medicaid enrollment will remain high until the state’s economic recovery begins and there is a return to pre-pandemic employment levels.

Before the pandemic, Hawaii’s unemployment rate was less than 3%. To control the spread of COVID-19, in March, Hawaii had imposed a mandatory 14-day quarantine on arriving visitors to any of the islands. The flow of visitors slowed from about 30,000 arriving per day to a few hundred. About 25% of jobs in the state are connected to tourism. In April, the state’s unemployment rate rose to 23.8%; and dipped in May to 22.6%.

DHS had awarded the QUEST Integration (QI) MCO contracts on January 22, 2020. The contracts, valued at $17 billion, were awarded to four of the five incumbents: AlohaCare, HMSA, UnitedHealthCare Community Plan, and Ohana Health Plan/WellCare. AlohaCare and WellCare were to serve Oahu, while HMSA and United was to serve statewide. Kaiser did not submit a bid. The contracts were slated to begin July 1, 2020, and run through December 31, 2025, with four optional renewal years. The contract called for the MCOs to offer a dual-eligible special needs plan for Medicare and Medicaid members in Hawaii no later than January 1, 2021.

A link to the full text of “Hawaii Med-QUEST/Medicaid Data By County, Weekly Application & Enrollment Data Update” may be found at www.openminds.com/market-intelligence/resources/062920hawaiimedqueststats.htm.

For more information, contact:

  • Public Information & Communications Officer, Hawaii Department of Human Services, Post Office Box 339, Honolulu, Hawaii 96809-0339; 808-586-4892; Fax: 808-586-4890; Email: dhs@dhs.hawaii.gov; Website: https://humanservices.hawaii.gov/

eHome Counseling Group announced the expansion of the virtual eHome post-traumatic stress disorder (PTSD) treatment program. The program combines mental health counselors with 24/7 technology to treat those impacted by post-traumatic stress completely virtually. The eHome PTSD treatment program removes the barriers many people face when seeking treatment, with minimal impact on work or family time, and the ability to have counseling sessions conveniently and confidentially on a smartphone, tablet, or computer.

The program includes an artificial intelligence app that can connect consumers to a counselor 24/7 if help is required between counseling sessions. It also has assessments and online educational resources for comprehensive care. eHome uses metrics-based treatment to rapidly diagnose mental health issues and track improvement. Through the Deep Mind Insight™ program, clients receive an online assessment that quantitatively measures anxiety, depression, PTSD, addiction disorder, and other conditions. The client gets a written report that is discussed with their therapist at the first session. The assessment is then repeated periodically to show progress and final outcomes.

eHome Counseling Group is a nationwide virtual counseling network based in Orlando, Florida that provides anytime, anywhere mental health treatment by computer, tablet or smartphone. The organization provides a convenient, confidential, highly effective alternative to traditional office-based counseling programs using a HIPAA-compliant, customer friendly, integrated platform.

Priority Health and Cigna announced they have formed a strategic alliance and will partner to make comprehensive health care coverage more affordable and accessible to Michigan employers, their employees and families. This new strategic alliance will offer a competitive network solution for employer groups in the state, leveraging the best capabilities of each organization and the strength of their provider organization relationships.

Starting January 1, 2021, Cigna clients and customers will have access to Priority Health’s comprehensive network of high-quality provider organizations, which includes 97% of primary care physicians in Michigan, a wide variety of specialists and access to the vast majority of hospitals, labs and ancillary care services in the state. Priority Health members who live, work, or travel outside of Priority Health’s service area will have access to Cigna’s national network of quality physicians, specialists, hospitals, labs and facilities around the country. The strategic alliance will make it simpler for customers to find in-network provider organizations and navigate their health care experience in Michigan and around the country. Priority Health and Cigna have worked together since 2018 to provide competitive network solutions for Michigan employers that have a national footprint, which continues to be an area of growth for Priority Health.

With over 30 years in business, Priority Health is the second largest health plan in Michigan offering a broad portfolio of health benefits options for employer groups and individuals, including Medicare and Medicaid plans. Serving more than one million members each year and offering a network that includes 97% of primary care physicians in Michigan, Priority Health focuses on quality, customer service, transparency, and product innovation.

Cigna Corporation is a global health service company. All products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna Life Insurance Company of New York, Connecticut General Life Insurance Company, Express Scripts companies or their affiliates, and Life Insurance Company of North America.

Contact information

  • Emily Potts, Senior Marketing Specialist, Priority Health, 1231 East Beltline Avenue, NE, Grand Rapids, Michigan 49525-4501; 616-885-6253; Email: Emily.Potts@priorityhealth.com; Website: www.priorityhealth.com
  • Holly Fussell, Business Communications Lead, Cigna, 900 Cottage Grove Road, Bloomfield, Connecticut 06002; 423-304-9128; Email: Holly.Fussell@cigna.com; Website: www.cigna.com

Optum, a leading health services company, and Wider Circle, a tech-enabled community-based health care services company that drives better health for older adults and other vulnerable communities, have partnered with Helping Hands Community (HHC) to launch the “Community Food Circle” initiative to bring food to thousands of Optum consumers in Los Angeles County during the COVID-19 pandemic. The initiative supports Optum’s goal of helping people reach their health and well-being goals, including addressing social determinants of health.

Optum volunteered from its AppleCare and HealthCare Partners physician groups, Wider Circle staff, volunteered from HHC and other community partners, packed and loaded food supplies into Uber vehicles. Uber drivers then delivered the food to consumers across Los Angeles County. Since the beginning of California’s shelter-in-place order, Optum and Wider Circle have offered social support and meal delivery services free of charge to more than 20,000 Optum consumers in Los Angeles County. The recent partnerships with HHC expands the meal delivery service by offering it to an additional 60,000 individuals. Each food package provides an individual 10 days of food.

Optum California is an integrated health system that serves more than 1.4 million individuals across Southern California through its family of medical groups and provider organization networks. Optum California’s network includes OptumCare Medical Group, HealthCare Partners, AppleCare Medical Group, Monarch HealthCare, and North American Medical Management of California.

Wider Circle works with health plans nationally to deliver unique community care programs that connect neighbors for better health. Centered on trusted relationships, Wider Circle connects health plan members with familiar neighbors to inform, support and motivate one another, empowering them to be more proactive about their health. Wider Circle’s trusted delivery network has been proven to drive resilience, improve member experience and engagement, and reduce hospitalizations.

Helping Hands Community is a non-profit organization dedicated to serving those most vulnerable to COVID-19: senior citizens, the immunocompromised, and people with pre-existing medical conditions which put them at additional risk. The community of volunteers deliver groceries, medicine, and other necessary supplies, and local and national partners help the organization identify and reach those in need wherever they may be.

Contact information:

  • Brad Lotterman, Communications, Optum, 11000 Optum Circle, Eden Prairie, MN 55344; 714-445-0453; Email: brad.lotterman@optum.com; Website: www.optum.com
  • Jessy Green, Media Contact, Wider Circle, 711 Nevada St, Suite 20, Redwood City, CA 94061; 917-689-9295; Email: jessy.green@svmpr.com; Website: https://awidercircle.org/
  • Lauren Volkmann, Public Relations & Corporate Communications, Helping Hands Community, 831-331-3307; Email: lauren@helpinghands.community; Website: https://helpinghands.community/

In an unfamiliar environment, the leader with the best data has a distinct advantage. That is a frequently heard adage, but I was really struck by the concept at one of The OPEN MINDS Executive Leadership Retreats. The historian talked about how Robert E. Lee’s strategy at Gettysburg was compromised when his cavalry (the advanced surveillance unit of its time) was waylaid.

While leaders know that the right information allows better decision making, in a recent survey, 67% of U.S. corporate executives say they are not comfortable accessing or using data from their tools and resources. And shockingly, the number of companies that say they are data-driven actually declined from 37% in 2017 to 31% in 2019.

So where is your organization on the journey to a data-driven culture? One way to assess that is to look at the OPEN MINDS process for becoming a data-driven organization. Where is your team on this path?

  1. Identify a market-driven strategy

The first step on the path to becoming data-driven requires the executive team to get on the same page as to what metrics are considered important for monitoring strategy in terms of growth, quality, and finance. Specifically, what are the key actionable drivers that will give a clear indication that the strategy is working?

  1. Begin the participatory process through c-suite technical assistance

The second step in the process is to engage in a participatory discussion to start identifying the metrics desired by each member of the executive team to manage strategy. In this step of the process, you may walk away with a 10-person wish list totaling 600 measures but it will get you on the road to narrowing the list down to those metrics that matter most.

  1. Create the “wish list”

After each executive team members’ desired metrics are identified, the next step in the process is to create an inventory of potential metrics, prioritizing each by what data is available, what is actually feasible to measure, and what is the anticipated cost of measuring each.

  1. Select the C-suite base metrics set

Once the C-suite metrics are identified and prioritized, the key is to start small. Creating a very limited data set with key metrics is critical to the implementation process and to avoiding ‘data overload’.

  1. Operationalize and automate

Going from vision to production is not necessarily complicated, but it can be time consuming. In this step of the process, ensuring that the metrics are clearly defined and operationalized is critical, along with how the data will be displayed. Once defined, the reporting must be automated to ensure timeliness and limit work on the backend (if it’s not automated, put it back on the wish list to revisit in the future).

  1. Practice at the C-suite level

The next step in the process is to actually practice using the data at the C-suite level. But, it’s important to remember, initial disbelief is common particularly when turnover is reporting as especially high or productivity is especially low. Make sure the data is valid and reliable—and then turn to problem solving. Pick out the major pain points and hone in on those to guide executive team meetings rather than taking a deep dive into every data point.

  1. Add high-value metrics that require investment

As executive teams begin to master the basics, additional metrics can be added in terms of their return on investment (ROI). Whether the team desires to merge two electronic health records, pull data in from the financial system, or highlight claims data, this all comes at an increased cost and should show a clear ROI. The point to remember here is, no performance dashboard is ever static. The metrics that are important now may be overshadowed by other metrics over time as your business model or payer contracts change.

  1. Extend within the organization

The next step to becoming a data driven organization—once the executive team and board are “on board”—is to extend and distribute the data across the organization (billing department, web team, clinical staff and programs, contract managers). Consider the data that each team needs to successfully manage their own performance. While transparency in this regard is important, focus is key, because what gets measured is what gets done.

  1. Educate

While every organization may educate team members differently, it’s critical for supervisors and clinical staff to not only understand the data, but also understand why it matters—whether it’s to the consumer or payer or for financial sustainability. The more meaningful the data is, the more likely the team will learn to embrace it.

  1. Implement performance-based team compensation

Once the executive team has laid out clear, data-driven performance expectations to staff members, they can be integrated into both performance evaluations and compensation planning.

  1. Share with external stakeholders

As you begin to “know” your data (and the equivalent benchmarking data of competitors), there is a new opportunity to use performance data as a marketing advantage. As provider organizations conduct outreach to consumers or engage in discussions with health plans, knowing your performance is superior (and having the data to quantify and prove it) is essential to become an advanced data-driven organization.

  1. Share (real-time) with partners

The final (and hardest) step is data transparency. Sharing data in real-time with key stakeholders, affiliation partners, or health plans is a characteristic of a mature, strong partnership and one that will likely be more successful with shared performance metrics.

The executive teams that have the best data—and the best insights based on that data—are those that have been able to pivot quickly in our current crisis. But they will likely need to pivot again. As we enter the post-crisis normal, demonstrating your value, and having the data to back it up, will be key not only for future strategy development but also for long-term sustainability.

After the successful opening of three Walmart Health centers in Georgia, Walmart is opening the newest location in Northwest Arkansas at the Supercenter. With the new Walmart Health located at 4870 Elm Springs Road in Springdale adjacent to the Supercenter, the community will have access to transparent pricing for key health center services, regardless of insurance status.

This facility provides quality, affordable and accessible health care. In addition, Walmart Health is partnering with several on-the-ground health provider organizations to be a first-of-its-kind health center to deliver primary and urgent care, labs, x-ray and diagnostics, counseling, optical and hearing services all in one facility at affordable, transparent pricing regardless of an individual’s insurance status. Additionally, Walmart Health plans to add dental services starting in July.

Walmart Health Elm Springs is the fourth such location the retailer has opened. The first opened in September 2019 in Dallas, Georgia. Each location is unique and serves as a prototype to test and learn the right mix of health and wellness services for individual communities. Walmart Health is operated by qualified medical professionals, including physicians, nurse practitioners, dentists, behavioral health providers and optometrists. Onsite Walmart Care Hosts and Community Health Workers will help customers navigate their visit, understand resources and be a familiar presence for regular visits.

Walmart operates approximately 11,500 stores under 56 banners in 27 countries and eCommerce websites in 10 countries. They employ approximately 2.2 million associates around the world with 1.5 million in the U.S. alone.

Contact information:

  • Walmart, 702 SW 8th Street, Bentonville, Arkansas 72712; 800-925-6278; Website: https://corporate.walmart.com/

Centerstone, a national leader in behavioral health care, is introducing a zero-suicide initiative at its locations in Illinois. While Centerstone has long had a focus on crisis and suicide prevention services, the goal of this new initiative is to add further resources around the issue of suicide.

According to Jenna Farmer-Brackett, clinical manager at Centerstone, zero lives lost due to suicide has always been the goal and the Zero Suicide initiative will further support that goal. The Zero Suicide initiative will additionally help clients by providing a safe place for them to talk about suicide, help erase the stigma of talking about this issue, and will educate people to have conversations and take steps to get help. Educational training and professional development opportunities will be provided to staff to further increase comfort and knowledge around suicide, suicide screenings, and supporting clients when safety may be a concern.

Centerstone is a non-profit health system providing mental health and addiction treatment. Services are available nationally through the operation of outpatient clinics, residential programs, the use of telehealth, and an inpatient hospital. Centerstone serves over 170,000 people and families in Florida, Illinois, Indiana, Kentucky, and Tennessee.

If you or someone you know is in crisis, please contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

Contact information

  • Centerstone of America, 44 Vantage Way, Nashville, Tennessee 37228; 615-460-4020; Email: mediainquiries@centerstone.org; Website: https://centerstone.org

On June 9, 2020, the federal Department of Health and Human Services (HHS) announced a $15 billion Provider Relief Fund allocation for provider organizations that participate in state Medicaid and Children’s Health Insurance Program (CHIP) programs, but that have not received a payment from earlier relief allocations. The Provider Relief Fund was created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The initial General Distribution provided payments to approximately 62% of all provider organizations participating in state Medicaid and CHIP programs. The Medicaid and CHIP targeted distribution will make the Provider Relief Fund available to the remaining 38%. As of June 29, 2020, HHS was still determining the recipients that would receive allocations from the fund.

To be eligible for this new funding allocation, health care provider organizations must not have received payments from the $50 billion Provider Relief Fund General Distribution and must either have directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for health care-related services between January 1, 2018 and May 31, 2020. HHS estimates this will provide relief to several hundred thousand more provider organizations with many considered safety net organizations.

According to the “HHS Instructions For The Medicaid Provider Distribution” released on June 26, 2020, to apply for the funds, organizations must meet all of the following six eligibility criteria:

  1. Must not have received payment from the $50 billion General Distribution
  2. Must have either directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for health care-related services during the period of January 1, 2018, to December 31, 2019, or own (on the application date) an included subsidiary that has either directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for health care-related services during the period of January 1, 2018, to December 31, 2019
  3. Must have either filed a federal income tax return for fiscal years 2017, 2018, or 2019 or be an entity exempt from the requirement to file a federal income tax return and have no beneficial owner that is required to file a federal income tax return (e.g., a state-owned hospital or health care clinic)
  4. Must have provided consumer care after January 31, 2020
  5. Must not have permanently ceased providing consumer care directly, or indirectly through included subsidiaries
  6. If the applicant is an individual, have gross receipts or sales from providing consumer care reported on Form 1040, Schedule C, Line 1, excluding income reported on a W-2 as a (statutory) employee

HHS will accept applications from eligible provider organizations through July 20, 2020; tardy applications submitted after that date will not be considered. The application must include gross revenue from consumer care for calendar years 2017, 2018, or 2019; the most recent federal income tax returns for 2017, 2018 or 2019; the applicant’s Employer’s Quarterly Federal Tax Return on IRS Form 941 for Q1 2020, Employer’s Annual Federal Unemployment Tax Return on IRS Form 940; and the applicant’s Full-Time Equivalent Worksheet. Some applicants may be required to submit the Gross Revenue Worksheet.

HHS partnered with UnitedHealth Group (UHG) to provide rapid payment of the Medicaid and CHIP distribution to provider organizations eligible for the distribution of the initial $30 billion in funds. The provider organizations will be paid via Automated Clearing House account information on file with UHG or the Centers for Medicare & Medicaid Services (CMS). Automatic payments will come to provider organizations via Optum Bank with “HHSPAYMENT” as the payment description. Provider organizations who normally receive a paper check for reimbursement from CMS will receive a paper check in the mail for this payment as well. Within 45 days after receiving the payment, the provider organization must attest to confirm receipt of the funds and agree to the terms and conditions. If the payment is not returned within 45 days of receipt, HHS will count the non-return as acceptance of the terms and conditions.

On June 10, 2020, HHS launched an enhanced Provider Relief Fund Payment Portal that will allow eligible Medicaid and CHIP provider organizations to report their annual consumer revenue, which will be used as a factor in determining their Provider Relief Fund payment. The payment to each provider organization will be at least 2% of reported gross revenue from consumer care. The final amount each organization receives will be determined after the data is submitted, including information about the number of Medicaid beneficiaries the organizations serve.

A link to the full text of “Medicaid Provider Distribution Application Form” may be found at www.openminds.com/market-intelligence/resources/060920medicaidproviderreliefapplication.htm.

A link to the full text of “HHS Instructions For The Medicaid Provider Distribution” may be found at www.openminds.com/market-intelligence/resources/062620instmedicaidrelieffunddist.htm.

A link to the full text of “HHS Terms & Conditions For The Medicaid Provider Distribution” may be found at www.openminds.com/market-intelligence/resources/062620medicaidrelieffundterms.htm.

The National Council letter issued on June 18, 2020, is posted at https://www.thenationalcouncil.org/wp-content/uploads/2020/06/HHS_BH_Provider_Relief_Sign_On.pdf?daf=375ateTbd56.

PsychU last reported on the CARES Act Provider Relief Fund in the following articles:

For more information, contact: 

  • S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, District of Columbia 20201; 202-690-6343; Email: media@hhs.gov; Website: https://www.hhs.gov/provider-relief/index.html

“No one wants to give a significant contribution to an organization that is circling the drain.” This comment was made by a board member of a community foundation in a recent meeting. The discussion was whether they were going to provide funding for a local provider organization that has been hard hit by the pandemic crisis. The board member said there were many organizations (more than they could fund) asking for financial relief and that this particular organization didn’t appear to be sustainable going forward, even with the financial relief. As the conversation continued, the suggestion was made that the organization’s board consider a merger with another similar organization to stabilize its financial future.

This conversation illustrates the problem faced by many organizations right now (whether non-profit or for-profit, by the way). It’s not that they are going to run out of cash over the next couple months, but they don’t have a recovery plan and sustainable business model for the next year or two. And they have an urgent need for cash and capital. Using collaborations to address this very situation was the focus of the recent web briefing, Using Mergers, Acquisitions & Affiliations To Address ‘Urgent’ Cashflow Needs, by OPEN MINDS, Senior Associate, Ken Carr. His advice—recognize that it’s not enough to find cash to run the business for a couple more months. What recovery really requires is building a sustainability plan for the next 12 to 18 months.

In his briefing, Mr. Carr addressed the big questions every health and human service executive team and board member needs to answer in the recovery planning process:

  • Are we financially sustainable right now, during the crisis?
  • As the economy moves from crisis to post-crisis normal, will we be financially sustainable?
  • If yes, what are the market scenarios that would potentially harm our sustainability?
  • If no, what growth strategy do we need to become financially sustainable? And is size alone enough?

While size is an element in sustainability, size alone is not enough. Mr. Carr said, “For your specific market, in your state, you need to look where you are going and utilize this as a strategy, not to just get larger but to prepare for the future. You will need to review and assess your diversity of revenue sources, service lines, profitability, debt ratio, and cash on hand, all so that whether you are an acquiring organization or want to be acquired, you have more information to put out there with which to create a better relationship with someone who is looking to partner.”

And now is not the time for the wishful thinking that many board members engage in. The “Recovery Tracker” from Harvard University, Brown, and the Bill and Melinda Gates Foundation, presents a grim picture—consumer spending across the U.S. has decreased by 8.5% from January to June 2020. And two-thirds of the total reduction in spending came from households in the top 25 percent of the income distribution, causing businesses in the most affluent neighborhoods in America to lose more than 70% of their revenue and lay off people. As a result, household names like Virgin Airlines, General Nutrition, Chuck E. Cheese, Hertz, and Cirque de Soleil are filing for bankruptcy and likely going out of business. And health care organizations are feeling the pinch. Trinity Health announced an expected $2 billion in losses and another 1,000 layoffs, in addition to the 2,500 furloughs previously announced. Tower Health is down $212 million and cutting more jobs, and Signature HealthCARE has reported 100 layoffs at its corporate headquarters.

At the same time, there is a stream of new competitors entering the space. Walmart is planning to launch what it calls “healthcare supercenters,” tech-enabled in-home health care provider organization, DispatchHealth, announced $135.8 million in growth capital financing, and virtual mental health services provider organization, AbleTo, expanded its suite of mental health services.

This is the time to be clear-eyed about the need for affiliations and the opportunities in those affiliations. Mr. Carr noted, “As you move forward, how big you are can determine goals. Ask some questions. Why do you want to move forward? What collaboration model would work best? How do you get engagement from the board and executive team for both considering and escalating this strategy? All are critical questions.”

And maybe answers will lead us to reprise the famous lines from the Joseph Stein musical, Fiddler on the Roof, “Matchmaker, Matchmaker/make me a match/find me a find/catch me a catch.”

While the natural tendency is for every organization to “find the catch” or be the acquirer, it is important to be realistic about the limits of any organization’s cash and management talent—often assets that come from being acquired by a larger organization.

In this fluid market, executive teams need to speed up their processes for developing a recovery strategy, determining whether/how affiliations fit in that strategy, and executing the process. To do this, they must determine their goals, build a plan based on organizational needs, and maximize the return on investment in terms of finances as well as leadership time spent. Then they must review and assess their organizational potential through a “market positioning” lens that spells out exactly what their efficiencies and prospects are or are not. Next, they need to assess the current market and build a “go forward plan” to identify the structure for the ideal collaboration. Finally, they can start identifying potential collaboration partners, and due diligence beforehand will reveal if the goals, resources, and market potential of the potential partners line up or not.

Mergers are not a popular option, particularly for non-profit organizations where boards and executive team members fear loss of their positions, changing the mission, or altering the brand. Mr. Carr shared that in a recent study of non-profit mergers, 88% of participating organizations reported that they were better off after the merger.

The right affiliation executed at the right time can be like a healthy dose of vitamins for the overall health of a provider organization and can bring in an infusion of funding, staffing, services, reach, and consumers to keep the doors from closing for good.

Martin Luther King Jr. once said, “Every crisis has both its dangers and its opportunities. Each can spell either salvation or doom.” This is exactly how it has been for health and human service provider organizations of all hues during the coronavirus pandemic. And the outlook could be grim, or exciting, as we crawl back to “the new normal.” Right now, most health care provider organizations are struggling to see their way through the crisis and find a path to sustainability in the post-crisis period.

To provide a framework for executive action in the face of this crisis, The OPEN MINDS team developed the OPEN MINDS Executive Blueprint For Crisis Management. Its goal is to help executive teams optimize their performance and financial viability during and after the crisis. The framework consists of seven components—crisis management, cash management, virtual service delivery and operations, virtual revenue generation, short-term revenue maximization, short-term business development, and post-disruption sustainability.

AbleTo, Inc., a leading virtual mental health provider organization, announced an integrated suite of solutions for payers to address the growing mental health needs across their populations with AbleTo’s care model. AbleTo’s evidence-based care is found to significantly reduce mental health symptoms and improve overall health. The solution allows payers to meet the increasingly high demand for mental health services, especially teletherapy.

With the expanded product suite, AbleTo’s clinically rigorous care is available to treat mental health needs across broad populations. Each solution offers structured cognitive behavioral therapy (CBT) programs that are tailored to the participant’s unique needs for a personalized treatment experience. AbleTo uses a data-driven approach to assess needs and goals to guide individuals to a customized experience across the suite of solutions. Each participant receives up to eight weeks of treatment with a blend of human and technology support according to the severity of need and personal preference. The entire suite of solutions is integrated across a data-driven care management platform to ensure quality across programs and enable measurement-based care.

AbleTo, Inc. provides technology-enabled behavioral health care. AbleTo’s proprietary platform connects individuals and their care teams with AbleTo licensed clinical professionals who deliver weekly sessions by phone or video supported by an integrated digital experience.

Contact information:

  • Mary Mooney, Marketing Director, AbleTo, Inc., 320 West 37th Street, 7th floor, New York, New York 10018; 312-593-4280; Email: mary.mooney@ableto.com; Website: www.ableto.com

Martin Luther King Jr. once said, “Every crisis has both its dangers and its opportunities. Each can spell either salvation or doom.” This is exactly how it has been for health and human service provider organizations of all hues during the coronavirus pandemic. And the outlook could be grim, or exciting, as we crawl back to “the new normal.” Right now, most health care provider organizations are struggling to see their way through the crisis and find a path to sustainability in the post-crisis period.

To provide a framework for executive action in the face of this crisis, The OPEN MINDS team developed the OPEN MINDS Executive Blueprint For Crisis Management. Its goal is to help executive teams optimize their performance and financial viability during and after the crisis. The framework consists of seven components—crisis management, cash management, virtual service delivery and operations, virtual revenue generation, short-term revenue maximization, short-term business development, and post-disruption sustainability.

Crisis Management

At this point, most provider organizations have a crisis management plan in place. But remember, it’s important to continuously update and refresh that plan to address evolving safety threats to staff and consumers, ensure continued operations of your organization, and communicate across stakeholders. A robust crisis management plan must outline possible crisis scenarios and your likely responses. It must designate a clear chain of command—the crisis SWAT team—and the communication responsibilities of each team member. You’ll need a plan to analyze financial impact and build stability. And you must put into place new policies and procedures for conducting all business activities.

Cash Management

Cash flow has been the single biggest challenge for provider organizations in the pandemic crisis with declining volume of services and increasing expenses. And we know that 90% of small businesses that close do so because of cash problems. So, it is critical to manage cash aggressively and improve your financial strength and resilience by looking at both the revenue and expense sides. On the revenue side, you could explore how to improve the speed of billing and collections, request prepayment for services, secure additional short-term financing in the form of emergency relief funds and loans and look for quick collaboration opportunities. On the expense side, consider renegotiating payment terms with your vendors and developing financial thresholds to discontinue non-optimal service lines. You’ll also need to aggressively manage costs, streamline operations through activity-based costing, eliminate unnecessary expenses, optimize the performance of revenue-producing team members, improve the efficiency of administrative staff, and outsource non-core services.

Virtual Service Delivery & Operations

It has become clear that virtual is the new norm and here to stay, beyond the crisis. It’s time to shore up your telehealth platform, policies, and operating procedures for the long-term, factoring in regulation and reimbursement changes that will start to take effect as pandemic-related allowances are retracted. Virtual service delivery must be synced to your electronic health record, scheduling, documentation, and billing systems. And you need to determine how to measure treatment efficacy and modify performance measures, as payers will look for demonstration of value. Behind the scenes, you need to think about remote operations and what “work from home” looks like as a permanent option, even as you deal with the challenges of reopening your physical locations. You may need to re-channel investments from brick and mortar facility upgrades and maintenance to new training, equipment, and connectivity tools for staff.

Virtual Revenue Generation

The proliferation of virtual services means your current and future customers will be looking for you online. Your digital brand and reach will have a significant impact on your sustainability. You need to assess how to enhance your online presence to drive volume in virtual services. Improving the content, design, and performance of your website and social media channels must be a priority. You must optimize your website for search—so you rank at the top of the listings when consumers Google the services you provide—and then consider how to convert visitors to customers by offering quick and convenient access to appointments, information, reviews, and recommendations.

Short-Term Revenue Maximization

Despite decreases in service volume, there are ways to stabilize revenue by streamlining your processes, so you get paid for all services provided and track net collections. You can put your referral generation plan on steroids to bring in new business and address the growing need for mental health and addiction treatment that has escalated during the crisis. This is also a good time to have conversations with payers and negotiate rates and contracts— they are open if you can establish value and approach them with a concrete plan for how you will keep your doors open for the vulnerable populations you serve. And ask your payers about new reimbursement models for emergency/high-demand services.

Short-Term Business Development

While survival may seem like the only priority during a crisis and in its immediate aftermath, you don’t want to miss the opportunities for diversification and growth that any market disruption yields. Assess the urgent needs in your markets and create a rapid response model with creative and nimble service planning, pricing, staff deployment, and outreach to funders. Explore how you can maximize the revenue of current services and assets through re-purposing and repositioning in an increasingly virtual market. For example, virtual services may prime the pump for geographic expansion, and it would pay to identify replicable services and target markets.

Identify services and programs you provide today that could be repurposed for other consumer and payer markets. Look out for any competitor contracts at risk and monitor local organization “failures” that may open opportunities for you to fill the service gaps. It’s also important to develop a strategic short-term fundraising plan—identify your “critical services” to public agencies and health plans and request financial support; consider targeted appeals for specific programs; and make time for personal outreach to key donors and local charities.

Post-Disruption Sustainability

Market disruption demands fresh thinking about many things that were once untenable for most non-profits. It requires losing the “we serve; therefore, we will get paid” complacency and acknowledging the new competitors in the market. Think about how you would redesign your organization if you were starting from scratch and recalibrate frequently to keep up with market changes and needs. Strategic planning for long-term sustainability in the post-crisis market must be based on a growth mindset and include some essential elements focused on marketing, service line portfolio analysis, leverage of technology and organization-wide performance measurement.

Improving overall cost management and organizational efficiencies must be a continuous endeavor. Consider how you can become the provider organization of choice by delivering superior customer experiences. And above all, foster a culture of continuous innovation—planning, developing, and launching new service lines (while you let go of unprofitable “sacred cows”) to meet evolving needs and expectations of a market that will be in flux for a long time.

 

There is a lot we don’t know about coronavirus disease 2019 (COVID-19). The death rates, the incidence in the population, and the effect of antibodies are still big questions. But there are conclusions about one issue that seem to be emerging in almost every study—hospitalization and death rates are being driven by underlying chronic medical conditions.

Among people diagnosed with COVID-19, the most common underlying health conditions linked to hospitalization and death were cardiovascular disease (32%), diabetes (30%), and chronic lung disease (18%). And last week, the Centers for Disease Control and Prevention (CDC) expanded its list of populations at highest risk, including those with chronic kidney disease, chronic lung diseases, weak immune systems from transplants, obesity, heart conditions, sickle cell disease, and diabetes.

This data is consistent with earlier findings in China and Italy. The March 2020 Italian epidemiological study found that more than 99% of Italians who died of COVID-19 had a chronic illness, including hypertension, diabetes, heart disease, cancer, dementia, or history of stroke. Of that group, 48.5% had three or more chronic illnesses, 25.6% had two chronic illnesses, and 25.1% had one chronic illness. Another study from Wuhan found that 48% of consumers who were hospitalized had a comorbidity, including hypertension (30%), diabetes (19%), and coronary heart disease (8%).

Unfortunately, almost half (45%, or 133 million) of all Americans suffer from at least one of these conditions. We also know that approximately 75% of individuals with a serious mental illness have at least one chronic health problem and half have a diagnosis of two or more chronic health problems. Chronic pulmonary illness was the most prevalent at 31%. Among consumers with an intellectual and developmental disability (I/DD), 45% have three or more chronic conditions; and among people in prison, this percentage rises to 50%.

For provider organizations serving these populations, there is an opportunity to both “do the right thing” and gain market differentiation needed for building a sustainable market position. These vulnerable populations need care management approaches that fully embrace chronic disease management and the “whole person” care approach—and that is exactly what health plan managers have been saying they want as well.

Many times, when this idea is raised, the common push back is that we are too far into the pandemic crisis for wellness and prevention programs to make a difference. But some interesting researchers have dissuaded me of that. David Katz, M.D., founding director of the Yale-Griffin Prevention Research Center, makes a great case for creating a national health promotion campaign for those at highest risk. His point is that the pandemic has turned America’s chronic health liabilities into an acute threat. As he says, “The very things we tell people to do to improve their long-term health actually do fortify your immunity. Those healthy practices can affect how your immune system functions in hours, certainly in days, and a whole lot in a span of weeks….”  In his article, he continues this train of thought, “This…is what we in Preventive Medicine call a ‘teachable moment’… The immunologic responses of generally healthy bodies are an obviously high-potency defense against the ravages of SARS-CoV-2. Why race for the extrinsic salvation of a vaccine while neglecting the rarefied, intrinsic defenses of our native immune system….?”

For provider organization executive teams looking to the future, this wellness-oriented support for our most vulnerable and high-risk consumers is also exactly what health plans are looking for. This is one of those moments in time when organizations can do well by doing good.

“The most important factor in survival is neither intelligence nor strength but adaptability”—Charles Darwin

What can we say about leadership during this pandemic crisis? We have a health crisis that is changing the health and human service field in very fundamental ways. We have an economic crisis that is just beginning with recession and likely to slide into a depression in the fourth quarter. Over 47 million Americans have already filed for unemployment and more are likely to follow in the third quarter.

But what we know about the future as leaders is limited. There will be more virtual services and there is high risk to essential workers. Unemployment will continue to increase. An estimated 25,000 retail stores are going to close this year. Government agencies will be strapped for funds.

More problematic for leaders—whose job is to assure organizational survival and recovery to continue their mission—are the big unknowns. When will the most severe part of the health crisis be over? What is the likely shape of the economic recovery—a sharp “V” or a long “L”? What is the likely timing of an economic recovery? What industry sectors, what organizations, and what individuals will have access to government financial aid? For various health and human service lines, what is a sustainable service model and business model when moving to recovery? What will be the sustainable service model and business models when recovery happens?

To manage during the crisis, we have developed a framework for executive action. And when your team gets to developing a recovery strategy, my advice to leaders is to try to let go of the anchors of the past and think creatively about your organization’s assets and opportunities. My suggestion is to ask yourself and your team a few essential questions:

  1. Why does your organization exist? What is its role in the community and in the field?
  2. If you continue at your current rate of revenue and expenses, is your organizational sustainable? And if not, how long can your organization continue to operate? And how can you reduce expenses while continuing to serve your mission?
  3. What is it that your organization does that “pays the bills?” Look at your service lines individually and in the aggregate—revenue, payers, consumers, and margins. What makes money and what does not?
  4. Based on your assessment of the most likely future, what is your vision for your organization’s role in the community and its mission a few years in the future?
  5. What are the key objectives that your organization needs to achieve over the next year?
  6. What is the best-case future scenario for your organization?
  7. What are the future scenarios that would severely damage your organization’s sustainability?
  8. What service lines have the potential for short-term revenue growth? For long-term revenue growth?
  9. What should your team do in the next month to achieve those future objectives?

These are the tough questions that shape future strategy. And with this assessment (which needs to be repeated with any shift in the market), you can develop a recovery strategy and mobilize your team to move ahead.

But, having the framework for crisis management and plan for crisis recovery is not enough. Leaders need to bring their teams with them on this new and surreal journey. There are essential executive actions that are needed, regardless of the plan, in order to assure success.

There are some specific leadership competencies that are required for success at that time. The ability to use data and the ability to manage in a virtual environment are two of many. But to be creative and develop innovative solutions requires distance. So, once you’ve thought and planned and organized and communicated, step away. No matter where you find mindfulness (whether gardening or video gaming or needlepoint or music or hiking), take a break and let it all percolate. You will likely need to do it all over again soon.

In its latest move to address mental health in the workplace, Starbucks is making mental health training available for all U.S. assistant store managers, store managers, and above, in addition to all non-retail employees. The coffee chain announced that training will be available through July and is intended to provide employees with a resource that can help them listen for, recognize and respond to signs of mental health and addiction issues and provide resources available to their teams.

The training—dubbed Starbucks Mental Health Fundamentals—is inspired by the National Council for Behavioral Health’s Mental Health First Aid and includes four 30-minute modules: effective listening; providing encouragement and reassurance; providing resources and information; and the importance of self-care. The training is the latest offering the employer has added to its roster of mental health benefits, which Starbucks leaders started examining last year. In April, Starbucks added a new therapy benefit through provider Lyra Health to provide all U.S. employees—and their eligible family members—access to 20 sessions a year with a mental health therapist or coach. Sessions can be in-person or via video-chat.

In January, the coffee chain introduced Headspace, a daily meditation and mindfulness app, as a benefit for employees. Employees can sign up for a free subscription and access hundreds of sessions and guided meditations on topics ranging from stress to anxiety to sleeplessness. Last month, Starbucks said more than 68,000 employees in the U.S. and Canada are now using Headspace.

Founded in 1971, Starbucks Coffee Company is an American coffee company that currently operates more than 30,000 stores worldwide. Starbucks was founded and is headquartered in Seattle, Washington.

Contact information

  • Starbucks, Post Office Box 34067, Seattle, Washington 98124-1067; 206-318-7100; Email: info@starbucks.com; Website: https://www.starbucks.com/

As executive teams look to diversify, there is one challenge that comes with every new service—identifying and managing new performance measures. The range of performance measures—and how to set up a system that can adapt to a wide range of measures, was the focus of a new white paper, Maximize Success With Performance And Quality Measures, that Monica E. Oss, Chief Executive Officer, OPEN MINDS wrote with Scott Green, Senior Vice President and General Manager of Human Services at Netsmart.

How different are the performance measures? It depends on your service lines. A recent analysis of performance measures found there were 558 unique mental health performance measures. This includes the “alphabet soup” of measurement systems like the Merit-Based Inventive Payment System (MIPS), Meaningful Use (MU), Certified Community Behavioral Health Clinic (CCBHC), Inpatient Psychiatric Facility Quality Reporting (IPFQR), and the Treatment Episode Data Set (TEDS) initiatives.

At the service line level, what do performance reporting requirements look like? Take just these three examples—health homes, CCBHCs, and long-term services and supports (LTSS). Medicaid health homes are required to report on eight quality measures and three utilization measures to receive payment. Some measures on the table include initiation and engagement of alcohol and other drug abuse or dependence treatment, controlling high blood pressure, screening for depression and follow-up plan, follow-up after hospitalization for mental illness, all-cause readmissions, adult Body Mass Index assessment, and the Prevention Quality Indication (PQI) 92: for chronic conditions. CCBHCs are tracking follow-up after hospitalization for mental illness, adherence to antipsychotics for individuals with schizophrenia, initiation and engagement of alcohol and other drug dependence treatment, and suicide risk assessment for major depressive disorder.

In contrast, LTSS provider organizations need to measure metrics related to assessment, care planning, and care coordination through comprehensive assessments and care plans. Some of the specifics include shared care planning with the primary care professional; reassessment/care plan update after inpatient discharge; and screening, risk assessment, and plan of care to prevent future falls.

The constant comment from provider organization executive teams is that there are too many different performance measures—with different requirements depending on the service, the consumer type, and the health plan. I don’t see that changing any time soon. Rather, management teams need to build a technology infrastructure with flexible reporting capabilities. There are six key elements to a “best practice” infrastructure: a shareable electronic health record (EHR); integrated workflows; customizable measures for each type of contract; identified gaps in care; visual dashboards; and the ability to calculate everything in real-time.

A shareable EHR—On-demand data interoperability is essential to care coordination and managing transitions of care, and for a provider organization to truly be high-functioning, it needs everyone on the care team to have access to the metrics that can build and support a whole-person approach to care. Developing a shared platform across all users equips the team to identify behavioral health concerns exposed by the data, and then to align the treatment plans.

Integrated workflows—Feeding data into the daily workflows across all clinical, financial, and operational decision making is at the heart of increasing efficiency and leveraging the potential to meet metrics requirements, increase quality, and capture the requisite outcome measurement scores. Building this “new” workflow approach should focus on clinical form consolidation, point-of-service access to health records, increased record compliance, and enhanced health record reviews and audits.

Customizable measures for each type of contract—When it comes to measures, not all contracts are created the same, and many executives will have to embrace and remain diligent in the face of “measurement fatigue.” But it’s an inescapable reality that every contract will have its own requirements and quality measures. Investing in collection methods and tools that can flexibly allow executives to target and report different data is a must.

Proactively identify gaps in care—There is no competitive advantage if provider organizations don’t have the ability to put performance measures to good use in improving consumer care. That is the key competitive advantage in a data-rich, performance-based world. Shared data and integrated workflows alone are good but run the risk of being reactive instead of proactive. A targeted investment in predictive analytics allows executives to look ahead and identify the gaps in care that threaten to keep the care team from achieving its goals.

Reporting and visual dashboards—The key to the effective use of any data is automating the data collection and analysis, and then delivering actionable information through customized reporting and dashboards for end users. These are the hands-on tools that can take large chunks of unwieldy and dense data and deliver them in a “digestible” way.

Calculate everything in real-time—Real-time data is far more valuable than lagging indicator data because it supports a proactive approach to outcomes management. It allows managers to change performance rather than just discussing why poor performance happened.

On June 12, 2020, the federal Department of Health and Human Services (HHS) finalized changes to a section of the Patient Protection and Affordable Care Act (PPACA) to eliminate protections from discrimination based on gender identity. The change affects Section 1557 referring to sex discrimination. The HHS Office of Civil Rights said it will enforce Section 1557 by returning to the government’s interpretation of “sex” discrimination based on the presence of male or female genes. HHS said this was the plain meaning of the word “sex.” The rule is effective August 18, 2020.

Section 1557 of the PPACA is a civil rights provision that prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. Congress prohibited covered health programs or activities from discriminating on any of the grounds protected by four federal civil rights statutes:

  • Title VI of the Civil Rights Act of 1964 (Title VI) (prohibiting discrimination on the basis of race, color, or national origin).
  • Title IX of the Education Amendments of 1972 (Title IX) (prohibiting discrimination on the basis of sex).
  • Section 504 of the Rehabilitation Act of 1973 (Section 504) (prohibiting discrimination on the basis of disability).
  • Age Discrimination Act of 1975 (Age Act) (prohibiting discrimination on the basis of age).

It is unknown how the HHS changes in definition regarding “sex” to enforce PPACA Section 1557 will be affected by the June 15, 2020, ruling by the United States Supreme Court in Bostock v. Clayton County, which held that federal employment discrimination law protects gay and transgender employees. The ruling means that an employer who fires an individual solely for being gay or transgender violates Title VII of the Civil Rights Act of 1964. The court said that gender identity—being gay or transgender—is “inextricably bound up with sex.”

A link to the full text of “HHS Office Of Civil Rights Final Rule: Nondiscrimination In Health & Health Education Programs Or Activities, Delegation Of Authority” may be found at www.openminds.com/market-intelligence/resources/061920hhsocraca1557rule.htm.

A link to the full text of “Fact Sheet: HHS Finalizes ACA Section 1557 Rule” may be found at www.openminds.com/market-intelligence/resources/061220hhs1557factsheet.htm.

A link to the full text of “Supreme Court Of The United States Opinion In Bostock v. Clayton County” may at www.openminds.com/market-intelligence/resources/061520scotusrulingbostockvclaytoncty.htm.

For more information, contact:

  • Luben Montoya, Supervisory Civil Rights Analyst, Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, District of Columbia 20201; 800-368-1019; Email: OCRMail@hhs.gov; Website: https://www.hhs.gov/ocr/index.html.

The Madonna hit from the ‘80s, “I am a material girl living in a material world” crept into my subconscious when I was thinking about how we are each called upon to be a digital leader because you know that “we are living in a digital world.” The pandemic sent health and human services headlong into a “digital first” world and most executives learned to adapt quickly, along with their staff, consumers, payers, and other stakeholders. And of course, we all know that lockdowns or not, digital is the way most health care—and in fact most of life—will be in the foreseeable future. Connecting with a clinical professional will be akin to ordering paper towels on Amazon, getting food delivered through GrubHub, or even watching a Broadway show on YouTube. Are we ready to deliver?

The answer is no, according to a survey of 1,200-plus executives, in which more than half (53%) of respondents said they believe the management or senior leadership at their company is unprepared to implement a successful digital strategy. Steven Nilsen, a partner at Boyden—the firm that conducted the survey—notes that for the new generation of leaders who are poised to capture the digital transformation, “…digital is not a task to be done. It is how a task gets done. It is a culture and a mindset.”

A digitally savvy leader is more than one who knows how to use their smartphone, weigh in on social media, and look cool on Zoom meetings —although those are all good skills to cultivate.

The culture and mindset for leadership in a digital world requires different approaches than it did in our previously nondigital (but evolving) world. An MITSloan Management Review research report, cautions that “time is running out for leaders who are holding on to old ways of working and leading.” This report reiterates that only 48% of executives agree that their organizations are prepared to compete in digitally driven markets and economies. While 82% believe that leaders in the new economy will need to be digitally savvy, less than 10% of respondents feel that their organizations have leaders with the right skills to thrive in the digital economy.

The authors of the MITSloan report also present emerging behaviors of digitally savvy leaders— purpose-driven, nurturing passion, making data-driven decisions, demonstrating authenticity, demonstrating empathy, employing an inclusive approach, showing humility, and working across boundaries. These would seem like enduring behaviors for all times. In addition, I would say that digitally savvy leaders in the health care world must assimilate seven truths to prepare for success in a digital world.

Digital is not a substitute for nondigital—it’s a new way of doing business.
Back in early March of 2020, most provider organizations started to provide—or ramped up capacity to provide—virtual services only because brick and mortar facilities began to close. But before long, most organizations realized that while digital can’t replicate the in-person visit, it offers other advantages. Leaders who embrace digital will recognize opportunities for new value propositions to new markets. It’s not just about telehealth. Think artificial intelligence to improve the accuracy and efficiency of routine tasks. Think telework to expand your talent pool and improve staff productivity. Think online scheduling. Think late evening appointments and even 24/7 care if clinical professionals can work shifts from home. And think about new consumers who are looking online for online services.

Digital first is not tech first, it’s people first.
Yes, today’s leaders must be tech savvy, web savvy, and social media savvy. But remember technology is only an enabler to help meet consumers wherever they are. Think about what consumers want, what they can and cannot do, and how they are willing to access and pay for care. Whether you provide services through a virtual or in-person model—or some combination of the two—the people who use your services want the same experience that they have on Amazon, Facebook, or TripAdvisor. Ease of access, instant gratification, intuitive to use, ability to connect with others who use the same services, and ability to provide feedback and have a dialogue. Digitally savvy leaders are those who can walk a mile in their customers’ shoes every day and recognize that shoe styles and sizes are changing as lifestyles and preferences evolve rapidly in a digital world.

Digital can empower deeper relationships.
Digital can empower strong face-to-face connections with consumers and stakeholders, while enabling two-way communication and the ability to obtain continuous feedback for continuous improvement. Technology also makes it easier to stay in touch with stakeholders and to engage with them often. Digitally savvy leaders use technology to listen to their audience and not just to talk at them. Digital also expands the possibilities when it comes to marketing and advertising, allowing for personalization and customization in a way that traditional channels would not allow. Just think about how Netflix, Hulu, and HBO can hold you captive with “Watch Next” or “Because you watched Tiger King, we think you’ll like…” popups, text alerts, emails, and customized home pages.

Digital demands a data-driven culture.
Google and the iPhone and social media have turned every human into a walking data cache. The “If you don’t measure it, you can’t improve it” adage in health care has been underscored by all the tools and capabilities that technology bestows on us. Digital savvy leaders are focused on data but not just for data’s sake. They seek the insights that data can provide and create a culture that “starts with why” (the phrase made legendary by Simon Sinek) and that asks the right questions before determining what data will be collected and analyzed. And digital leaders in a digital world must be prepared to deal with the skeptics who are likely to decry the data if it means they must change the way they do things.

Digital requires connecting the dots.
Leaders who “get” digital will nurture a culture where all managers will see how their work is connected to the work of others in the organization. Digital can serve as the great connector and eliminate silos by enabling transparency, faster and broader communication, and platforms for sharing information and results. Clinical professionals can’t remain oblivious to the challenges in accounting and vice versa; IT can’t live in an ivory tower; and HR is not the only problem solver. Technology can bring people together in meaningful ways and enable goals to be aligned and the big picture to remain in the spotlight.

Digital expands the competition, but also the possibilities.
Smart leaders recognize that digital ushers in more competition. A growing number of apps, e-counseling platforms, and virtual employee assistance programs are competing with traditional behavioral health organizations for consumer attention and even payer contracts. Primary care practices might consider embedding their own behavioral health services through telehealth. Assessing the competitive landscape and planning and refining the strategy to gain an edge over competitors is more critical than ever before in the digital domain. But savvy leaders also recognize that digital opens new opportunities for collaboration and partnerships. Behavioral health provider organizations may be able to embed medical care through telehealth or accept warm handoffs virtually. Digital also provides new channels for community education and engagement.

Digital divides and leaves gaps.
Discerning leaders who serve vulnerable populations recognize that the “digital divide” or the gap between the haves and the have nots in terms of tech devices and Internet bandwidth is real and growing. Even as they think about expanding services through digital channels, health care leaders must think about how to address the needs of those who cannot access such care. Digital access is increasingly being listed as a social determinant of health and is an issue that payers and policymakers know they must address.

At the end of the day, digitally savvy leaders are those who leverage the opportunities yielded by the digital world while keeping the human element front and center. “‘Cause everybody’s living in a digital world” as Madonna might say in a reprise of “Material World.”

Aegis Treatment Centers, a California-based outpatient treatment provider organization owned by Pinnacle Treatment Centers, has opened an opioid treatment program in Ceres, California. The facility is the 36th Aegis location in the state.

Aegis Ceres is providing medication assisted treatment services, including methadone and buprenorphine, as well as individual and group counseling for the treatment of opioid addiction. The facility will also incorporate cognitive behavioral therapy, motivational interviewing, relapse prevention, life skills training, contingency management, mindfulness, and stress and relaxation techniques. According to Joe Pritchard, chief executive officer of Pinnacle, the new location supports the organizations’ overarching commitment to drive affordable services into underserved communities.

Aegis Treatment Centers is a large outpatient addiction treatment center in California. The organization serves over 9,200 people through the support of over 600 staff members.

Contact information:

  • Aegis Treatment Centers, LLC., 7246 Remmet Avenue, Canoga Park, California 91303; 818-206-0360; Email: info@aegistreatmentcenters.com; Website: https://aegistreatmentcenters.com

Toledo, Ohio-based ProMedica has made a bid to assume the day-to-day operations of University of Toledo Medical Center (UTMC). Under the proposal, the University of Toledo would maintain ownership of UTMC. ProMedica would provide management and other services.

University of Toledo stated it was considering a sale of its hospital after the medical center reported more than $12 million in operating losses through the first half of fiscal year 2020, a loss of $7 million in fiscal 2019 and a $3.6 million loss in fiscal 2018. ProMedica said in its proposal it believes it can provide a unique local solution that will enable UTMC to become financially stable. ProMedica said if it wins the bid, it would work to stabilize UTMC’s finances, replace its outdated EMR and continue to offer academic and research opportunities at UTMC. A third-party advisor will review the submissions and make recommendations to the university’s board. Shortly after ProMedica announced its bid, community members voiced concerns about the potential partnership.

ProMedica is a health system serving communities in 28 states. ​The health system includes 13 hospitals, four ambulatory surgery centers, and more than 400 post-acute facilities. ProMedica has nearly 56,000 employees and more than 2,100 physicians with privileges system wide. In collaboration with educational institutions locally and regionally, ProMedica offers research, grants, and residency programs, as well as fellowship, clerkship, nursing, pharmacy, allied health, and continuing education opportunities.

Contact information:

  • ProMedica,100 Madison Avenue, Toledo, Ohio 43604; 800-774-3627; Website: www.promedica.org

The Center for Medicare and Medicaid Innovation (CMMI) will accept Letters of Intent from hospices and other provider organizations that seek to participate in the professional or global Primary Care First Direct Contracting models until July 6. The direct contracting options include three voluntary payment models that are designed to help the U.S. Centers for Medicare & Medicaid Services (CMS) and health care provider organizations reduce the cost of care and improve quality within Medicare fee-for-service programs.

The three models include the professional, global, and geographic options. The models adapt and integrate concepts from other programs such as Accountable Care Organizations, the Medicare Shared Savings Program, and Medicare Advantage, as well as strategies used in the private sector. The direct contracting program is associated with the agency’s Primary Care First Initiative, which also consists of a general payment option and a Serious Illness Population (SIP) option. All of these programs were slated to launch January 1, 2021, but CMS has pushed back the SIP and direct contracting implementation dates to April 1 of that year.

Under direct contracting professional model, provider organizations would accept the risk for 50% of shared savings or losses for all Medicare Part A or Part B services for individuals that fit the Primary Care First eligibility requirements. Organizations working in this model would receive a risk-adjusted monthly payment for primary care services equivalent to 7% of the total cost of care. Within the global model, provider organizations would also bear 100% of the risk associated with eligible individuals.

The Centers for Medicare & Medicaid Services is the agency within the U.S. Department of Health and Human Services that administers the nation’s major health care programs. The CMS oversees programs including Medicare, Medicaid, the Children’s Health Insurance Program, and the state and federal health insurance marketplaces.

Contact information:

  • Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 877-267-2323; Website: www.cms.gov

AAC Holdings Inc., the publicly traded parent of American Addiction Centers (AAC), filed for Chapter 11 bankruptcy protection. The Brentwood, Tennessee-based company listed debt of $517.4 million and assets of $449.3 million in its filing in U.S. Bankruptcy Court in Delaware.

The company stated it expects to emerge from bankruptcy in 125 days after executing on a recapitalization plan that will slash its debt. AAC lined up $62.5 million of initial financing that will allow it to maintain operations during the restructuring, according to a separate statement. The company, which operates rehab centers in seven states, has struggled with its debt load, including borrowings it took on from its acquisition of AdCare in 2018. The company defaulted on its debt obligations in 2019 and entered into a forbearance agreement with lenders. AAC operates rehab facilities in California, Florida, Texas, Nevada, Mississippi, New Jersey, and Rhode Island. The case is AAC Holdings Inc., 20-11648, U.S. Bankruptcy Court for the District of Delaware.

American Addiction Centers’ mission is to provide quality, compassionate, and innovative care to adults struggling with addiction and co-occurring mental health disorders. Through comprehensive and customized treatment plans, we instill hope that long-term recovery is possible. Their purpose and passion is to empower you, your family, and your community by helping you achieve recovery and optimal wellness of the mind, body, and spirit.

Contact information:

  • American Addiction Centers, 200 Powell PIace, Brentwood, Tennessee 37027; 888-987-1784; Website: https://americanaddictioncenters.org/

While the adage “The best defense is a good offense” is typically associated with military combat and sports (and is often attributed to Michael Jordan), it was first said by George Washington in 1799, “…offensive operations, often times, is the surest, if not the only means of defense.” In the midst of the current crisis, it may appear that defense is the best choice—hunkering down and waiting it out seems safe. But defense is not the only option. Crises often present opportunities but executive teams need to plan their offense. They need a plan for how to “grow” in the midst of turbulence.

A structured approach to growth in a time of crisis was the focus of The 2020 OPEN MINDS Strategy & Innovation Institute session, Proven Methodology For Identifying Strategic Opportunities: Cultivating, Negotiating & Decision Making. The presenter, Matthew M. Dorman, Chief Executive Officer of Credible Behavioral Health, Inc. discussed his structured approach to evaluating growth choices by considering both the current and future customer base and service offerings. His three-step process—understand the market position of your current service line portfolio, set your growth targets and strategy, and use growth tools to make that strategy a reality.

Understanding market position

Traditionally, serving long-time customers with long-time products has been the “safe” thing to do for health and human service organizations. But maintaining status quo could sound the death knell in this highly disrupted market. At best, “you may be left behind” given the aggressive and growing competition in the market, Mr. Dorman warns.

It’s time to evaluate your TAM (the total demand for your product), SAM (the market based on your current business model in the context of geographic location, employee base, and internal infrastructure), and SOM (what you can do based on the practical limits of your current strategy and model).

And it’s time to take a hard look at your numbers—reimbursement rates, current market share and demand for your services, your organization’s capacity and cost to market and provide the services, and the return-on-investment.

Turning those numbers into key metrics that are tangible, understandable, and relevant is critical. As Mr. Dorman emphasized, “Make sure you are graphing numbers that are relevant to your end goal—otherwise you will get lost in the data and you’ll burn a lot of time.”

Setting growth targets and strategy

With knowledge of the market and the position of the organization’s portfolio, executive teams can set growth targets and strategy.

A low risk option is to leverage current relationships to sell new products to old customers. That’s not without challenges, especially if the new products don’t fit into the long-standing brand your old audiences are familiar with. Selling new products to new customers is the most exciting strategy—but comes with the highest risk and lowest return. The optimal growth strategy is to leverage what you already do well with current products and expand it to new consumers.

Interestingly, we’re seeing these growth strategies in play right now. The pandemic crisis has pushed us over the tipping point in terms of telehealth and we know it’s here to stay. And that has two implications—telehealth could pave the way toward better outcomes from increased consumer and family engagement and convenience. On the flip side, it could help us define our niche for service delivery that demands an in-person or blended model for efficacy. The pandemic also underscores the urgent need for integrated care so we can deliver holistic care for vulnerable populations with co-occurring, complex, and chronic conditions.

And what about new markets? Will we see increased demand for services and increased spending? Are there opportunities for more home-based services? What does the rising rate of nursing home closures mean for home and community-based services? Growth strategies that involve entering these new markets will require a keen eye on the landscape and moving in quickly where competitors fail or where gaps in care start to surface.

Making strategy a reality  

But strategy alone isn’t enough. Making the growth strategy a reality is what matters—and leveraging tools to make that happen is key.

Being transparent about your growth strategy is critical to obtaining organizational and board buy-in and ensuring long-term success. To sell the broader team on any new strategic initiatives and prepare for smooth execution, executives must clearly explain the choice of the growth strategy, communicate the roles and expectations of each team member in the process, and be clear about deadlines and timelines.

Making strategy happen also requires negotiating—whether it’s negotiating the cost of services, the ability to add employees, expand internal capacity, or expand geographically through new locations and facilities. Executive teams must know what they are bringing to the table and figure out their breakeven point in terms of costs. Mr. Dorman explained, “When you know your goals and your numbers, you also know your threshold for failure,” ultimately giving you more leverage in the negotiation process.

It’s important to realize there is more than one path to growth—and sometimes that path means being prepared to walk away for a new opportunity. Mr. Dorman discussed, “We can get so focused on a particular outcome that we don’t realize when we try to go from A to B to C, there’s another path that gets us to that same outcome. The best alternative is always a solution that gets you to your end goal with as little sacrifice as possible—you have more power than you realize.”

A sustainable strategy doesn’t have to be all-or-nothing, there are many paths to growth—the key is to make sure it’s the right path for you.

On June 3, 2020, the Centers for Medicare & Medicaid Services (CMS) announced risk adjustments to the Medicare accountable care organization (ACO) Track 1+ and the Next Generation ACO models to account for the coronavirus disease 2019 (COVID-19) pandemic public health emergency (PHE). The goal is to account for changes in health care delivery and related additional costs due to the pandemic and ensure that provider organizations are not at risk for costs due to the pandemic. The adjustments make changes to the financial methodology, quality reporting requirements, and the model timelines.

CMS Innovation Center Changes To ACO Track 1+ & Next Generation ACOs To Account For COVID-19 Public Health Emergency
Innovation Center Model Financial Methodology Changes Quality Reporting Changes Model Timeline Changes
Medicare ACO Track 1+ Model Remove episodes of care for treatment of COVID-19

Medicare Shared Savings Program Extreme and Uncontrollable Circumstances policy applies to 2020 financial reconciliation

2019 Web Interface quality measure reporting deadline extended from March 31, 2020 to April 30, 2020

Medicare Shared Savings Program Extreme and Uncontrollable Circumstances policy applies to 2019 and 2020 reporting

 

Continue to monitor impact on 2020 quality reporting

 

Voluntary election to extend agreement for one year through December 2021

 

Next Generation ACO Model (NGACO) Reduce 2020 downside risk by reducing shared losses by proportion of months during the PHE.

Cap NGACOs’ gross savings upside potential at 5% gross savings

Remove episodes of care for treatment of COVID-19

Use retrospective regional trend, rather than prospective, for 2020

Remove 2020 financial guarantee requirement

2019 Web Interface quality measure reporting deadline extended from March 31, 2020 to April 30, 2020

2019 quality audit canceled

Continue to monitor impact on 2020 qua

 

The adjustments to the ACO models were done as CMS was making changes to all of its value-based care (VBC) models to account for the impact of the COVID-19 pandemic. CMS used the following principles to determine which changes were appropriate:

  • Use flexibilities that already exist in current model design.
  • Continue sufficient financial incentives that encourage higher-quality outcomes.
  • Ensure equity and consistency across models.
  • Align as much as possible with national value-based and quality payment programs.
  • Minimize risk to model participants, the Medicaid program, and the Medicare Trust Funds.
  • Limit delays in new model implementation, while providing additional opportunities for participation in new models.
  • Minimize reporting burden.
  • Complement and build off the new CMS COVID-19 Public Health Emergency flexibilities as outlined in regulation and waivers.

A link to the full text of “CMS Innovation Center Models COVID-19 Related Adjustments” may be found at www.openminds.com/market-intelligence/resources/060220cmmicovidadjustments.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

St. Luke’s University Health Network (SLUHN) will acquire Easton Hospital on July 1, 2020, including affiliated physician practices and two physician residency programs with 36 physician residents. This acquisition will preserve the 125-year-old hospital for future generations, ensuring future jobs and bringing St. Luke’s world class health care to the citizens of the greater Easton-area community. St. Luke’s and Steward Health Care of Dallas, the current owner of Easton Hospital since May 2017, recently signed an asset purchase agreement that will allow for the transfer of ownership to SLUHN effective on July 1.

The acquisition, which was approved by the St. Luke’s Board of Trustees, is subject to certain conditions, including review and approval by various regulatory agencies. Financial terms of the acquisition were not disclosed

Steward Health Care is a large private, tax-paying physician-led health care network in the United States. Headquartered in Dallas, Texas, Steward operates 35 hospitals in the United States and the country of Malta that regularly receive top awards for quality and safety. The Steward network includes multiple urgent care centers and skilled nursing facilities, substantial behavioral health services, over 7,200 beds under management, with more than six million annual consumer encounters.

Founded in 1872, St. Luke’s University Health Network is a fully integrated, regional, non-profit network of more than 15,000 employees providing services at 11 hospitals and 300 outpatient sites. With annual net revenue greater than $2 billion, the Network’s service area includes 11 counties: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill, and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey.

For more information, please contact:

  • Sam Kennedy, Corporate Communications Director, St. Luke’s University Health Network, 1736 Hamilton Street, Allentown, Pennsylvania 18104; 484-526-4134; Email: samuel.kennedy@sluhn.org; Website: www.slhn.org
  • Darren Grubb, Vice President Communications, Steward Health Care System Corporate Headquarters, 1900 North Pearl Street, Suite 2400, Dallas, Texas 75201; 469-341-8901; Email: darren.grubb@steward.org; Website: www.steward.org

Health care costs for people with treatment-resistant depression (TRD) are much higher than costs for people whose depression responds to antidepressants within 12 months of starting medication. Higher costs for the TRD population were observed for commercial insurers, Medicare, and Medicaid. For those who responded to treatment, their all-cause monthly per-person costs dropped by 21% to 32% from baseline to month 12, and their per-person monthly mental health related costs dropped by 33% to 61%. However, for those with TRD, the change in their all-cause monthly per-person costs ranged from an increase of 1% to a decrease of 13% from baseline to month 12; the change in their mental health-related costs was 0% to -37%. Those with TRD had higher utilization and costs at baseline, and higher costs persisted for each month during the 12 months after starting depression treatment.

Comparison Of Per-Person Annual Baseline Total Health Care Costs By Payer Based On Antidepressant Response
Type Of Cost Treatment Responsive Treatment Resistant
Commercially Insured
All Cause $6,491.85 $9,111.29
Mental Health-Related $1,100.86 $1,507.58
Medicaid
All Cause $5,631.69 $6,736.44
Mental Health-Related $2,009.95 $2,279.44
Medicare
All Cause $16,726.87 $17,362.93
Mental Health-Related $1,382.08 $2,622.60

Among those with TRD the odds of hospitalization were 32% to 76% higher; the odds of an emergency department visit were 38% to 45% higher and the odds of outpatient visits were 29% to 54% higher compared to those who responded to antidepressants. Costs for people with TRD were from $4,093 to $8,054 higher than people who responded to antidepressants.

Incremental Annual Per-Person Cost Of Treatment-Resistant Depression By Payer
Payer All Cause Mental Health-Related
Commercial $6,742.29 $3,428.10
Medicaid $4,093.37 $2,122.87
Medicare $8,054.41 $3,316.14

 

These findings were reported in “Incremental Health Care Burden of Treatment-Resistant Depression Among Commercial, Medicaid, and Medicare Payers” by Anshu Shrestha, M.P.H., Ph.D.; Meaghan Roach, M.P.H.; Kruti Joshi, M.P.H.; John J. Sheehan, Ph.D., M.B.A.; Prodyumna Goutam, Ph.D.; Katie Everson, M.S.; Kristin Heerlein, M.D.; and Anupam B. Jena, M.D., Ph.D. The researchers conducted a multi-payer retrospective cohort study of claims for adults diagnosed with major depressive disorder who had received one or more antidepressant treatments. They analyzed the Truven Health Analytics commercial, Medicaid, and Medicare supplemental claims databases for 2006/2007 through 2017. The analysis included 111,544 commercial claims, 24,036 Medicaid claims, and 8,889 Medicare supplemental claims. For each payer, the researchers compared annual use (hospitalization, outpatient, and emergency department) and costs for people with TRD and people without TRD. The researchers concluded that TRD may exist and affect health care utilization before a person with depression is identified as being non-responsive to antidepressants.

The full text of “Incremental Health Care Burden of Treatment-Resistant Depression Among Commercial, Medicaid, and Medicare Payers” was published April 2, 2020, by Psychiatric Services. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900398.

For more information, contact:

  • Anshu Shrestha, MPH Ph.D., Senior Epidemiologist, Public Health Institute, 555 12thStreet, 10th Floor, Oakland, California 94607; 510-285-5500; Fax: 510-285-5501 Email: communications@phi.org; Website: https://www.phi.org/.

For provider organization executives looking at recovery planning, “top of the list” is different relationships with payers. In most discussions, higher rates, less administrative costs, standardized performance measurement, and sharing in savings are the key talking points. The question—how do you get to that new kind of relationship? The health plan executives in the session, Health Plan-Provider Partnerships: Improving Care Through Collaboration, at The 2020 OPEN MINDS Strategy & Innovation Institute, had an answer—reach out to health plan managers and let them know both what you can do and what you want.

Alexsis Desrochers, Vice President, Value-Based Programs at Magellan Complete Care; and Neha Patel, Director of Care Delivery Transformation, Southeast Region, Anthem, Inc., provided some very useful perspectives on what health plans are looking for, and how they evaluate provider organization partnerships. Magellan Complete Care is focused on whole person care (physical, behavioral, and social needs), and is present in six markets—Arizona, Florida, Massachusetts, New York, Virginia, and Wisconsin. They have a range of value-based reimbursement (VBR) arrangements with their network provider organizations on the physical health side, and their behavioral health-centered VBR programs are still in negotiation.

Ms. Desrochers explained, “We have a lot of programs along the continuum, from basic administrative tasks, to shared risk. A lot depends on the sophistication of the provider organization, their staff, and their capabilities. Usually our VBR sits on top of our normal fee-for-service (FFS) contracts, although we can go further to do some wrap around type contracts.”

Anthem’s approach to VBR is exemplified through its Enhanced Personal Health Care (EPHC) program. Launched in 2013, it’s a consumer-centered, value-based care program focused on collaborating with provider organizations by providing the necessary tools, resources, and consulting to achieve VBR success. They have a continuum of VBR programs dependent on the capabilities and willingness of provider organizations. It is also Anthem’s largest value-based initiative. Ms. Patel noted, “This is not an easy conversation to have because the stigma of the payer as the enemy is hard to combat. One of the ways we have tried to do this is to bring in the tools and resources, and to support them from a PMPM rate perspective as a part of our program. We also provide people power to really bring this all to life.”

As provider organization management teams think about telling health plans about “what they do,” it is important to think about your presentation (in a document and in person) from the perspective of the health plan managers. Ms. Desrochers and Ms. Patel recommended that the discussion include three key issues—readiness and experience with VBR, current performance and outcome measures, and the ability to participate in integrated care initiatives.

VBR competency is an issue—While many provider organization executive teams may say they are ready to assume some type of financial risk, health plan managers are hesitant to accept those assurances at face value. Sharing data is the key to convincing the payer. Ms. Patel explained, “It’s hard getting provider organizations to sit at the table with us, to look at their own data, and to see what their practice looks like from a data perspective. They say they are doing things, but is it showing up in the data?”

Health plans look for provider organizations with an integrated technology platform with all-inclusive clinical data, performance management analytics, and care coordination functionality. They look for experience with data-informed decision making in real-time, as well as a thorough understanding of service delivery cost variables and the risk-based contracting process. Mastery over administrative functions can help land contracts reimbursing an administrative fee for services or offering quality incentives that reimburse for individual metrics and targets.

Ms. Desrochers noted, “No matter where you come out in an assessment, there is an opportunity, but you need to understand where you are along the continuum. Are you just activity based, or are you ready to move into the outcomes-based programs? You need to come into the negotiation understanding what you are ready for, and what you are not.”

Current measures of success—Every executive believes their organization has good outcomes and solid performance. But that needs to be demonstrated in metrics. What are your current performance stats? How do they compare to competition? To answer those questions, provider organizations need to be strategic about what data to collect and analyze, ­and the story that data is telling payers. The key is not to silo what is reported to payers from what is used to make internal decisions about clinical efficacy, productivity, and growth.

Creativity and dialogue about what to measure are also encouraged. Payers are willing to admit they don’t have all the answers and to factor in perspectives from the frontlines.

Ms. Desrochers suggested going through all of the Healthcare Effectiveness Data and Information Set (HEDIS) measures, but not being limited to those. She said, “In general, there is no set game plan or cemented playbook for what measures VBR must include. Come to the table with your own suggestions. For example, daily living activities that can measure consumer functionality, or any social determinants of health.”

Be sure to provide feedback to payers on what’s working and what’s not. Ms. Patel explained, “Whatever your current relationship is, be willing to share your thoughts, experiences, and barriers. We gather that feedback. We don’t have answers to everything, but we must make decisions on the short, medium, and long-term impacts. Hearing provider organization feedback helps us understand the impacts and engage.”

And provider organizations should seek benchmarks, set goals, and not hesitate to ask payers how they compare against their peers and competitors.

Ability to participate in integrated care initiatives—The key to improving consumer care and reducing use of unnecessary resources is coordination, which drives health plan interest in integrated care models. Provider organizations must be prepared to outline how their organization would “fit” into those initiatives. They must demonstrate how they can support interoperability; drive referrals; and expand the scope of services delivered, geography covered, or consumers served.

Health plans also look for experience in whole person care and population health management. This is where the specialty provider organization takes on a role more akin to primary care to “quarterback” consumer care, and take total responsibility for physical health, medication, and other costs, while ensuring better outcomes. In addition, provider organizations must be ready to openly discuss how they can manage social determinants of health, pharmacy, or social services. Executives need to be prepared to show that their organization can cover every element of consumer care. Ms. Patel explained, “We are firm believers in looking at populations and looking at the trends in the data to improve care. But we need to decide who should be the quarterback, such as community mental health care or primary care. The ability to transition back and forth is the evolution and success is about who is on my care team.”

If the future of health and human services is value-based, then the future requires a different relationship between health plans and the provider organizations—one based on the ability to come to the negotiating table with confidence. The most confident organizations will be able to step up and push for integrated care with value-based strategies.

Follow-up mental health visits, within 14 days after emergency department contact, are lower among those with substance addiction than those with other mental health diagnoses. Approximately 40.2% of 57,797 individuals who visited the emergency room for a mental health issue had a follow-up mental health visit within 14 days: just 25.2% were those with initial substance use visits.

Of those with follow-up visits that were not related to substance use, about 56.1% initially presented with bipolar disorder, 51.1% initially presented with major depressive disorder, and 46.4% initially presented with schizophrenia. Psychiatrist follow-up visits accounted for about 33.1% of those who initially presented with bipolar disorder, 26.0% for those with schizophrenia, and 21.4% for those with major depressive disorder. Primary-care follow-up visits accounted for about 29.7% of those with major depressive disorder, had primary care follow-up only (N=5,243), 23.0% for those with bipolar disorder, and 20.4% for those with schizophrenia.

The researchers concluded that successfully transitioning individuals to outpatient care following an emergency department visit for mental health reasons will require system-wide and coordinated solutions. Physicians alone are unlikely to be able to adequately care for those with complex mental health conditions without coordinated and well-resourced interprofessional teams with case management support. This is especially true in the case of those presenting with substance addiction, where time is limited to seek care before potentially rapid deterioration occurs.

These findings were presented in “Urgent Outpatient Care Following Mental Health ED Visits,” by Lucy C. Barker, M.D.; Nadiya Sunderji, M.D., M.P.H.; Paul Kurdyak, M.D.; et.al. The researchers analyzed Ontario health administrative data at ICES (was the Institute for Clinical Evaluative Sciences), an independent nonprofit health research institute. The population-level data was from Ontario, Canada’s most populated province (approximately 14 million individuals), between 2010 and 2012. The cohort was comprised of 143,662 Ontario residents ages 19 and over with an psychiatric emergency department visit, (including 31,592 presenting with substance use disorders and 112,070 whose primary presentation was not a substance use disorder). The goal was to determine the likelihood of receiving outpatient mental health care after psychiatric emergency department visits in a population-level sample.

The full text of “Urgent Outpatient Care Following Mental Health ED Visits” was published February 24, 2020, by Psychiatry Online. An abstract is available online at https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900466.

PsychU last reported on this topic in “Following A Positive Suicide Screen In ER Visit, 42% Of Older Adults Receive A Follow-Up Mental Health Evaluation,” which published on October 16, 2017. The article can be found at https://www.psychu.org/following-positive-suicide-screen-er-visit-42-older-adults-receive-follow-mental-health-evaluation/.

For more information, contact:

  • Lucy Barker, M.D., Psychiatry Resident, Department of Psychiatry, University of Toronto, 250 College Street, 8thFloor, Toronto, Ontario M5T 1R8; 416-979-6948; Email: lucy.barker@utoronto.ca; Website: https://www.researchgate.net/profile/Lucy_Barker5

“Hybrid” is a word that is no longer associated with just cars, and plants. The pandemic crisis has changed all of that. We couldn’t dine in our favorite restaurants, but takeout meals ordered online saved the day. Farmer markets have created portals for online orders that are picked up at the market. Grocery stores and drugstores are offering home delivery and curbside pickup that can be initiated with a telephone call or email. But as we move into the post-crisis period, hybrid will take on a new meaning in the delivery of health and human services. The models that will likely win the race for competitive advantage are not the traditional face-to-face models or the all-telehealth-all-the time models. The winning service model is one that blends the best of both for maximum convenience and value for both consumers and payers.

We got a close look at what these new hybrid models look like in the addiction treatment field last week in the exclusive OPEN MINDS Circle web briefing, Blended Virtual & Onsite Services For Continuity Of Care, led by OPEN MINDS, Senior Associate, Deb Adler. Executives from two addiction treatment provider organizations—Lakeview Health and Hazelden Betty Ford Foundation, and from two health insurance organizations—Cigna and Optum, discussed the promising practices for blended addiction treatment models that combine the onsite and the online for intensive outpatient (IOP) and partial hospitalization programs (PHP). Both provider organizations are providing addiction treatment services using proprietary hybrid service models. Their executives stressed two important factors in program design—balancing consumer convenience and safety with the solid value proposition.

The Emerging Models  

Lakeview Health runs multi-site adult addiction treatment programs in Florida and Texas and treats consumers with alcohol and substance use disorders simultaneously with any co-occurring mental health or physical health issues. The organization has a value-based contract with Aetna and is the preferred provider organization for NFL Trust, Mayo Clinic, and Cleveland Clinic. Lakeview switched to virtual services for consumers in IOP and PHP programs where feasible and permitted by state regulations. Family workshops and visitations went entirely virtual.

However, the organization kept its facilities open for those who needed in-person care, especially for consumers with co-occurring disorders and complex medical conditions. To do this, Lakeview sanitized all facilities and practiced social distancing according to guidelines from the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). Consumers who came in and exhibited symptoms were sent home to quarantine but received daily check-ins through telehealth. As an integrated care facility with physicians and nurses onsite, Lakeview was able to offer nursing assessments seven days a week for all consumers—those with a temperature were isolated, tested, and sent to the emergency room. Screening and two levels of testing (point of contact testing for antibodies and nasopharyngeal swabs) were instituted—at first for staff and symptomatic consumers but eventually for all. As Lakeview has a 3-building campus, one of the buildings was designated as a quarantine facility through which all new residential consumers were admitted before being transitioned to other facilities. This facility also allowed for isolation of residential consumers who tested positive for COVID-19. With the blended care model, they saw readmission rates for IOP and PHP consumers drop to an all-time low of 2.3% while PHQ-9 and GAD-7 scores between admission and discharge dropped significantly.

The Hazelden Betty Ford Foundation provides comprehensive inpatient and outpatient treatment for adults and youth affected by alcohol and drug addiction, as well as co-occurring mental health conditions. The organization has 17 locations nationwide and collaborates with an expansive network throughout health care. Hazelden’s Butler Center for Research advances knowledge about addiction treatment and recovery and helps to integrate addiction treatment research into practice. Hazelden Betty Ford started to offer telehealth about a year before the COVID-19 crisis started and learned many lessons on the go about how to improve virtual service delivery. This was valuable as they ramped up telehealth during the crisis. But they also modified programs to work better virtually—for example, family groups that were done over three days in-person transitioned to one-day virtual events.

Starting May 1, 2020, Hazelden is following more than 1,000 IOP consumers and monitoring how they are doing one, three, six, nine, and 12 months after discharge. They’ve had continuous interaction with payers to determine what performance measures they want to see. “Why do some patients do better?” asked Quyen Ngo, Ph.D., executive director of the Butler Center for Research at Hazelden Betty Ford Foundation. The Butler Center is tracking data for four groups of consumers—those in in-person IOP for the three months prior to the virtual transition, those who stepped in to virtual IOP following the virtual transition, those who started in in-person and transitioned to virtual, and those who started in virtual treatment and transitioned to in-person treatment.

The Payer Perspective

Ms. Adler pointed out that pre-COVID-19 key performance indicators have not changed—length of stay in IOP and PHP; readmission rates within 30, 90, and 180 days; 90-day episode costs; medical costs (emergency room, labs, or pharmacy); outpatient follow-up within seven days; consumer-reported outcomes; migration to lower levels of care; Consumer Assessment of Healthcare Providers and Systems surveys; and net promoter score.

Deb Nussbaum, senior director of behavioral product at Optum, and Erin Boyd, solutions and program director at Cigna, both emphasized that payers want to know what provider organizations are measuring and want to have a dialogue to ensure better outcomes with virtual and hybrid care. They want to monitor treatment outcomes over time to understand who needs to be seen in person and who needs to be seen virtually. Cigna is working with Hazelden Betty Ford to help shape what is measured in their longer-term research but in the meantime, the payer will compare the standard performance indicators for in-person vs. telehealth visits to gauge variations in efficacy.

Payers are pleased to see a significant uptick in the use of virtual services. Pre-COVID, Optum mainly offered reimbursement for virtual therapy sessions and medication management visits while Cigna also offered virtual IOP reimbursement. But few provider organizations used any of these options before the crisis. However, payers added reimbursement of virtual services for more complex IOP, PHP, and medication assisted treatment (MAT) during the pandemic crisis to respond to consumer needs and maintain continuity of care.

While the number of consumers seeking PHP and IOP services dropped by nearly 30% during the crisis, those who did get services largely opted for telehealth. Cigna contracted with digital provider organizations (such as Talkspace, Meru Health, and nocd) to expand virtual services. Optum also noted a 125% increase in registrations for its free wellness app, Sanvello, during the crisis.

Business Model Considerations

In the future, Cigna intends to contract with virtual-only IOP provider organization platforms that embed peer support. “There’s no turning back,” said Ms. Boyd, but treatment efficacy must continue to be monitored closely to determine the long-term viability of blended care, beyond the crisis. Ms. Boyd also suggests embedding virtual services into discharge plans for consumers who receive IOP and PHP services, to demonstrate continuity of care to payers.

“A hybrid model is a win-win for all,” said Ms. Adler. Consumers like the advantages of virtual and can stay engaged. Provider organizations can meet consumer preferences with a smaller footprint and have fewer no-shows to contend with. And payers appreciate the increased utilization and increased efficiency, with regulatory compliance.

So what does this mean for traditional provider organizations with addiction treatment programs? From the comments of our panel, it appears that the payers think they will get the addiction treatment outcomes they are looking for in treatment services that are largely virtual. A return to pre-crisis levels of residential or even facility-based outpatient addiction treatment is unlikely. For crisis recovery planning, executive teams of addiction treatment provider organizations need to plan on the majority of services remaining virtual. This means creating treatment program packages that are funded with a business model that is sustainable—at a price point that is set largely by virtual behavioral health organizations. And it means looking at how to get payers to contract with traditional provider organizations for expanded virtual care, in preference to digital-only provider organizations. In short, how can provider organizations become the virtual platform of choice for health plans?

Any level of onsite and residential services can likely be sustained only if integrated care for co-occurring medical and behavioral health disorders is a key element of the model. So think about which integrated model is feasible for rapid implementation.

And, referral generation and marketing planning must change as well. The traditional models for addiction treatment referral generation will need to be enhanced with a stronger virtual marketing plan.

It appears that the hybrid model is the future of addiction treatment. Finding the business model for that future is the challenge.

Uplift Family Services announced the receipt of a two-year $4,000,000 grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency with a mission to reduce the impact of addiction and mental illness in the United States. As part of the grant, Uplift Family Services, in partnership with School Health Clinics of Santa Clara County and Pacific Clinics, will form a consortium to become a Certified Community Behavioral Health Clinic (CCBHC).

The CCBHC will serve 2,000 low-income individuals in Santa Clara County by offering access to and improving the quality of mental and addiction treatment in the community by integrating physical health services. The consortium is among 200 behavioral health organizations and health centers in the nation, and one of five in California, to become a CCBHC.

Uplift Family Services is one of the largest, most comprehensive mental and behavioral health treatment programs in California. Uplift Family Services takes a state-of-the-art approach to children and adolescents with complex behavioral health challenges and helps them recover from trauma such as abuse, severe neglect, addiction, and poverty.

School Health Clinics of Santa Clara County improves the health and well-being of more than 5,400 low income, medically underserved adults and children each year by providing comprehensive, easily accessible primary health care. The organizations’ six clinics are Patient Centered Medical Home certified and located on public school campuses in San José and Gilroy in the low income neighborhoods where families live and work.

Founded in 1926, Pacific Clinics is a community-based behavioral health agency that provides outpatient services to individuals of all ages at over 50 locations and 325 schools across Los Angeles, Orange, San Bernardino, and Ventura counties. Each year over 22,200 individuals benefit from comprehensive and supportive services, including case management, health navigation, early education, school-based services, housing support and employment assistance.

For more information, please contact:

  • Rachel Lepold, Editorial Contact, Uplift Family Services, 251 Llewellyn Avenue, Campbell, California 95008; 408-628-5579; Email: rachel.lepold@upliftfs.org; Website: www.upliftfs.org
  • Stephanie Kleinheinz, Chief Executive Officer, School Health Clinics of Santa Clara County, 6840 Vía Del Oro #210, San Jose, California 95119; 408-284-2288; Email: stephaniek@schoolhealthclinics.org; Website: http://www.schoolhealthclinics.org/
  • Myeisha Peguero Gamiño, Editorial Contact, Pacific Clinics, 800 South Santa Anita Avenue, Arcadia, California 91006; 626-254-5054; Email: MGamino@PacificClinics.org; Website: www.pacificclinics.org

Landmark Health and its affiliated medical groups in 46 U.S. communities announced the launch of its proprietary telemedicine app. The Landmark Health app was developed to securely connect individuals with their Landmark medical provider organizations via smartphone. The app is available to Android users as of April 27, 2020 and will soon be available to iOS users.

Telemedicine helps extend Landmark provider organizations and clinical teams into the homes of individual with higher frequency, especially those living in more rural areas. Landmark’s typical consumer is in their mid-80’s with six or more chronic conditions. The company opted to build a telemedicine app to fully customize the user experience for simplicity, while being HIPAA-compliant.

Individuals can download the Landmark Health app and go through a one-time-password (OTP) authentication registration. From there, they are brought to a home screen where they can call their local 24/7 Landmark clinical line and view their upcoming Landmark appointments. During a video call, the individual sees their provider on-screen, with a small corner video of themselves. They can flip the camera front/back if they need to show the provider a rash, swollen ankle, medication bottle, etc. The Landmark provider can call an individual directly through the app as well. The individual sees the Landmark logo and words “Incoming Call” and taps “Accept” to connect to their provider. This simplicity is critical for an older adult – it removes the need for them to remember the appointment time or find the dedicated link to connect with the provider. They simply answer a call.

Founded in 2014, Landmark Health and its affiliated medical groups deliver comprehensive in-home medical care to older adults. Specialized in complex chronic care, more than 100,000 people across 14 states and 46 metropolitan communities can access Landmark’s care at no cost.

For more information, please contact:

  • Landmark Health, 7755 Center Avenue, Suite #630, Huntington Beach, California 92647; 657-237-2450; Website: www.landmarkhealth.org

Homelessness in Los Angeles County, California increased approximately 12.7%, from 58,936 in January 2019 to 66,433 in January 2020. This increase happened despite a sustained increase in the number of people who have been rehoused after homelessness. The estimated inflow over 2019 was 82,955 individuals, with 22,769 housing placements, and an estimated 52,689 individuals finding other housing.

Figures show that 18,395 individuals experiencing homelessness in Los Angeles County were sheltered in 2019: this is a 25% increase from 14,722 during 2018. While there was a 36.8% increase in sheltered families during the year, Los Angeles County saw an 82.8% increase in unsheltered families (resulting in an overall 45.7% increase in homeless families).

According to experts, Los Angeles County needs approximately 509,000 new affordable housing units to meet the current demand. The average monthly rent is $2,182; this means that renters in Los Angeles County need to earn 2.8 times the City’s minimum wage to make rent (renters need to earn $41.96 per hour).

These statistics were reported in “2020 Greater Los Angeles Homeless Count” by the Los Angeles Homeless Services Authority. The annual report captures a picture of homelessness in Los Angeles County as it was in January 2020, the time of this year’s Homeless Count.

A link to the full text of “2020 Greater Los Angeles Homeless Count” may be found at www.openminds.com/market-intelligence/resources/061220losangelesshmlss.htm.

For more information, contact:

  • Chris Yee, Communications Specialist, Los Angeles Homeless Services Authority, 811 Wilshire Boulevard, #600, Los Angeles, California 90017; 213-219-1417; Email: cyee@lahsa.org; Website: https://www.lahsa.org/

United Us announced that Staple Health will join its growing data analytics team through the recent acquisition of the company. Founded in 2017, Staple Health combines in-house predictive analytics and comprehensive integrated care in the community. The organization was founded during a time when health care provider organizations were becoming more interested in social determinants of health (SDoH) data in the move towards value-based care. Staple Health specifically provided detailed and predictive analytics about the impact of social factors on acute care, behavioral health, addiction, and other health outcomes.

In preparation, Unite Us has worked to strengthen its data team to better analyze outcomes data and its use in communities to address and prevent the factors that negatively impact health, according to Kelly Binder, chief of staff for Unite Us. In addition, Unite Us is introducing Unite Us Insights and social risk analysis to clients nationally.

Unite Us is a technology company that builds coordinated care networks of health and social service provider organizations. With Unite Us, provider organizations across sectors can send and receive secure electronic referrals, track every person’s total health journey, and report on tangible outcomes across a full range of services in a centralized, cohesive, and collaborative ecosystem.

For more information, please contact:

  • Emily Rogan, Communications Manager, Unite Us, 217 Broadway, 8th Floor, New York, New York 10007, US; 516-381-4781; Email: Emily.rogan@uniteus.com; Website: https://uniteus.com/

Spero Health has announced plans to open a new addiction treatment clinic in Warren, Ohio as part of the organization’s quick response to the growing need for expanded services as communities continue to adjust to the COVID-19 outbreak. CARF-accredited and community based, Spero Health is a national leader in providing care for individuals struggling with addiction and will bring affordable, high quality addiction treatment services through a combination of telehealth and in-person visit options at this new clinic.

The new Warren clinic opened on June 23, joining a network of more than 35 Spero Health locations throughout Kentucky, Ohio, Tennessee, and Indiana, providing care for more than 7,200 consumers each month. To ensure access to care is not a barrier to treatment, Spero Health accepts Ohio Medicaid and most commercial insurance plans. The Warren Spero Health clinic is one of several new clinics the organization is opening over the next few months to meet the high demand for access to addiction treatment services close to home.

Spero Health, Inc., is an integrated health care services organization specializing in local and affordable outpatient care for individuals with addiction. Spero Health utilizes an innovative evidenced-based integrated care model that combines both physical and behavioral health care services to provide whole person health care.

For more information, please contact:

  • Spero Health, Inc., 2529 Maple Ave, Zanesville, Ohio 43701, 740-297-8859; Email: info@sperohealth.com; Website: https://sperohealth.com

WellCare of New Jersey, a subsidiary of Centene Corporation, announced a plan to provide additional mental health resources to New Jersey residents impacted by the COVID-19 pandemic. Through a series of local partnerships across the state, WellCare will enable provider organizations to better support communities experiencing elevated levels of stress and mental strain caused by an increase in grief, loss, economic pressure, unemployment, and social isolation.

As part of this effort WellCare, in partnership with its parent company Centene, is announcing investments to support various programs. They will support training for clinical professionals and support for frontline health care workers dealing with the COVID-19 crisis and the increase in mental health-related challenges in their practices. WellCare will support ‘Warmline’ call centers by making a donation to a local organization in New Jersey coping with an increase in demand for their ‘warmline’ services, which provide early interventions to potential mental health crises. WellCare will make an investment to help the National Council for Behavioral Health transition part of their training program to a virtual program, which will make Mental Health First Aid (MHFA) training more accessible for people in New Jersey and nationwide. WellCare will also support those impacted by domestic violence by making a $500,000 donation to the National Domestic Violence Hotline, a national service provider organization which offers service via call, chats, and texts providing support for those impacted by domestic violence in times of crisis.

WellCare of New Jersey provides government-sponsored managed care services to families, children, seniors and individuals with complex needs primarily through Medicaid, Medicare Advantage, and Medicare Prescription Drug Plans across the state. WellCare is a wholly subsidiary of Centene Corporation, a leading multi-national health care enterprise committed to helping people live healthier lives.

For more information, contact:

  • WellCare, 8725 Henderson Road Tampa, Florida 33634; 800-960-2530; Website: www.wellcare.com

Kindred Healthcare, LLC (Kindred) and Landmark Medical Center, a subsidiary of Prime Healthcare, announced a definitive agreement to create a partnership that will own and operate the Rehabilitation Hospital of Rhode Island in North Smithfield, Rhode Island. Kindred will have a 60% ownership interest in the joint venture and Landmark will own 40%. The hospital is licensed for 82 rehabilitation beds.

Under the agreement, Kindred will bring its proven rehabilitation management and services expertise to the existing hospital, which serves patients from across Rhode Island and neighboring Massachusetts. Each year, Kindred Rehabilitation Services treats nearly 50,000 consumers at its joint venture inpatient rehabilitation hospitals across the country. Kindred’s inpatient rehabilitation hospitals serve patients who are recovering from a variety of conditions, including stroke, brain injury, spinal cord injury, orthopedic injury, neurological conditions, amputation and trauma. Kindred and Prime expect to complete the transaction by the third quarter of 2020, subject to the completion of due diligence, regulatory and licensing approvals.

Kindred Healthcare, LLC is a health care services company based in Louisville, Kentucky with annual revenues of approximately $3.2 billion. At March 31, 2020, Kindred through its subsidiaries had approximately 31,800 employees providing healthcare services in 1,731 locations in 46 states, including 64 long-term acute care hospitals, 21 inpatient rehabilitation hospitals, 10 sub-acute units, 95 inpatient rehabilitation units (hospital-based) and contract rehabilitation service businesses which served 1,541 non-affiliated sites of service.

The Rehabilitation Hospital of Rhode Island is a stand-alone rehabilitation hospital with a capacity of 82-beds. Prime Healthcare Services acquired the Rehabilitation Hospital of Rhode Island in North Smithfield, Rhode Island in January 2014.

For more information, please contact:

  • Susan E. Moss, Kindred Healthcare, Senior Vice President, Marketing and Communications, 680 South Fourth Street, Louisville, Kentucky 40202; 502-596-7296; Email: susan.moss@kindred.com; Website: www.kindredhealthcare.com

During the coronavirus disease 2019 (COVID-19) pandemic emergency, Massachusetts emergency departments and outpatient settings conducted fewer psychiatric assessments per week in late March compared to January and February. The share of emergency department visit notes with mentions of depression dropped by 44%, from a mean of 1,446 visits per week in January and February to 886 visits the week of March 19 to 25. The share of outpatient visit notes with mentions of depression dropped by 81%, from 49,312 visits in January and February to 9,315 visits the week of March 19 to 25. Similar patterns were observed for other symptoms.

In emergency department settings, the odds of COVID-19 testing increased by nearly 50% in visits during which violence was referenced in the record. In outpatient settings, notes with the presence of psychiatric terms were associated with a 20% reduction in the likelihood of COVID-19 testing for anxiety, 36% reduction for depression, 37% reduction for psychosis, 27% reduction for suicide, and 60% reduction for violence.

These findings were reported in “Electronic Health Record Documentation of Psychiatric Assessments in Massachusetts Emergency Department and Outpatient Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic” by Victor M. Castro, MS; Roy H. Perlis, M.D., MSc. They sought to determine the trend in documentation of psychiatric symptoms in narrative clinical notes as COVID-19 activity increased in eastern Massachusetts. They analyzed electronic health records for all individuals seen in outpatient or emergency department visits between January 2 and March 25, 2020, from two large academic medical centers and three affiliated community hospitals in Massachusetts.

The presence of depression, anxiety, suicide, psychosis, and violence was identified by the presence of terms related to these conditions. These terms included depressed, depressive, dysphoric, dysthymic, sad, and tearful for depression; anxiety, anxious, fearful, frighten, hypervigilant, nervous, panic, phobia, phobic, scared, stress, tense, and worried for anxiety; suicide, suicidal, and suicidality for suicide; psychotic, psychosis, hallucination, delusion, paranoid, paranoia, hallucinate, hallucinated, and delusional for psychosis; and violence and violent for violence.

The full text of “Electronic Health Record Documentation of Psychiatric Assessments in Massachusetts Emergency Department and Outpatient Settings During the Coronavirus Disease 2019 (COVID-19)” was published June 8, 2020, by JAMA Network Open. An abstract is available online at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766817.

For more information, contact:

  • Roy H. Perlia, M.D., MSc, Division of Clinical Research, Center for Quantitative Health, Massachusetts General Hospital, 185 Cambridge Street, 6thFloor, Boston, Massachusetts 02114; Email: rperlis@mgh.harvard.edu

Addcounsel Chief Executive Officer Paul Flynn announced a new service, Orchestrate Health, to treat clients with complex mental health needs from the comfort of their home. Mr. Flynn designed the at-home alternative for people who need mental health care but do not need or want to go into psychiatric units.

The goal of the home treatment option is to enable clients to live their lives in the least restrictive way possible, allowing them the best quality of life despite the mental health difficulties they face. Orchestrate Health offers an alternative to the mainstream and is also able to act as the continuum of care for people who may have been through treatment, and although no longer in need of complex inpatient care, require a level of support at home or for individuals who would prefer to be treated at home.

Orchestrate Health provides anonymous, private mental health services and care across the United Kingdom and internationally in the comfort of the client’s home. The services offered at Orchestrate Health are exclusive mental and behavioral health care treatment from the privacy of the client’s home and round the clock rapid response home mental health care.

For more information, please contact:

  • Addcounsel Ltd, LG, 28 Grosvenor Street Mayfair, London, United Kingdom W1K 4QR; +44 (0)203 709 3968; Email: enquiries@addcounsel.com; Website: https://addcounsel.com/

On June 3, 2020, the Centers for Medicare & Medicaid Services (CMS) announced adjustments to 16 value-based care (VBC) models to account for the coronavirus disease 2019 (COVID-19) pandemic public health emergency (PHE) that began in March 2020. The goal is to account for changes in health care delivery and related additional costs, and to give the participating provider organizations more time to transition VBC. As much as possible, the participating provider organizations will not be at-risk for costs due to the pandemic.

CMS Innovation Center Changes To Value-Based Care Models To Account For COVID-19 Public Health Emergency
Innovation Center Model Financial Methodology Changes Quality Reporting Changes Model Timeline Changes
Bundled Payments for Care Improvement Advanced Yes No No
Comprehensive ESRD Care Model (CEC) Yes Yes Yes
Comprehensive Care for Joint Replacement (CJR) Model Yes No Yes
Direct Contracting (Global and Professional) Yes Yes Yes
Emergency Triage, Treat, and Transport (ET3) No No Yes
Home Health Value-Based Purchasing Model (HHVBP) No Yes No
Independence at Home (Section 3024 of the ACA) No Yes No
Integrated Care for Kids (InCK) Model No No Yes
Kidney Care Choices Yes Yes Yes
Maternal Opioid Misuse Model (MOM) No No Yes
Medicare Care Choices Model No No No
Medicare Diabetes Prevention Program Expanded Model (MDPP) No Yes No
Medicare ACO Track 1+ Model Yes Yes Yes
Next Generation ACO (NGACO) Yes Yes Yes
Oncology Care Model (OCM) Yes Yes Yes
Primary Care First—Serious Illness Component No No Yes

CMS seeks to make the changes consistently across models and programs to provide stability and predictability for the model participants. For some models, reporting requirements and timelines have been delayed. For other models, the payment methodology has been changed to mitigate risk during the emergency, or cost targets and benchmarks have been modified. CMS used the following principles to determine which changes were appropriate:

  • Use flexibilities that already exist in current model design.
  • Continue sufficient financial incentives that encourage higher-quality outcomes.
  • Ensure equity and consistency across models.
  • Align as much as possible with national value-based and quality payment programs.
  • Minimize risk to model participants, the Medicaid program, and the Medicare Trust Funds.
  • Limit delays in new model implementation, while providing additional opportunities for participation in new models.
  • Minimize reporting burden.
  • Complement and build off the new CMS COVID-19 Public Health Emergency flexibilities as outlined in regulation and waivers.

A link to the full text of “CMS Innovation Center Models COVID-19 Related Adjustments,” which includes summaries of the changes to each model may be found at www.openminds.com/market-intelligence/resources/060220cmmicovidadjustments.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/. 

Miami’s Monte Nido & Affiliates, an eating disorder treatment provider organization, has selected Kipu as Mydecine Innovations Group Inc. (Mydecine) announced that it has signed a definitive share exchange agreement with Mindleap Health Inc. (Mindleap) for the acquisition of a 100% interest in MindLeap’s Digital Telehealth Platform focused on the emerging psychedelics industry. Mydecine will acquire 100% of the issued and outstanding shares of Mindleap in exchange for: (i) 6,363,636 common shares in the capital of the Company, and (ii) the binding commitment to advance CAD $500,000 in working capital to Mindleap upon closing of the transaction and an additional CAD $500,000 on or before September 1, 2020.

Certain principals of Mindleap will be subject to resale restrictions on the sale of the Mydecine shares for the periods ending 4, 12, 18, and 24 months from closing. Closing of the acquisition is subject to the receipt by Mindleap of the signatures of all of its shareholders on the share exchange agreement.

Mydecine Innovation’s Group is a life sciences company focused on the development and commercialization of products and services that contribute to improving overall health and well-being. The company’s mission is to create a healthier world through advanced technologies, natural products, and psychedelic derived medicines.

Mindleap Health is developing an advanced digital telehealth platform that will provide support for people that are looking to achieve personal transformations and overcome mental health challenges. MindLeap’s telehealth platform combines telemedicine with mood, emotion, and habit tracking.

For more information, please contact:

  • Mydecine Innovation’s Group, 789 West Pender Street Suite 810 Vancouver, British Columbia V6C 1H2 Canada; 888-871-3936
  • Mindleap Health, The King George Building, 905 W Pender St, Vancouver, British Columbia V6C 1L6; 800-972-5194; Email: hello@mindleap.health; Website: https://mindleap.health

There are a few interesting observations about ‘reopening’ of health care service operations after the pandemic crisis closures, based on discussions during last week’s virtual 2020 OPEN MINDS Strategy & Innovation Institute. Executives are conflicted—for many reasons—about reopening their office-based operations. And, there is a real lack of clarity about the mandates and availability of testing.

The Centers for Disease Control and Prevention (CDC) guidelines for the reopening of operations of any type are ambiguous at best. I’ve read most of them. They are a combination of vague, seemingly off base, and impractical. And there is no mention of testing in any of them.

There are also variations in state and county regulations. For example, in Pennsylvania, you can hold a meeting of up to 250 people for counties in the ‘green’ phase. But, in Orange County, California, the limit is 100 people. In North Carolina, gatherings are still limited to no more than 10 people indoors, and no more than 25 people in outdoor spaces. During the Institute discussion, one executive of a multi-location provider organization discussed the complexity and cost of tracking what the requirements are—and putting them in place.

Another issue is employee perceptions of safety. During the session, Navigating The New Normal With COVID-19 Part 2: An Update On Sustainable Strategies For The Disrupted Market, David Klements, Chief Executive Officer of Qualifacts, talked about forming a cross functional team of employees to develop the guidelines that Qualifacts will use for reopening. Every team member wants to think their work environment is as safe as possible.

There are also questions about whether the delivery of many therapies will ever return to office-based practice. Not only do the majority of consumers prefer the convenience of virtual services, every executive at the 2020 OPEN MINDS Strategy & Innovation Institute who discussed their move to virtual services talked about the decrease in no-show rates, the increase in clinical professional productivity, and the elimination of the costs of office space. Therapy services weren’t profitable before the pandemic crisis occurred—and those rates are not likely to go up in the future. Many executive teams may make the decision to keep much of their therapy capacity—and those services—in a virtual delivery model. The executive commented, “We’re not going to open our offices any time soon. We’re focused on expanding our home-based services instead.”

Finally, there is the testing issue. First, none of the CDC guidelines mention testing. Yet there is a broad consensus that employee and consumer testing is a key to reopening. In testimony to Congress on June 4, Georges Benjamin, M.D., Executive Director of the American Public Health Association, told members of the U.S. Senate committee on Health, Education, Labor and Pensions that without adequate testing, universities “can’t function at all.”

There are admittedly variabilities in the accuracy of different tests. But there is widespread agreement that rapid testing—combined with sanitation measures, contact tracing, and quarantines—is an important tool for moving ahead.

One key tool for executive teams planning for recovery after this crisis period is having the metrics to make the right decisions – think of this data in three domains. There is financial data for short-term cash management strategy. There is strategic market information for planning long-term post-recovery strategy (this includes both external and internal data). And there is service performance data to optimize value.

We got a great example of service performance data in the presentation, Measurable Client Outcomes – A Provider’s Journey Continues, by Scott Zeiter, executive vice president and chief operating officer, and Jeremy Ulderich, director of educational consulting at Grafton Integrated Health Network, at The 2020 OPEN MINDS Strategy & Innovation Institute. Grafton has implemented a sophisticated approach to providing measurement-based care (MBC) in their programming for consumers with complex behavioral challenges. The program started over a year ago. Their presentation focused on what they have learned after fully implementing the MBC service model.

The model is based on a five-step process—identify the consumer behaviors that are problematic and need to change; develop a goal for behavior change; select an “intervention”;  develop a plan for integrating the intervention into a consumer care plan; and measure the effectiveness of the intervention. This sounds simple but is a complicated undertaking to determine what interventions are most effective in specific consumer groups. Mr. Zeiter explained, “We needed to come up with a response to value-based contracting. Defining value is difficult. We needed to take a step ahead of the external stakeholders. That has had a positive impact, and the payers have taken an interest in it, as a way to define true value. We wanted to root this into evidence-based practices.”

What were the key effects of this process at Grafton? Mr. Ulderich shared a few stats, showing that in their Assessment of Basic Language and Learning Skills, the overall consumer score increased from an average of 318.05 to an average of 545.62—up to 80% growth from prior assessment. And in the Assessment of Functional Living Skills Criterion, there was a 32% increase in overall consumer scores. Mr. Zeiter noted the success, saying, “Once we gave the staff that tool, it was incredibly effective, and the staff felt tremendously empowered. The message we wanted to give the staff at Grafton was, we are going to give you control of the data. It is going to emanate from you. We are going to give you that and give you the roadmap we are following in hopes that you will help us follow it.”

There were three big takeaways from the session—the importance of the tech infrastructure; the challenges of a shift in clinical culture to embrace MBC; and the possible strategic advantages of MBC in a market moving to value. The tech infrastructure discussion was interesting. The keys to success are the combination of access to “big data,” the ability to automate the compilation and reporting of that data, and the ability to customize dashboard views for Grafton teams.

Mr. Zeiter and Mr. Ulderich explained that this reveals the true promise in their work, to allow specialists to correlate variables like demographics, diagnoses, frequencies of concerning behavior, and evidence-based practices, to determine what factors were more effective in determining outcomes. The key is to begin “gathering the data pile.” Mr. Zeiter explained, “Historically we were concerned about precision when we talked about testing things. When you look at Silicon Valley, they are now less interested in precision and more interested in gathering as much as possible and then weeding through it to determine the correlations.”

And after you get the “data pile,” the key is automating the data collection and the production of customized dashboards for end users. Grafton is currently running 65 different reports to support its programs and has the potential to run as many reports as needed. Mr. Zeiter explained, “With the information, we can dashboard anything, but we are just scratching the surface of all the data we are collecting. At this point we have immediate access to data and can use it for a variety of reasons.”

But beyond getting the technology right, there is the challenge of creating a metrics-based culture, particularly among direct care staff and clinical professionals. It takes time to change the culture. As Mr. Zeiter noted, “There are many clinicians clearly still focused on relationships and process but that doesn’t exclude their interest in the data. They want to see the concrete impact of their interventions.” But it takes a lot of administrative time to ensure staff are using the tools correctly and staying on point with the treatment goals. Mr. Zeiter added, “Constantly having to follow behind to ensure the treatment goals are updated has been very work intensive. They need constant supervision.”

Most exciting was the Grafton view of the role of this information in their future strategy. Mr. Zeiter noted that by the end of this month, they will develop a data set with integration of all of their operating databases. The purpose is to use the assessment data, the behavior data, and the goal mastery to start to identify the factors that can predict the cost of care.

In 2021, health and human service budgets are going to be stressed—and all payers will be looking to get more “value” for their expenditures. The ability to tie services to outcomes and to cost will be a key competitive advantage.

As of June 9, 2020, 24 health care provider organizations each received over $100 million in relief funding from the federal Department of Health and Human Services (HHS) Provider Relief Fund created as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The New York and Presbyterian Hospital received and attested to the highest total amount—$567 million. The second largest Provider Relief Fund payments—$403 million—went to New York University Langone Hospitals.

The allocations are intended to help health care provider organizations cover lost revenue and increase costs during the public health emergency due to coronavirus disease 2019 (COVID-19). HHS has been distributing the funds since April 10, 2020. The data on relief fund allocations are available on the Centers for Disease Control and Prevention (CDC) website.

The CARES Act and the Paycheck Protection Program and Health Care Enhancement Act provided $175 billion in Provider Relief Funds to hospitals and other health care provider organizations. HHS is distributing the payments through the Health Resources and Services Administration (HRSA) for $50 billion general distribution, $12 billion targeted allocation to high impact areas, $10 billion targeted allocation to rural provider organizations, $4.9 billion to skilled nursing facilities, $500 million to Tribal Hospitals, Clinics, and Urban Health Centers.

Provider Organizations That Received More Than $100 Million In CARES Act Provider Relief Funds
Provider Organization Name State City Payment
The New York And Presbyterian Hospital New York New York $567,285,060
New York University Langone Hospitals New York New York $403,339,290
Hackensack Memorial Hospitals Corporation New Jersey Hackensack $356,441,388
Long Island Jewish Medical Center New York Westbury $326,631,509
Mount Sinai Hospital New York New York $262,819,360
Dignity Health Nevada Henderson $190,189,565
William Beaumont Hospital Michigan Southfield $179,686,440
North Shore University Hospital New York Manhasset $175,200,130
Advocate Health And Hospitals Corporation Illinois Downers Grove $160,977,911
Henry Ford Health System Michigan Detroit $157,899,088
Maimonides Medical Center New York Brooklyn $151,365,990
Ochsner Clinic Foundation Louisiana New Orleans $124,854,422
Beth Israel Medical Center New York New York $118,083,784
Regents Of The University Of Michigan Michigan Ann Arbor $116,857,156
University Hospital At Stony Brook New York Stony Brook $112,581,243
Vanderbilt University Medical Center Tennessee Nashville $108,292,719
Staten Island University Hospital New York Staten Island $106,912,606
Bronxcare Health System New York Bronx $105,345,390
New York-Presbyterian/Brooklyn Methodist New York Brooklyn $104,187,532
County Of Los Angeles California Commerce $103,853,772
Cedars-Sinai Medical Center California Los Angeles $103,347,125
The Cleveland Clinic Foundation Ohio Independence $103,289,897
St Josephs Hospital And Medical Center New Jersey Cedar Grove $102,568,689
Stanford Health Care California Palo Alto $102,405,229

HRSA released the allocations in a dataset on the CDC website that lists all provider organizations that received and attested to the Terms and Conditions for a payment from the General Distribution, High Impact Area, Skilled Nursing Facilities, Tribal, and/or the Rural Targeted Allocation of the Provider Relief Fund. Each organization listed has attested to receiving one or more payments and agreed to the terms and conditions within 90 days of payment.

HRSA released a separate dataset with payments to 395 hospitals who received a payment under the $12 billion High Impact Area Targeted Allocation. About $2 billion of the payments from the COVID-19 High-Impact Area Allocation were distributed to these hospitals based on their Medicare disproportionate share and uncompensated care payments.

Each of the 395 hospitals provided inpatient care for 100 or more people with COVID-19 through April 10, 2020. These hospitals accounted for 71% of COVID-19 inpatient admissions reported to HHS from nearly 6,000 hospitals around the country. The payments ranged in size from $7.6 million to $277 million. Twelve hospitals received payments of $100 million or more.

Hospitals Receiving Provider Relief Fund COVID-19 High-Impact Payments Of $100 Million Or More
Hospital Name State City Payment
Long Island Jewish Medical Center New York New Hyde Park $277,653,312.42
Holy Name Medical Center (AKA Holy Name Health) New Jersey Teaneck $213,428,946.86
Tisch Hospital New York New York $203,180,446.74
Montefiore Hospital – Moses Campus New York Bronx $156,708,591.59
NewYork-Presbyterian/Columbia University Irving Medical Center New York New York $152,747,325.41
NewYork-Presbyterian Queens New York Flushing $143,251,512.11
Mount Sinai Medical Center (AKA the Mount Sinai Hospital) New York New York $140,754,860.74
Sandra Atlas Bass Heart Hospital at North Shore University Hospital New York Manhasset $137,531,542.64
Maimonides Medical Center New York Brooklyn $131,500,615.31
NewYork-Presbyterian/Weill Cornell Medical Center New York New York $118,647,056.76
NYC Health and Hospitals – Elmhurst (FKA Elmhurst Hospital Center) New York Elmhurst $111,346,403.33
NYU Winthrop Hospital (FKA Winthrop University Hospital) New York Mineola $108,038,387.94

The data set of CARES Act Provider Relief Fund payments can be viewed online at https://data.cdc.gov/Administrative/HHS-Provider-Relief-Fund/kh8y-3es6/data.

The data set of 395 hospitals that shared the $12 billion high impact allocation can be viewed online at https://data.cdc.gov/Administrative/Provider-Relief-Fund-COVID-19-High-Impact-Payments/b58h-s9zx.

PsychU reported on the CARES Act Provider Relief Fund on May 4, 2020, in “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured” at https://www.psychu.org/hhs-begins-releasing-100-billion-cares-act-funding-to-provider-organizations-for-relief-assistance-treating-the-uninsured/.

For more information, contact:

  • Health Resources and Services Administration, 5600 Fishers Lane, Rockville, Maryland 20857; Website: https://www.hrsa.gov/about/contact/index.html

Crises of any kind are known to increase mental health and addictive disorders. This pandemic crisis is no exception. The initial estimates are sobering.

An early April poll by the Kaiser Family Foundation shows that nearly half (45%) of all U.S. adults say the pandemic has affected their mental health, while 19% say it has had a “major impact.” Prescriptions for anti-anxiety drugs spiked 34% between February 16 and March 15, and also increased for antidepressants (18.6%) and anti-insomnia drugs (14.8%), according to a report from Express Scripts.  Companies like Ginger and TalkSpace delivering virtual mental health care have seen a massive surge in demand for services with COVID-19—with increases of 50% to 65% in February and March.

The scenario is ripe for increased addiction challenges as well. Millions of Americans with opioid use disorder who depend on face-to-face health care delivery are at increased risk. A Health Affairs blog notes that social distancing and self-quarantine are risk factors for relapse for people with addiction disorders. The fear and uncertainty associated with social and economic distress, along with mandated isolation, can aggravate anxiety and depression—and many people will self-medicate with drugs and alcohol to ease the stress. On a similar note, experts at the National Institute of Mental Health have stated that COVID-19 can be a trigger for those who already have anxiety disorder and obsessive-compulsive disorder as the “Purell is everywhere.” Rising alcohol sales maybe an early warning sign of an increase in addiction disorders—online alcohol sales increased 55% in the first two weeks of March, reported Nilesen. One alcohol delivery app, Drizy, serving 26 states and Washington D.C. said alcohol sales the week of March 16-21 were up about 300% from earlier in the year.

Trauma is another behavioral health challenge expected to be exacerbated by COVID-19. Researchers are warning that the coronavirus pandemic could inflict long-lasting emotional trauma on an unprecedented scale and leave millions wrestling with debilitating psychological disorders. The combined stressors—the global nature of the pandemic, the isolation and social distancing, unemployment, and impending recession—are taking their toll. “The scale of this outbreak as a traumatic event is almost beyond comprehension,” said Yuval Neria, the director of trauma and post-traumatic stress disorder at the New York State Psychiatric Institute and a professor of psychology at Columbia University Medical Center, talking to CNBC.

Lancet Psychiatry reports that suicide risk might increase because of stigma towards individuals with COVID-19 and their families and the increase in depression, anxiety, and post-traumatic stress among the general population and those with high levels of exposure to illness caused by COVID-19, such as essential workers. An 85% increase in gun sales in March (the highest ever sales recorded in the U.S.) also leaves experts concerned about a potential increase in gun-related suicides.

From this emerging early data, it appears that long after the acute health effects of the novel coronavirus on the population subside, we will see lasting effects in the form of increased demand for behavioral health services. For executives planning their post-recovery strategies, the unanswered questions are how the services will address these issues be delivered and how will they be funded.

While predictions are dangerous this early in the arc of the pandemic, there are a few factors that will shape the post-pandemic market. There will be increased political pressure for health benefit coverage for the entire U.S. population. But, like all things political, whether or not that happens will depend on the elections this fall. We do know that the pandemic will increase enrollment in Medicaid due to the burgeoning ranks of the unemployed—at a time when state budgets are strapped and policy suggestions like ‘state bankruptcy’ are floating around. But, like the pandemic itself drove rapid adoption of virtual care models, the financial consequences of the pandemic are likely to accelerate the use of integrated care and value-based reimbursement models for both managed care organizations and provider organizations. Regardless of the exact scenario, the successful strategy is likely to be one focused on ‘value’ defined as the low costs with a high value service to consumers.

On May 28, 2020, Capital BlueCross announced an advance payment program for its network provider organizations in Pennsylvania affected by revenue drops due to the coronavirus disease 2019 (COVID-19) public health emergency. The payments are intended for organizations that have a 40% or greater decrease in average payment for services provided to Capital BlueCross members during March and April 2020. The goal is to help those provider organizations “bridge the financial gap” as members gradually resume in-office visits and procedures.

Provider organizations can apply by contacting Capital BlueCross. The payments will be available through July 15, 2020. The amount of the funding advances is based on the provider organizations’ average monthly payments during 2019.

Capital BlueCross said it launched several initiatives to help its network provider organizations, its members, and the community during the pandemic. The initiatives for provider organizations and members include the following:

  • Relaxed the provider organization claims and appeals timeframes and extended pre-authorizations.
  • Expanded the types of provider organizations whose services are covered through telehealth.
  • Waived member costs (copayments, coinsurance, and deductibles) for COVID-19 diagnostic testing, related office visits, and in-network, inpatient hospital treatment for COVID-19.
  • Allowed early refill of prescription drugs for members with its pharmacy benefit.
  • Waived member costs for tele-dentistry for members with its dental coverage.

To assist the community, Capital BlueCross increased its funding support to food banks and other community organizations to help address food insecurity. The insurer is also providing meals to health care workers, first responders, and nursing home staff and residents as part of its effort to help communities and front-line workers.

Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. It provides health insurance products, services, and technology solutions in Central Pennsylvania and the Lehigh Valley.

For more information, contact:

  • Melissa Fox, Supervisor, Public Relations and Social Media, Capital BlueCross, 2500 Elmerton Avenue, Harrisburg, Pennsylvania 17177; 717-541-6843; Email: melissa.fox@capbluecross.com; Website: https://www.capbluecross.com/

Plans of any type—including plans for crisis management and financial recovery—are only as good as their implementation. For most organizations, success of new plans depends on the leadership team that is charged with the planning and its implementation. That was the focus of Monica Oss’ closing remarks, Strategy In A Crisis – Staying Afloat Vs. Navigating; at The 2020 OPEN MINDS Strategy & Innovation Institute.

But what do leaders need to do to make that happen? The panelists—Charles Ingoglia, chief executive officer (CEO) at the National Council for Behavioral Health; David Klements, CEO at Qualifacts Systems, Inc., and Jon Wolf, CEO at Pyramid Healthcare, Inc., discussed specific leadership “must dos” in the session, Navigating The New Normal With COVID-19 Part 2: An Update On Sustainable Strategies For The Disrupted Market. They discussed twelve essential leadership actions in the session. But the real gems were the first-hand practices and advice from this group.

Mr. Klements spoke to the importance of data in planning for success and continuously reframing recovery efforts. As an example, he cited recent survey data on the evolving virtual care landscape. “Laptops are going to be three times more important to providers than tablets…90 days ago, the data would have suggested the opposite. And it turns out that internet access and poor connectivity are the biggest challenges to providers moving to virtual service delivery.” His point? The key to navigating is to keep on top of the data—and plan and act accordingly.

Mr. Wolf described their approach to communicating during virtual operations in a crisis, saying, “Communication is so important to the staff in this crisis. But we’ve learned a lot. We’ll never go back to meeting the way we once did.”

He also spoke of recalibrating the need to meet in person and the convenience of virtual meetings for both management and all employees. He explained that they have increased the number of team meetings at Pyramid, using travel time saved to actually meet more. “We’ve tried to ramp up the way we communicate,” he explained. “Using more chat functions—Team, Jabber, and the tools in the Qualifacts system. We also do a lot of internal staff webinars; we have an intranet for our employees, and we’ve set up a function to rapidly answer employee questions. There is still a lot of fear out there and staff want to know what is going on. Our system is set up for rapid communication to answer questions.”

Mr. Ingoglia also had an interesting perspective on communication. “When this started, I assumed we would be working off site for two weeks and I started a daily email to staff,” he said. “We’re way past two weeks, but I get feedback from staff to keep my daily email. I have more touchpoints with staff now than I did and I am trying to think about how to keep that in the future.”

These new communication models aren’t the only “learning” happening from the crisis. Mr. Wolf spoke about the shift in his organization to be more engaging with consumers. “One big problem in behavioral health is engagement,” he said. “Our numbers, the percentage of people going from an assessment to admission to services was 50% pre-COVID-19. It’s now 65%. We’ve changed. We’ve become more engaging, more customer focused. That is a magnificent thing. It would be absurd for us to go back.”

Both Mr. Klements and Mr. Wolf spoke about the need for nimble decision making and operational flexibility that only comes with a system that allows decentralization of management. Mr. Klements noted specifically, “There is critical-path work that needs to happen from the top down. Conversely, bottom up communication is from the teams closest to consumers. For example, they are the team members who identified our clients’ needs for more support with virtual health. It’s an interesting dynamic to manage fewer critical things from the top down, and let the staff identify what is important to consumers.”

At Pyramid, they have accomplished decentralized decision making with a new approach. Mr. Wolf explained, “We have segmented the operations into silos, like communication, protective personal equipment (PPE), managing consumers, and then we assigned leaders for each of those segments. The change was rapid, and there is the need for short-term and long-term strategic plans. Segmenting and focusing on the communication allow us to manage the change more broadly.”

At the close of the session, the group discussed the challenges of “returning to normal.” There are the practical considerations voiced by Mr. Klements, like the additional operating costs that will be required for technology, PPE, testing, and the process for reopening offices. “Right now we’re working on how to safely reopen our offices and have set up a cross-functional committee led by our chief financial officer to evaluate all the possibilities,” he said. “Opening varies by location and market sector.”

Mr. Ingoglia spoke of these differences across the country—including navigating the different rules and COVID rates varying by geography, that make it difficult to have a single approach. Mr. Wolf agreed about the differences between states, noting, “Every market is different, every state is different. You can’t apply the same rules and timeline.”

And on top of those differences, each CEO expressed frustrations of not knowing what the federal policies and supports will be for the health and human service sector in general, and for specialty provider organizations in particular. Mr. Ingoglia explained, “The larger issue is that our system operates on the periphery of federal health care policy. The dilemma is, what exactly is a substance use provider organization, or a mental health organization? We have no definitions in federal law. We are doing our best to advocate for the sector. But having some clarity would be helpful. We need a framework for legislators.”

At the close of the session, the three CEO colleagues were in unanimous agreement about one fact—the only certainty is uncertainty.

On May 22, 2020, the San Diego County Health and Human Services Agency, Housing and Community Development Services released a request for proposals (RFP 10141) seeking a contractor to provide comprehensive care coordination, service navigation, peer support, housing and housing-related assistance to veterans referred through the Veterans Moving Forward (VMF) program. The VMF program is a veteran-only, incentive-based housing unit for male veterans who served in the United States military and are held at the county’s Vista Detention Facility. VMF assists incarcerated veterans by providing necessary in-custody treatment, services, and community linkages to reduce the cycle of incarceration.

Currently the VMF services do not specifically include care coordination. There is no incumbent care coordination vendor. The San Diego County Sheriff’s Department formed VMF in 2013. It is a partnership with the VA, the Office of Military and Veterans Affairs, and community provider organizations. The VMF unit was created without any specialized funding. At that time, the Sheriff’s staff sought support from department leadership to work closely with the VA to reallocate staff to the program. The services were provided by Sheriff’s Department staff and by volunteers and others in the community. On October 15, 2019, the San Diego County Board of Supervisors accepted a proposed Community Care Coordination for Veterans Implementation Plan to enhance the VMF program using a peer support team to increase connections to services and reduce recidivism through housing assistance, care coordination, and increased opportunities for vocational training for local veterans.

Proposals are due by July 7, 2020. The county anticipates awarding a single county-wide cost reimbursement contract with one base year followed by four one-year option terms. The estimated allocation for the base year is a maximum of $1.15 million. For each subsequent year, the allocation is a maximum of $2.15 million, for a total contract cost not to exceed $9.75 million.

Startup funding is available for one-time costs associated with the development and implementation of the Community Care Coordination for Veterans Program. The start-up funding is included in the initial term maximum amount and cannot exceed 2.5% of the initial contract term amount. Start-up funds will be paid on a cost reimbursement basis.

VMF services will begin while the veteran is in custody and continue for up to 12 months in the community. Engagement, service navigation, and peer support will be provided in both a custodial (jail) setting and in the community. Services can include: case management, placement in immediate housing, transportation, peer support, benefit assistance, housing navigation for permanent housing, tenant support, landlord mediation, family reunification, system navigation to connect veterans to mental health services, addiction treatment, health care, and other needed supportive services that improve the veteran’s quality of life and reduces the risk of recidivism. The contractor must ensure that all veterans are connected to safe and secure housing immediately upon release from custody and linked to permanent housing within six months of exiting custody.

The selected contractor must have experience serving veterans. The peer support specialists should be part of the military community. The contractor will work closely with all partners, including, but not limited to, the Sheriff’s Department, United States Department of Veterans Affairs (VA), Probation Department, and various divisions within the county Health and Human Services Agency, including Housing and Community Development Services, Office of Military and Veterans Affairs, Self-Sufficiency, and Behavioral Health Services.

In March 2019, the initial VMF program outcomes were reported in “Veterans Moving Forward: Process and Impact Evaluation Results of the San Diego County Sheriff’s Department VMF Program” by Cynthia Burke, Ph.D.; Sandy Keaton, MA; Gregor Schroeder, MS; and Kandice Ocheltree, MA. The report was released by the San Diego Association of Governments, which had collaborated to launch the initial VMF program. The researchers conducted a program evaluation and surveys with 141 VMF participants at intake, exit, and six-months after exit. They interviewed key staff and deputies and analyzed program record data to track assessment and service provision. They analyzed justice system records to identify the participants’ criminal history, rule violation, and recidivism. Since 2013, 1,200 inmates have gone through the program.

The key findings were as follows:

  • Compared to a historical group of veterans who did not receive VMF services, VMF participants tracked from 2015 and 2016 had significantly fewer rule violations and were significantly less likely to have a conviction for a new offense in the 12-months following release. The VMF recidivism rate has been 16% compared to 27% for other veterans not in the program.
  • VMF clients received about 14 different classes on average and appeared to be involved in around 30 hours of programming on average per week.
  • The program had challenges maintaining program fidelity and consistency due to the reliance on program volunteers and simultaneous lack of dedicated funding. However, the use of volunteers and collaboration did contribute to the success of the VMF unit. Staff were positive about the program. Participants expressed thanks for the safe environment to work on their underlying needs and receive services not available in the general population. More than 95% of participants at exit and follow-up said they would recommend VMF to another veteran.

A link to the full text of “San Diego Board Of Supervisors October 15, 2019 Meeting: Approval Of The Community Care Coordination For Veterans Implementation Plan For Successful Reentry” may be found at www.openminds.com/market-intelligence/resources/101519sdboscarecoordveteransplan.htm.

A link to the full text of “Veterans Moving Forward: Process & Impact Evaluation Results Of The San Diego County Sheriff’s Department VMF Program” may be found at www.openminds.com/market-intelligence/resources/032519sdctyveteransmovingforward.htm.

For more information, contact:

  • Cristina Duroiu, Procurement Contracting Officer, San Diego County Department of Purchasing and Contracting, 5560 Overland Avenue, Room B, San Diego, California 92123; 858-505-6358; Email: Cristina.Duroiu@sdcounty.ca.gov
  • Sarah Sweeney, Communications Officer for Health and Human Services Agency, San Diego County, 5560 Overland Avenue, Suite 270, San Diego, California 92123; 619-685-2522; Email: Sarah.Sweeney@sdcounty.ca.gov; Website: https://www.sandiegocounty.gov/hhsa/

Navigating the health care system, particularly mental health services, is a daunting task during “normal” times. Facing the fluidity and uncertainty of a global pandemic presents many new unique challenges to accessing and utilizing health care services, but it also affords some promising advancements. Combining this environment with the current societal unrest sparked by cultural/racial disparity within our nation adds another layer of complexity to the situation.

This panel will discuss their roles within the current health care system, and detail the obstacles and opportunities presented by the coronavirus pandemic amidst the fight to end cultural, racial, and other types of disparity in our nation. Panelists will cover the good, the bad, the ugly, as well as the potential for those living with a mental health condition to thrive in our “new normal” health care landscape.


Featuring:

  • Gaurava Agarwal, MD
    • Assistant Professor in the Department of Psychiatry and the Behavioral Sciences
    • Assistant Professor of the Department of Medical Education
    • Director, Physician Well-Being for Northwestern Medical Group
    • Director, Undergraduate Medical Student Education in Psychiatry at Northwestern University Feinberg School of Medicine
  • Alan “Tony” Amberg, MS, MSN, APRN, PMHNP-BC
    • PsychU Nurses Corner Section Advisor
    • Psychiatric Consult Liaison
    • Psychiatric Nurse Practitioner, Northwestern Memorial Hospital
  • Phyllis Foxworth, BS
    • Vice President of Advocacy, Depression Bipolar Support Alliance (DBSA)
  • Jonathan Singer, PhD, LCSW
    • Associate Professor, Loyola University Chicago
    • President, American Association of Suicidology
  • Rachel Self, MS, PhD
    • Senior Medical Science Liaison, Otsuka Neuroscience Medical Affairs

If you or someone you know is in crisis, call: Suicide Prevention Hotline/Lifeline 1-800-273-TALK(8255) Or text: Crisis Text Line 741-741

Gaurava Agarwal, MD, and Sloan Manning, MD, Alan “Tony” Amberg, MS, MSN, APRN, PMHNP-BC, Phyllis Foxworth, BS, and Jonathan Singer, PhD, LCSW are paid consultants of Otsuka Pharmaceutical Development & Commercialization, Inc.

Rachel Self, MS, PhD, is a paid employee of Otsuka Pharmaceutical Development & Commercialization, Inc.

Optimizing both population health and individual patient care will require major changes in how health care is delivered, starting with a systemic focus. In this webinar, three expert panelists from OPEN MINDS—Sharon Hicks, MBA, MSW; Richard Louis III; and Paul Duck—discuss the current paradoxical state of care delivery, in which providers are sometimes expected to achieve mutually incompatible goals. Their conversation covers the critical role that care management, clinical communication, and electronic interoperability must play for successful population management to occur. Additionally, the critical importance of the social determinants of health (SDoH) is considered.

Featuring:

  • Sharon Hicks, MBA, MSW
    Senior Associate, OPEN MINDS
    Former Chief Operating Officer, Community Care Behavioral Health
  • Richard Louis III
    Vice President–Western Region, OPEN MINDS
    Former Director of Development – Behavioral & Addiction Medicine, Southern California Hospitals Healthcare Systems Inc.
  • Paul Duck
    Senior Associate, OPEN MINDS
    Former Vice President–Strategy and Development, Beacon Health Options

Sharon Hicks, MBA, MSW, is a Senior Associate with OPEN MINDS and has more than 20 years of experience in the health and human services field, with expertise in health plan management, clinical operations management, and technology.

Richard Louis, III, is the Vice President–Western Region with OPEN MINDS and has extensive experience as a behavioral health care administrator, business development specialist, and innovator of new service lines for behavioral health care organizations.

Paul M. Duck has more than 30 years of experience in leadership and management, with a focus on managed care, health information technology organizations, strategy, business development, market expansion, and customer experience optimization. He serves as a Senior Associate with OPEN MINDS.

As of June 17, 2020, more than 120 behavioral health provider organizations had been awarded funding through the $200 million Federal Communications Commission (FCC) coronavirus disease 2019 (COVID-19) Telehealth Program. To date, the FCC has awarded about $128 million in approved funding for 367 health care provider organizations in 42 states plus the District of Columbia. The average award is about $349,393, and the median is $242,600, with amounts ranging from the low of $1,468 to Leyden Family Services and Mental Health Center to $1 million awarded to 14 hospital systems.

The COVID-19 Telehealth Program was created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act to support the expansion of telehealth services during the coronavirus disease 2019 (COVID-19) pandemic. The CARES Act also created the three-year, $100 million Connected Care Pilot Program. The pilot will provide funding from the FCC’s Universal Service Fund (USF) to support 85% of health care provider organization costs for telehealth equipment and the cost of providing eligible services. The goal is to help assess how the USF can be used in the long-term to support telehealth. The FCC released the pilot program rules on April 9, 2020. Pilot program applications will be due by July 31, 2020. No awards have been made as of June 21, 2020. The anticipated number of awards or the award size have not been released.

On June 10, 2020, the FCC had announced that more than 100 behavioral health provider organizations had been awarded funding through the COVID-19 Telehealth Program of the 305 awarded as of that date. On June 17, the FCC announced 62 more awards. The list indicates that 21 awards were made to behavioral health provider organizations or community health centers that intended to use telehealth to provide behavioral health services.

The FCC COVID-19 Telehealth Program provides immediate support to eligible health care provider organizations responding to the COVID-19 pandemic by fully funding their telecommunications services, information services, and devices necessary to provide telehealth services until the program’s funds have been expended or the COVID-19 pandemic has ended. The funding can be used to purchase laptop computers, tablets, smartphones, videoconferencing equipment, mobile hot spots, video monitors, remote monitoring devices, software licenses, network upgrades, and subscriptions for telehealth platforms. The maximum grant is $1 million.

Rules for the Connected Care Pilot Program were released on April 2, 2020. The FCC released more information about the pilot in “Report & Order: Promoting Telehealth For Low-Income Consumers.” Participation in the pilot will be open to non-profit or public health care provider organizations including the following eight provider organization types:

  1. Post-secondary educational institutions offering health care instruction, teaching hospitals, and medical schools
  2. Community health centers or health centers providing health care to migrants
  3. Local health departments or agencies
  4. Community mental health centers
  5. Non-profit hospitals
  6. Rural health clinics
  7. Skilled nursing facilities
  8. Consortia of health care provider organizations consisting of one or more entities falling into the first seven categories

For the purpose of the pilot, the FCC considers “connected care” as a subset of telehealth that uses broadband internet access service-enabled technologies to deliver remote medical, diagnostic, and treatment-related services outside of traditional medical facilities and directly to consumers at their mobile location or residence. Connected care services can be provided by physicians, nurses, or other health care professionals. Also for the pilot, the FCC defines “telehealth” as the broad range of health care-related applications that depend upon broadband connectivity, including telemedicine; exchange of electronic health records; collection of data through Health Information Exchanges and other entities; exchange of large image files (e.g., X-ray, MRIs, and CAT scans); and the use of real-time and delayed video conferencing for a wide range of telemedicine, consultation, training, and other health care purposes.

The FCC released a list of the organizations and their projects for the COVID-19 Telehealth Program approved as of May 13, 2020. A link to the list may be found at www.openminds.com/market-intelligence/resources/051320fcccovidtelehealthawards.htm.

On June 10, the FCC released another list, but this list has only the organization names approved for the COVID-19 Telehealth Program. It does not have project descriptions. This list is available at www.openminds.com/market-intelligence/resources/061020fcccovid19telehealthprogawards.htm.

A link to the full text of “FCC Report & Order: Promoting Telehealth For Low-Income Consumers” may be found at www.openminds.com/market-intelligence/resources/040220fccreporttelehealth.htm.

A link to the full text of “Promoting Telehealth For Low-Income Consumers; COVID-19 Telehealth Program” may be found at www.openminds.com/market-intelligence/resources/040920fccfinalrulecovid19telehealthpilot.htm.

PsychU last reported on the CARES Act in “HHS Begins Releasing $100 Billion CARES Act Funding To Provider Organizations For Relief Assistance & Treating The Uninsured,” which published on May 4, 2020. The article is available at https://www.psychu.org/hhs-begins-releasing-100-billion-cares-act-funding-to-provider-organizations-for-relief-assistance-treating-the-uninsured/.

For more information, contact:

  • Will Wiquist, Media Contact, Federal Communications Commission, 445 12thStreet Southwest, Washington, District of Columbia 20554; 202-418-0509; Email: Will.Wiquist@fcc.gov; Website: https://www.fcc.gov/.

For more information about the COVID-19 Telehealth Program, contact:

  • Email: EmergencyTelehealthSupport@fcc.gov; Website: https://www.fcc.gov/covid-19-telehealth-program

For more information about the Connected Care Pilot Program, contact:

  • Email: ConnCarePltProg@fcc.gov; Website: https://www.fcc.gov/document/fcc-fights-covid-19-200m-adopts-long-term-connected-care-study and https://www.fcc.gov/keep-americans-connected

During the week ended April 25, 2020, Medicare received 1.4 million claims for services provided by telehealth. During the week ended March 7, 2020, before the coronavirus disease 2019 (COVID-19) pandemic national emergency, the Centers for Medicare & Medicaid Services (CMS) received about 13,000 claims for telehealth services.

According to a CMS spokesperson, the number of Medicare beneficiaries receiving telehealth services increased rapidly, from the 13,000 per week before the national emergency, to 1.1 million during the first week of April, just a month later. During April, telehealth claims continued to rise to 1.3 million during the week ended April 18 and again to the 1.4 million claims during the week ended April 25.

On May 26, 2020, CMS Administrator Seema Verma said CMS is evaluating its Medicare telehealth waivers to determine if they should be extended past the scope of the national emergency. She said CMS is in the rulemaking process, and she indicated that some temporary provisions will be made permanent. As of June 17, 2020, further information had not been released.

On March 30, 2020, after the national emergency was announced on March 13, 2020, CMS relaxed regulations on Medicare telehealth eligibility to allow all beneficiaries to receive many services via telehealth technologies. The goal was to help beneficiaries shelter in place during the national emergency. CMS allowed Medicare beneficiaries nationwide to receive services where they live, including residents of nursing homes or assisted living facilities, and those receiving home health or hospice benefits. Telehealth services can be used to fulfill many Medicare face-to-face visit requirements for clinical professionals to see beneficiaries in inpatient rehabilitation facilities, receiving hospice services, or receiving home health.

Prior to the new flexibilities, telehealth was available only to beneficiaries living within a rural health professional shortage area or in a county outside of a metropolitan statistical area. The beneficiary had to present at an approved originating site and be previously established with the remote professional. The services could be delivered only by physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists and clinical social workers, registered dietitians, or nutrition professionals. Only certain services could be delivered via telehealth.

A link to the full text of “COVID-19 Emergency Declaration Blanket Waivers For Health Care Providers” may be found at www.openminds.com/market-intelligence/resources/061220cmsupdateswaiverscovid.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/; or Email: MedicareProviderData@cms.hhs.gov.

There is some confusion about where we are—economically—in the midst of the crisis caused by the coronavirus pandemic. We are in a recession and likely on the front edge of a depression. There is wide disagreement about the “shape” of the recovery. Unfortunately, “reopening” and “recovery” are being used interchangeably.

“Reopening” is the phrase being used for an end to some of the government-imposed restrictions on organizational operations in order to prevent the spread of coronavirus. Nearly all 50 states have moved to some level of reopening— “reopening” comes in all forms.

While “reopening” is often required for the financial “recovery” of many organizations, the terms are not synonymous. To reopen physical operations does not mean the return to profitability. There are increased costs of safety measures—from personal protective equipment, to testing, to ventilation systems, and more. In addition, restrictions on capacity are widespread. Limits on the proportion of restaurant capacity that can be used. Limits on the size of gatherings. Limits on the physical distance of consumers in establishments. There are also questions about how many consumers will return to “being served.”

For the health and human service field, the reopening versus recovery issues are many. In a recent discussion, a residential treatment provider organization executive said that given the design of their facility, for the foreseeable future, they would need to operate at 80% capacity to ensure the safety of consumers. There will likely be a significant decrease in rates for virtual services as the market capacity—and competition—increases. What ‘in office’ services will consumers be comfortable receiving is another question. If consumers want more service ‘at home’, how can they be delivered profitably—since home-based services were not profitable before the pandemic crisis.

In short, the reopening is tactical, but recovery as strategic. Reopening requires a policy, an implementation plan, and a budget. Recovery for most health and human service organizations will require not only a new strategic plan—but also new business models. What services an organization delivers, the operational framework for how they deliver those services, the breakeven volume and scalable profitability of each service, the overall portfolio mix of profitable and unprofitable services—these are the types of very fundamental questions that recovery planning needs to address.

On June 5, 2020, the National Committee for Quality Assurance (NCQA) announced adjustments to 40 Healthcare Effectiveness Data and Information Set (HEDIS) measures to support the use of telehealth during the coronavirus disease 2019 (COVID-19) pandemic and after. NCQA will apply the adjustment for measurement of health care quality starting in 2020. The adjustments align with guidance from the Centers for Medicare & Medicaid Services and other federal and state regulators.

NCQA is updating the measures in “HEDIS Volume 2 Technical Specifications,” which will be published on July 1, 2020. Telehealth revisions will be outlined in each measure specification’s “Summary of Changes” section. The guidance will specify how telehealth visits can be used, what will be included in the measure denominator and numerator, and what will be excluded. It will also specify what type of telehealth (e.g., synchronous telehealth visits, telephone visits or asynchronous e-visits or virtual check-ins) is permitted to meet the measure.

Eight of the adjustments affect behavioral health measures:

  1. Antidepressant Medication Management
  2. Follow-up Care for Children Prescribed ADHD Medication
  3. Follow-up After Hospitalization for Mental Illness
  4. Follow-up After Emergency Department Visit for Mental Illness
  5. Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medication
  6. Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
  7. Diabetes Monitoring for People with Diabetes and Schizophrenia
  8. Adherence to Antipsychotic Medications for Individuals with Schizophrenia

The remaining measures with new telehealth accommodations concern prevention and screening, respiratory care, cardiovascular care, diabetes care, musculoskeletal conditions, care coordination, access and availability of care, utilization, and risk-adjusted utilization. The accommodations also affect measures reported using electronic clinical data systems. Within these remaining measures, some also affect behavioral health services.

Prevention and Screening

  1. Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
  2. Breast Cancer Screening
  3. Colorectal Cancer Screening
  4. Care for Older Adults

Respiratory

  1. Use of Spirometry Testing in the Assessment and Diagnosis of COPD
  2. Asthma Medication Ratio

Cardiovascular Conditions

  1. Controlling High Blood Pressure
  2. Persistence of Beta-Blocker Treatment After a Heart Attack
  3. Statin Therapy for Patients with Cardiovascular Disease
  4. Cardiac Rehabilitation

Diabetes

  1. Comprehensive Diabetes Care
  2. Kidney Health Evaluation for Patients with Diabetes
  3. Statin Therapy for Patients with Diabetes

Musculoskeletal Conditions

  1. Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis- Scheduled for Retirement
  2. Osteoporosis Management in Women Who Had a Fracture
  3. Osteoporosis Screening in Older Women

Care Coordination

  1. Transitions of Care
  2. Follow-up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
  3. Access/Availability of Care

Access/Availability of Care

  1. Prenatal and Postpartum Care
  2. Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics

Utilization

  1. Well-Child Visits in the First 30 Months of Life
  2. Child and Adolescent Well Care Visits
  3. Mental Health Utilization

Risk-Adjusted Utilization

  1. Plan All-Cause Readmissions
  2. Hospitalization Following Discharge from a Skilled Nursing Facility
  3. Acute Hospital Utilization
  4. Emergency Department Utilization
  5. Hospitalization for Potentially Preventable Complications

Measures Reported Using Electronic Clinical Data Systems

  1. Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
  2. Depression Screening and Follow-up for Adolescents and Adults
  3. Postpartum Depression Screening and Follow-up
  4. Prenatal Depression Screening and Follow-up
  5. Breast Cancer Screening
  6. Colorectal Cancer Screening
  7. Follow-up Care for Children Prescribed ADHD Medication

More information about the changes is posted at https://www.ncqa.org/covid/.

For more information, contact:

  • Andy Reynolds, Assistant Vice President, Marketing And Communications, National Committee for Quality Assurance, 1100 13th Street Northwest, 3rd Floor, Washington, District of Columbia 20005; 202-955-3518; Email: reynolds@ncqa.org; Website: https://www.ncqa.org/
  • Matt Brock, Communications Director, National Committee for Quality Assurance, 1100 13th Street Northwest, 3rd Floor, Washington, District of Columbia 20005; 202-955-1739; Fax: 202-955-3599; Email: brock@ncqa.org; Website: https://www.ncqa.org/

Our coverage of primary care physicians’ views of addiction treatment and medication assisted treatment (MAT) brought quite a few comments. A recent study found that even though two thirds of physicians believe that addiction treatment is more effective with medication than without (67.1%)—and that consumers can safely use those medications (63.7%)—only 20% of physicians reported an interest in treating opioid use disorders (OUDs).

Add to this picture a primary care landscape where physicians seldom screen for addiction of their own accord, and nurse practitioners and physician assistants feel little responsibility or comfort addressing the issue at all. Only about 57% of primary care clinical professionals report screening consumers for any kind of addiction, only 46% provide any kind of intervention, and only 47% provide a referral for treatment.

The good news is that there are a number of “change management” models to increase the success of addiction treatment services in primary care. What these models share is a two-pronged approach to changing both systems and structure while addressing leadership and staff skills at the same time. But several readers suggested that an approach that is better than educating the broad primary care community about this issue is to turn the model around and embed primary care in addictions treatment.

One suggestion from OPEN MINDS Circle member Dr. Scot Adams, former Director of Nebraska Department of Health and Human Services, Division of Behavioral Health, is to move to a “whole person” model for addiction treatment—bringing primary care into addiction treatment organizations. He wrote, “One answer to the question of addictions treatment post-COVID is found in models like the Certified Community Behavioral Health Clinics (CCBHC). The Substance Abuse and Mental Health Services Administration (SAMHSA) has had three rounds of funding for these. In short, rather than bringing addictions treatment into the primary care office, they bring primary care into the addictions treatment center.”

Some addictions treatment provider organizations are well ahead on the integration journey. Lakeview Health has multi-site adult addiction treatment programs in Florida and Texas, treating alcohol use, opioid use, and substance use disorders (SUD) as well as co-occurring disorders. Lakeview Health’s staff includes a board-certified internist and a psychiatrist who is also a family practitioner—this helps the organization easily address the medical issues faced by its SUD consumers. Lantie Jorandby, M.D., Chief Medical Officer at Lakeview Health, explained how the integrated care model helped them provide holistic care during the pandemic crisis, test consumers for COVID-19, and address all of their co-occurring disorder treatment needs.

Tarzana Treatment Centers, Inc. (TTC) has been providing primary care services integrated with behavioral health since the mid-1990’s, and serves the underserved, low-income population of Los Angeles and surrounding counties. It currently contracts with primary care physicians to operate six primary care clinics that are co-located with TTC’s SUD and mental health treatment facilities. Chief Executive Officer and President Albert M. Senella explained that TTC’s primary care services are part of their whole person care approach integrating mental health, SUD, and primary care services for adults and youth. Their full range of mental health and SUD programs include outpatient, inpatient, and residential treatment, sober living services, a primary care assessment for consumers, and access to primary care treatment when needed. TTC created a “no wrong door” model to access, ensuring that all consumers in any of TTC’s programs or levels of care have access to primary care treatment. TTC also offers follow up primary care in consumers’ homes via telehealth. TTC is accredited by the Joint Commission as a Behavioral Health Home and Patient-Centered Medical Home.

Whatever the model, a key obstacle pointed out by Dr. Adams is the cultural difference between the mindsets of “traditional” addiction treatment professionals and other health care professionals. The reality is that primary care and addiction treatment (and behavioral health care overall) are very different cultures built on different approaches to clinical professional education, management, and business administration. Learning to communicate effectively with both sides of the house is a critical issue. He explained, “Many behavioral health practitioners who ‘grew up’ on the mental health side, without immersion into addictions, think it can be as simple as adding a 12-step meeting to routine mental health programming to call it ‘co-occurring treatment.’ Thus, they don’t really ‘hear’ the content. This dynamic in culture is important because persons in recovery are often better able to relate to and connect with persons actively immersed in addictive patterns. Missing the addiction can undermine all other treatments.”

Learning the critical skill of “code switching” becomes a priority when managing teams of different disciplines. In the post-crisis period, most analysts are predicting an increase in substance abuse and addictive disorders—and with it an increase in demand for treatment and related expenses. Payers and health plan executives will be in search of the treatment model with the best clinical outcomes and total cost of care. An integrated care model is most likely to deliver.

On June 19, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based purchasing (VBP) arrangements with drug manufacturers. The proposed rule provides drug manufacturers with regulatory support to enter into VBPs with payers. VBP arrangements can be defined as “performance requirements” under the definition of a “bundled sale.” If a manufacturer is participating in a VBP arrangement, the drug manufacturer can report multiple best prices for a therapy—the prices tied to specific VBP arrangements— under the Medicaid Drug Rebate Program (MDRP).

In a fact sheet about the proposed rule, CMS said it believes providing state Medicaid programs with flexibility to enter into VBP arrangements with drug manufacturers is an important strategy to manage drug costs and promote beneficiary access to needed medications. CMS recognized that the current MDRP regulations were a barrier to medication related VBP arrangements. By changing the regulations, CMS intends to encourage states to enter into VBP arrangements for drug therapies, especially in cases when the therapy will safeguard against unnecessary utilization of other, more expensive medical services. To reach this goal, the proposed rule presented changes allowing manufacturers to do the following:

  • Report multiple “best prices” for a therapy under the MDRP if the prices are tied to a VBP arrangement.
  • Define a VBP arrangement in terms of evidence-based and outcomes-based measures.
  • Include certain VBP arrangements under the definition of “bundled sale.”
  • Revise average manufacturer’s price (AMP) and best price reporting beyond the current 36-month time limit to allow for revisions to pricing metrics as a result of VBP arrangements.

CMS also revised how a drug manufacturer must calculate the AMP of a brand-name drug that has an authorized generic, which are made by the original manufacturer of the brand-name drug. Currently, manufacturers are permitted to include the sales of the authorized generic in the AMP of the brand name drug. However, this practice lowers AMPs and reduces rebates paid for the brand name drugs. The proposed rule excludes sales of authorized generic drugs when brand manufacturers have approved, allowed, or otherwise permitted an authorized generic to be sold under the brand name drug’s new drug application (NDA).

Comments on the proposed rule, “Establishing Minimum Standards In Medicaid State Drug Utilization Review (DUR) And Supporting Value-Based Purchasing (VBP) For Drugs Covered In Medicaid, Revising Medicaid Drug Rebate And Third Party Liability,” are due by July 20, 2020. The proposed rule did not state a target implementation date.

A link to the full text of “Establishing Minimum Standards In Medicaid State Drug Utilization Review (DUR) And Supporting Value-Based Purchasing (VBP) For Drugs Covered In Medicaid, Revising Medicaid Drug Rebate And Third Party Liability” may be found at www.openminds.com/market-intelligence/resources/061920nprmcmsmedicaidpharmavbid.htm.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/newsroom/fact-sheets/establishing-minimum-standards-medicaid-state-drug-utilization-review-dur-and-supporting-value-based.

For more information, contact (for both Humana and Healthmap Solutions): 

  • Alissa Krinsky, Corporate Communications, Humana, Inc., 550 West Adams Street, 5thFloor, Chicago, Illinois 60661; 312-441-5576; Email: AKrinsky@humana.com; Website: https://www.humana.com/

Physician-led accountable care organizations (ACOs) represented approximately 45% of all ACOs (about 549 of 1,221 total ACOs included in the study), as of December 2018. During this year, hospital-led ACOs accounted for approximately 25% of all ACOs, and joint-led ACOs represented 30%. ACOs consist of health care provider organizations that accept responsibility for the cost and quality outcomes of a defined population. Physician-led ACOs are defined as organizations that are involved in ACOs that do not involve hospitals directly in the payment arrangement, or in the broader organization.

As of December 2018, an estimated 28% of existing health systems or independent hospitals were participating in an ACO of the more than 1,700 hospitals or systems that could potentially form an ACO. Only an estimated 6% of the more than 8,200 physician groups that are large enough to ultimately form an ACO, have done so.

The researchers concluded that physician-led ACOs will likely be the dominant type of ACO in the future. This is due to the greater market potential of ACOs. However, current ACO policies and strategies that have been designed for hospitals and health systems must be restructured to better support physician-led ACOs. Additionally, policies should encourage the support of physician-led ACO partnerships with other organizations.

These findings were presented in “Accountable Care Organizations Are Increasingly Led by Physician Groups Rather Than Hospital Systems,” by David Muhlestein, Ph.D., J.D.; Tianna Tu, BA; and Carrie H. Colla, Ph.D. The researchers analyzed data from the Leavitt Partners ACO database, which tracks organizations that are participating in accountable care payment arrangements and includes information on organizational structure. This database represented 1,221 of 1,334 ACOs as of the end of 2018. The goal was to determine the overall structure of ACOs, and project the future of ACOs in the marketplace.

The full text of “Accountable Care Organizations Are Increasingly Led by Physician Groups Rather Than Hospital Systems” was published May 14, 2020 by The American Journal of Managed Care. A copy is available online at https://www.ajmc.com/journals/issue/2020/2020-vol26-n5/accountable-care-organizations-are-increasingly-led-by-physician-groups-rather-than-hospital-systems.

PsychU last reported on this topic in “Physician-Led ACOs Generated Almost 7 Times More Savings Than Hospital-Led ACOs,” which published on December 2, 2019. The article can be found at https://www.psychu.org/physician-led-acos-generated-almost-7-times-more-savings-than-hospital-led-acos/.

For more information, contact: 

  • David B. Muhlestein, Ph.D., J.D., Chief Strategy and Chief Research Officer, Leavitt Partners, 299 South Main Street, Suite 2300, Lake City, Utah 84111; 801-538-5082; Email: david.muhlestein@leavittpartners.com; Website: https://leavittpartners.com/

So much discussion of canoes these days. Until 12 weeks ago, executives of specialty provider organizations had to balance “two canoes”—operating in a fee-for-service (FFS) or cost-based environment, with operating in a wide array of emerging performance-based and value-based reimbursement (VBR) models. But with the pandemic crisis, another layer of complexity has been added—surviving through the crisis while developing a sustainable (and innovative) post-crisis recovery strategy. This is a situation more akin to controlling four canoes.

A common question from executive teams is whether to temporarily shelve the plans for alternative payment models during this crisis period. The answer is two-fold. Certainly, putting a crisis management financial survival plan is a first-order priority. This means grappling with cash flow, maximizing revenue as much as possible, determining a temporary break-even, and reducing expenses to match. These crisis management financial survival plans are the reason we see continuing announcements of layoffs and furloughs in the press.

But one could argue that for most provider organizations, being able to accept more VBR, with more financial risk, will likely be part of any recovery plan. As of OPEN MINDS last survey in March 2020, about 74% of primary care organizations and 61% of behavioral health organizations are participating in some form of VBR, and 16% of those organizations have 20% or more of their revenue in this type of contract. If the prognostications of health plan executives we’ve recently interviewed are any indication, this will likely increase in the post-crisis period.

With that in mind, the discussion during The 2020 OPEN MINDS Strategy & Innovation Institute session, One Foot In Two Canoes: Managing Service Lines For Value-Based Reimbursement & Fee-For-Service At The Same Time, provided some great insights into navigating the transition to VBR. The session featured Friendship Community Care’s Chief Executive Officer, Cindy Mahan, and Executive Vice President of Strategy and Planning, Craig Cloud; as well as Centerstone’s Vice President of Quality, M. Brad Nunn, Ph.D., and Director of Healthcare Innovation, Mandi Ryan, and was moderated by OPEN MINDS Senior Associate, Joe Naughton-Travers.

Dr. Nunn and Ms. Ryan presented Centerstone’s work with the Tennessee Health Care Innovation Initiative Strategy, which includes patient-centered medical homes (PCMH); health homes for severe and persistent mental illness; reimbursement using episodes of care; and quality and acuity adjusted payments for long-term services and supports (LTSS). The payment structure includes case rate payments for health home services and financial incentives for high-performing provider organizations. It also includes episodes of care payments (two of 48 diagnoses are behavioral health) based on a FFS model with penalties for high costs and gainsharing payments if costs are kept below a threshold.

Friendship Community Care is participating in the Arkansas Medicaid initiative— “Provider-Led Arkansas Shared Savings Entities” (PASSEs). These are “organized care” models that are at risk for all services (physical health care services, behavioral health services, and specialized home- and community-based services) for approximately 40,000 individuals who have intensive levels of treatment or care due to mental illness, addiction, or intellectual/developmental disabilities. In this model, provider organization/health plan collaboratives assume the financial risk.

So, what should executives leading the shift toward VBR—while managing FFS reimbursements at the same time—be doing to keeping both canoes on course? Focus on three areas—staff skills and training, system integration and data management, and financial performance. While things are moving rapidly, and the crisis is shifting timelines for the transition, it is important not to rush, advised our speakers. Stop and do things right, because the transition demands care and dexterity.

  1. Staffing:Whether it’s FFS or VBR, clinical professionals are providing the same type and level of care with the goal of helping consumers get better. But it is managers who need to have two diametrically opposite perspectives. Can one person really manage two antithetical programs—one based on service volume and the other based on the right outcomes with less volume? Can they “switch from a left brain to right brain approach,” as Mr. Naughton-Travers put it? What we may need is two different managers to paddle the two canoes. Staff across the organization who have operated in a traditional FFS model will need to be trained in the new norms of VBR and will need a clear understanding of expected outcomes.
  2. Systems and data: Provider organizations collect a large volume of data but that usually happens in silos. If all systems are integrated (for example, if the electronic health records are integrated with the enterprise resource planning system) and you invest in staff skilled at business analytics—as both Friendship Community Care and Centerstone have done—executives will have the data they need to continuously monitor the variables for both FFS (productivity) and VBR (impact). Further, policies and procedures to manage each payment stream must be clearly laid out and shared with all staff.
  3. Financial performance: Balancing both canoes requires a laser focus on financial performance. Revenue cycling is critical as Ms. Mahan pointed out. Concurrent clinical documentation is key so billing can happen quickly and accurately. Billing staff must have experience in both types of billing and have access to the data that payers expect.

The pandemic crisis already calls for some exceptional navigation skills to steer through extreme market turbulence. Having one foot in the FFS canoe and the other in VBR makes it more precarious than ever before. But health plans and payers have told us that VBR is gaining traction and we can’t ignore the future even as we manage the present.

The adoption of value-based reimbursement (VBR) has been inconsistent over the past few years. But the consensus is that the recession that is upon us and the likely reduced federal/state budgets will drive more VBR and more financial risk transfers from managed care organizations to provider organizations.

OPEN MINDS does a lot of organizational assessments of ‘readiness’ for VBR—and they have developed a self-assessment tool to do just that. The tool has several key domains including provider network management; consumer access and service engagement; financial management; leadership and governance; technology and reporting; and clinical management and performance optimization. But, readiness assessments tend to focus on the organizational management infrastructure. A big question for executive teams is whether clinical programs are ready for VBR. That was the focus of the session, “Creating & Managing The Clinical Models You Need For Value-Based Reimbursement,” led by Dominick DiSalvo, MA, LPC, Corporate Director, Clinical Services, KidsPeace at The 2020 OPEN MINDS Strategy & Innovation Institute.

KidsPeace offers a full continuum of behavioral health care services for children and families, from serving youth in the foster care and child welfare system to providing residential treatment, accredited educational services, and a free-standing psychiatric hospital. Headquartered in Pennsylvania, its services span 10 states and the District of Columbia. Between 2016 and 2017, the organization followed the state of Pennsylvania in its initial journey to VBR. Since then, KidsPeace has participated in performance-based contracting, including pay-for-performance, with payments linked to a specific set of benchmarked outcomes.

But success with VBR doesn’t come without its challenges—it requires a significant shift in both leadership mindset and organizational infrastructure. As Mr. DiSalvo discussed, “The most difficult task we have is to limit risk by finding the balance between person/family-centered care and structured programs that reduce variability in services and outcomes.” His advice? Focus on trauma-informed care; synthesize evidence-based clinical models; use data to drive clinical decision-making; and engage clinical professionals to engage consumers.

Focus On Trauma-Informed Care
KidsPeace began the move to VBR by using the Trauma History Questionnaire (THQ), a 24-item self-report measure that examines an individual’s experience with possible traumatic events including crime, physical or sexual assault, and neglect. Mr. DiSalvo described this as a necessary first step in moving toward a value-based framework for care, because when trauma wasn’t factored in, the desired treatment outcomes were not being achieved. After it started to implement trauma-informed care, KidsPeace found that youth self-reported experiencing an average of 10 traumatic categories before entering the program. The new focus on trauma as an underlying cause required a considerable shift in how clinical professionals were supporting consumers—and how senior leaders were supporting clinical professionals. “This data really convinced our leadership team that we needed to have a complete change in focus—we needed to be family and youth driven, trauma-informed, and have data drive what is going on in our programs,” said Mr. DiSalvo.

Synthesize Evidence-Based Clinical Models
After understanding the “value” of becoming trauma-informed to provide more effective treatment—and ultimately—more meaningful and measurable outcomes, KidsPeace completely restructured their clinical programming by synthesizing a core set of evidence-based practices within each program. The restructure allowed each individualized treatment plan to be guided by both the youth and their family—and driven by objective and relevant data—an essential part in defining “value” for each consumer. The organization adopted four clinical practice models—including trauma focused-cognitive behavioral therapy (with all clinical leadership becoming or in the process of becoming Nationally Certified Trauma Therapists); motivational interviewing (to increase motivation and engagement among youth); community living (to prepare adolescents for young adulthood and community inclusion); and individualized treatment planning. By using these four clinical models, the organization has the flexibility to provide individualized care as well as the consistency and structure to meet the needs of all youth and families that are served.

Use Data To Drive Clinical Decision Making
Before they restructured clinical program models to focus on value, Mr. DiSalvo noted that KidsPeace had challenges with using data to drive treatment and decision making processes. “When I had conversations with our foster care program in Indiana versus conversations with our residential program in Georgia, the way they captured data and assessed youth were very different.” To ensure consistency across all programs, no matter the location or service line, the organization moved to a corporate wide electronic health record and adopted the use of a data dashboard to visually track key metrics over time. Those metrics included discharge disposition and post-discharge follow up surveys, high risk behaviors (e.g. suicidal ideation), clinical treatment benchmarks, length of stay, and individualized score cards in graph format. The data is then broken down further by day, time of day, over time, and total score. “We’ve even gotten as granular as examining if there is a particular staff member that youth are struggling more with and if we need to provide more training.” The key quality indicators (in a simple, color-coded format) are reviewed quarterly with the senior leadership team to quickly identify any pain points and make changes to maximize program efficiency. Mr. DiSalvo explained, “Not only can we track youth individually, but we are also able to track specific program progress from an aggregate level—and then make changes and help continuously improve that program.”

Engage Clinical Professionals To Engage Consumers
To truly drive optimal outcomes in value-based clinical programming, Mr. DiSalvo highlighted a final key component—engaging clinical professionals. “It’s impossible to succeed with risk-based payment models if staff aren’t engaged. If a child feels like a staff member is there simply to get a paycheck, they are not going to respond well.” Rather, a significant shift in mindset was necessary for many professionals to continuously find ways to improve the overall experience for youth, families, and staff. “Once we started to have the data inform practice, our clinicians started seeing clear, quantitative results. Once that happened, it was a ripple effect—our youth found more enjoyment in their experience. Ultimately, it’s the clinicians who then become the champions for change.”

Any significant transformation isn’t sustainable without embedding those changes within the organizational culture. Mr. DiSalvo discussed the importance of cultivating a cohesive culture to act as the foundation of any clinical program focused on providing value, “Our initiative at KidsPeace is to integrate all of our resources to improve safety, engagement, connection, clinical practice and outcomes for all staff, youth, and families but it doesn’t come naturally. It requires robust training and a strong understanding about what engagement actually looks like. Clinical professionals must move away from the mindset that ‘we are the ones who know best’ and understand that the family and youth are the experts. We are simply here to join them in their journey.”

The major takeaway from the session is that it’s not enough to have your administrative and financial infrastructure “ready” for VBR. Making clinical programs VBR-ready is a critical aspect of strategy development for sustainability.

The health care economy continues to shift from the fee-for-service model that has been in existence for decades to value-based payment. While many forms of value-based models are being trialed and implemented, there are examples of models that span slight experimentation through provider organizations partnering with payers to take on full medical risk for a population. In this webinar, our speakers discuss innovations around new payment models in a lively townhall format.

Featuring:

  • Deb Adler, CPHQ
    Senior Associate, OPEN MINDS
  • Steven Remillard, D.C.
    Senior Associate, OPEN MINDS
  • Paul Duck
    Senior Associate, OPEN MINDS


Deb Adler, CPHQ, has more than 20 years of experience in executive health care roles, serving in a variety of capacities, including network executive, quality management executive, and COO. She is the former Senior Vice President of Network Strategy for Optum, where she was responsible for behavioral health network development, contracting, and strategy for more than 185,000 providers. In this role, she developed the largest performance-tiered behavioral health network, the largest telemental health network, and the largest medication-assisted treatment (MAT) network. She was also responsible for implementing network initiatives to promote medical/behavioral integration, improve member outcomes, and reduce total cost of care through collaborative care models. Currently, she serves as a Senior Associate at OPEN MINDS. Ms. Adler earned her MA in psychology and evaluation from Catholic University of America and is a Certified Professional in Health Care Quality (CPHQ).

Steven Remillard, D.C. currently serves as a Senior Associate at OPEN MINDS. With more than 25 years of experience in the health and human services field, he leads projects related to value-based purchasing, integrated care programming, HEDIS measurement, data-driven organizational development, and the social determinants of health. Previously, Dr. Remillard served as the Special Assistant to the Secretary of the Pennsylvania Department of Human Services. In this role, Dr. Remillard directed a federal grant to promote innovation in hospital-based behavioral and physical health care integration. Dr. Remillard also supported various stakeholder groups in the implementation of integrated care planning.

Paul Duck currently serves as a Senior Associate at OPEN MINDS. He brings more than 30 years of experience in leadership and management, focusing on managed care, health information technology, strategy, business development and market expansion, and customer experience optimization to the OPEN MINDS team. Previously, Mr. Duck has served in roles such as Vice President, Strategy & Development for Beacon Health Options, the Vice President of Business Development for Netsmart Technologies, and Chief Executive Officer for Coastal Orthopedics. Mr. Duck earned his BA in business management from Case Western Reserve University. He earned his AA in electronic engineering technology from the Electronic Technology Institute.

Prior to the coronavirus disease 2019 (COVID-19) pandemic, the average primary care physician compensation rose by 2.5%, from $237,000 in 2019 to $243,000 in 2020. Between October 4, 2019 and February 10, 2020, average specialist salaries rose by 1.5%, from $341,000 in 2019 to $346,000 in 2020. The highest average annual compensation was for orthopedics at $511,000; the lowest was for pediatrics at $232,000. Average annual compensation for psychiatrists was $268,000.

For the time period reviewed, about 58% of primary care physician practices, and 55% of specialist practices offered an incentive bonus. Examples of incentive bonuses are collections bonuses (monies collected from consumers, resulting in a net profit) and work relative value unit (productivity measure) bonuses. The average incentive bonus for all health care workers is about $26,000; however, the average incentive bonuses for specialty physicians ranges from $31,000 to $96,000. PCP physicians usually earn 64% of an incentive bonus, while specialists usually earn 69% of an incentive bonus.

These statistics were released on May 14, 2020, in the Medscape “Physician Compensation Report 2020” by Leslie Kane, MA. The findings are based on analysis of survey responses collected between October 4, 2019 and February 10, 2020, from more than 17,000 physicians working in 30 specialties. The survey examined salary, incentive bonus, and denied claims, and their attitudes about the field of medicine.

The full text of the Medscape “Physician Compensation Report 2020,” was released on May 14, 2020. A copy is available online at https://www.medscape.com/slideshow/2020-compensation-overview-6012684.

For more information, contact: 

  • Leslie Kane, MA, Business of Medicine, Medscape, 825 8thAvenue, New York, New York 10019; 212-301-6700; Email: LKane@webmd.net; Website: https://www.medscape.com/author/leslie-kane

The Medicare Advantage 2021 final rules include changes to telehealth that will allow plans to count telehealth clinical professionals in 12 specialty areas towards meeting network adequacy standards. The specialty areas are dermatology, psychiatry, cardiology, otolaryngology, neurology, ophthalmology, allergy and immunology, nephrology, primary care, gynecology/OB/GYN, endocrinology, and infectious diseases. The changes are intended to make telehealth more widely available in Medicare Advantage, give members access to the latest telehealth technologies, and increase plan choices for beneficiaries residing in rural areas.

The Centers for Medicare & Medicaid Services (CMS) is strengthening network adequacy rules for Medicare Advantage plans by finalizing its existing network adequacy methodology and policies that address maximum time and distance standards in rural areas, telehealth, and Certificate of Need (CON) laws. The Bipartisan Budget Act of 2018 incentivized Medicare Advantage plans to offer additional telehealth benefits to cover beneficiary access to health care beginning in 2020. As a result, CMS has been examining its network adequacy standards overall to determine how contracted telehealth professionals should be considered when evaluating the adequacy of a Medicare Advantage plan network.

CMS reduced the percentage of beneficiaries that must reside within the maximum time and distance standards in non-urban counties from 99% to 85% in order for the plan to comply with network adequacy standards. Medicare Advantage plans will be eligible to receive the 10-percentage point credit towards the percentage of beneficiaries residing within published time and distance standards when they contract with telehealth professionals.

CMS released the finalized requirements in “Medicare Program: Contract Year 2021 Policy & Technical Changes To The Medicare Advantage Program, Medicare Prescription Drug Benefit Program & Medicare Cost Plan Program.” CMS finalized a subset of the proposed policies in advance of the June 1, 2020, Medicare Advantage and Part D bid deadline for the 2021 plan year. The remaining proposals will be finalized later in 2020; they will apply to the 2022 plan year.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/.

On May 26, 2020, the Indiana Family and Social Services Administration (FSSA) awarded three contracts for Hoosier Care Connect, the state’s Medicaid managed care program for aged, blind, and disabled (ABD) beneficiaries, to incumbents Anthem and Centene/Managed Health Services (MHS), and to UnitedHealthcare. The full-risk contracts are worth a total of $6.4 billion. Implementation is expected April 1, 2021; the contracts will run for four years with two optional one-year renewals. Hoosier Care Connect serves approximately 90,000 individuals.

Hoosier Care Connect is a risk-based coordinated care program that launched on April 1, 2015. Currently, two MCOs—Anthem and Managed Health Services—serve approximately 90,000 beneficiaries with disabilities who are not eligible for Medicare, not living in an institution, and not enrolled in a waiver to receive home- and community-based services (HCBS). FSSA released the request for proposals (RFP 20-041) on October 21, 2019, with proposals due by January 6, 2020. Bids were also submitted by CareSource and MDwise.

Enrollment is mandatory for non-institutionalized aged, blind, or disabled individuals not eligible for Medicare; those receiving Supplemental Security Income; and individuals participating in the FSSA Medicaid for Employees with Disabilities (MED) Works buy-in program. MED Works offers the same coverage levels as regular Medicaid. It allows the participants to work without fear of losing Medicaid eligibility. Individuals in the following categories may voluntarily enroll in Hoosier Care Connect: children receiving adoption assistance, foster children, and former foster youth ages 18 to 26.

Hoosier Care Connect provides comprehensive coverage, including for Opioid Treatment Program (OTP) services. The plan covers short-term institutional care of up to 30 days. Members admitted to a state hospital for psychiatric treatment will be disenrolled; however, enrollment will only be suspended for members admitted to a psychiatric residential treatment facility. Hoosier Care Connect members who are admitted to an intermediate care facility for individuals with intellectual/developmental disabilities (ICF/IDD) are disenrolled and enrolled in Medicaid fee-for-service. Individuals approved for long-term services and supports are disenrolled, as are those who become eligible for Medicare. Hospice coverage is an exception and there is no limitation on days. Hoosier Care Connect has carve-outs for the following:

  • Certain high cost, low utilization drugs, such as hepatitis C and hemophilia drugs.
  • Diabetes supplies, such as test strips and meters.
  • Medicaid Rehabilitation Option (MRO) services, which are intensive community-based behavioral health services delivered exclusively by community mental health centers.
  • First Steps services.
  • School corporation services for student Medicaid beneficiaries with an individualized education plan for services provided by a school. However, the contractor must communicate and coordinate with the school to ensure continuity of care and avoid duplication of services.

The proposals were evaluated by assigning points to scoring categories; the maximum score was 103. Adherence to mandatory requirements was evaluated as pass/fail. For the scored components, 80 points were allocated to the management assessment/quality proposal. The remaining points were allocated at five points for each of the following preference categories: Buy Indiana, minority business enterprise subcontractor, women business enterprise subcontractor, and Indiana veteran business enterprise subcontractor. One bonus point for each of the last three preference categories (minority, women, and veteran) could also be earned.

For more information, contact: 

  • Jill Carnell, Chief Administrative Officer, Indiana Department of Administration, 402 West Washington Street, Room W-478, Indianapolis, Indiana 46204; 317-232-3150; Fax: 317-232-3153; Email: https://www.in.gov/idoa/; Website: www.in.gov/fssa/4828.htm
  • Will Shanley, Director of Public Relations, United Healthcare, 5901 Lincoln Drive, Minneapolis, Minnesota 55436; 612-486-4361; Email: will.shanley@uhc.com; Website: https://www.uhc.com/
  • Marcela Manjarrez-Hawn, Senior Vice President And Chief Communications Officer, Centene Corporation, 7700 Forsyth Boulevard, St. Louis, Missouri 63105; 314-445-0790; Email: mediainquiries@centene.com; Website: https://www.centene.com/
  • James Freeman, Media Contact, Anthem BlueCross BlueShield Indiana, 220 Virginia Avenue, Indianapolis, Indiana 46204; 215-756-2495; Email: james.freeman2@anthem.com; Website: https://www.anthembcbs-medicareadvantage.com/

On May 29, 2020, the Kentucky Cabinet for Health and Family Services (CHFS) awarded five Medicaid managed care contracts with an aggregate value of about $8 billion. The five companies are Aetna, Humana, Molina Healthcare, UnitedHealthcare, and WellCare. Aetna will also serve children in Kentucky SKY, the Medicaid risk-based managed care delivery program for the state foster care program and the Department for Juvenile Justice. The plans are at-risk for all Medicaid physical health, behavioral health, and pharmacy services. The contracts are slated to go live on January 1, 2021 and will run through December 31, 2024. The contracts may be extended by six additional two-year periods.

The state’s current managed care contracts are with Aetna (via Coventry Cares), Anthem, Humana (via CareSource), Passport Health Plan, and WellCare. These contracts have been extended through December 31, 2020. About 1.3 million beneficiaries are enrolled in one of the five current Medicaid managed care plans.

The state issued the request for proposals (RFP 2000000202) on January 10, 2020. This was a rebid after the state cancelled contracts awarded on November 26, 2019, due to concerns about how the award process was handled. Proposals were due by February 7, 2020. Responses were also submitted by Anthem Kentucky Managed Care Plan, Inc.; and Passport Health Plan, Inc.

The proposals received the following scores:

  • Aetna received 1,653 points.
  • WellCare received 1,662 points.
  • Humana received 1,605 points.
  • UnitedHealthcare received 1,520.5 points.
  • Molina received 1,507 points.
  • Anthem received 1,491 points.
  • Passport received 1,409.5 points.

The proposals for Kentucky SKY received the following scores:

  • Aetna received 1,126.3 points.
  • WellCare received 1,120.6 points.
  • Humana received 1,066.6 points.
  • UnitedHealthcare received 1,044.2 points.
  • Molina received 1,017.4 points.

PsychU last reported on this topic in “Kentucky Announces Cancellation Of Medicaid Managed Care Contracts; To Be Rebid In January,” which published on January 5, 2020. The article is available at https://www.psychu.org/kentucky-announces-cancellation-of-medicaid-managed-care-contracts-to-be-rebid-in-january/.

For more information, contact: 

  • Susan Dunlap, Executive Director of Public Affairs, Kentucky Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky 40621; 502-564-7042; Email: Susan.Dunlap@ky.gov; Website: https://chfs.ky.gov/
  • Kate Marx, Corporate Communications, Humana, 500 West Main Street, Louisville, Kentucky 40202; 502-271-9288; Email: kmarx1@humana.com; Website: https://www.humana.com/
  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802; 562-951-1588; Email: Caroline.Zubieta@molinahealthcare.com; Website: https://www.molinahealthcare.com/members/common/en-US/abtmolina/compinfo/newsmed/Pages/newsmed.aspx
  • Charles N. Talbert, Manager, External Communications, WellCare Health Plans, Inc., 211 Perimeter Center, Suite 800, Atlanta, Georgia 30346; 770-913-2181; Email: charles.talbert@wellcare.com; Website: https://www.wellcare.com/
  • Will Shanley, Director of Public Relations, United Healthcare, 5901 Lincoln Drive, Minneapolis, Minnesota 55436; 612-486-4361; Email: will.shanley@uhc.com; Website: https://www.uhc.com/
  • Leigh M. Woodward, Senior Communications Partner, Aetna Medicaid, 4630 Woodland Corporate Boulevard, Tampa, Florida 33614; 860-900-6058; Email: WoodwardL1@aetna.com; Website: https://www.aetna.com/

The Centers for Medicare & Medicaid Services (CMS) will require hospitals to adopt the Medicare Hybrid Hospital-Wide 30-Day Readmission (HWR) measure by 2023, and will begin a mandatory measurement period running from July 1, 2023 to June 30, 2024. In July 2025, the results will be posted to Medicare Hospital Compare. The HWR is based on electronic health record data and claims data for Medicare beneficiaries. CMS believes that the proliferation of EHR systems and standardization of extraction and reporting of clinical data for quality measurement provide an opportunity to integrate these data into measures of hospital performance. The HWR will replace the current Claims-Based Hospital-Wide All-Cause Readmission measure.

The new HWR measure was included in the Medicare 2020 Hospital Inpatient Prospective Payment System Final Rule, released on August 16, 2019. During 2019, 150 hospitals participated in a voluntary HWR pilot program. In preparation for the mandatory HWR reporting period that starts July 1, 2023, CMS will implement two voluntary year-long measurement periods, with the first starting on July 1, 2021 and running through June 30, 2022. The second period will start July 1, 2022, and run through June 30, 2023.

The HWR measure will be required as a part of each hospital’s inpatient quality reporting (IQR) program requirements. The Medicare Hospital IQR Program is a pay-for-reporting quality program which reduces payment to hospitals that fail to meet program requirements.

For the HWR measure, the numerator is unplanned all cause 30-day readmission. Readmission is defined as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an earlier, eligible index admission. The denominator is admissions for Medicare fee-for-service (FFS) beneficiaries age 65 and older enrolled in Part A for the 12 months prior to admission who are matched in EHR and claims data and who are discharged alive, and not transferred to an acute care facility. The measure excludes the following populations:

  • Admitted to Prospective Payment System-exempt cancer hospitals
  • Without at least 30 days post-discharge enrollment in FFS Medicare
  • Discharged against medical advice
  • Admitted for primary psychiatric diagnoses
  • Admitted for rehabilitation
  • Admitted for medical treatment of cancer

The HWR measure uses clinical data elements from the EHR for risk adjustment in addition to claims data. The goal is to use clinical data, such as laboratory test values and vital signs, to risk adjust for consumer-level factors that influence readmission to adjust for severity of illness in hospital outcome measures.

Under the current Claims-Based Hospital-Wide All-Cause Readmission measure, CMS reports risk-standardized readmission rates for several conditions, including acute myocardial infarction, heart failure, pneumonia, and hip and knee arthroplasty. CMS has also developed hospital readmission measures for stroke and chronic obstructive pulmonary disease. In 2013, CMS began publicly reporting a hospital-wide, all-condition readmission measure that captures 92% of readmissions following eligible admissions.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On May 19, 2020, Microsoft announced that it has launched a “health care cloud service” called Micorsoft Cloud for Healthcare. The goal of the service is to assist payers and provider organizations more easily function during the coronavirus disease of 2019 (COVID-19) pandemic by providing assistance with telehealth, care management, and consumer engagement through apps that monitor data collected by medical devices linked to the cloud. Microsoft Cloud for Healthcare is available through a free trial through mid-November 2020.

The new cloud service is a conglomeration of products that are already available by the company, which sits on top of a common data model that makes it easier to share data between applications and analyze gathered data. Microsoft is working to add additional tools in the near future. The tools currently offered through the platform include:

  • Microsoft 365: a way for businesses to subscribe to both Windows and Office software
  • Microsoft Dynamics: a set of intelligent business applications that offer predictive insights through proprietary artificial intelligence
  • Microsoft Power Platform: a platform that allows users to create and deploy tailored applications that can be used on desktop and mobile devices
  • Microsoft Azure: cloud services for building, deploying, and managing intelligent applications through a global network of data centers

In addition to the above tools, Microsoft is also working with specialized partners to provide health care provider organizations with specialized services. Current partners in the effort include Epic (health-related software development), Allscripts (electronic health record (EHR) system), GE Healthcare (provider of health care technologies, digital infrastructure, data analytics, and decision support tools), Adaptive Biotechnologies (commercial-stage biotech company focused on adaptive immune system biology), and Nuance (computer software technology).

Microsoft will be rolling out additional, industry-specific cloud offerings related to doing business during COVID-19 in the near future. However, details about these offerings, including a timeline, is not yet available.

For more information, contact:

  • Microsoft Cloud for Healthcare, c/o Microsoft Media Relations, WE Communications, 225 108th Avenue Northeast, Suite 600, Bellevue, Washington 98004-5737; 425-638-7777; Fax: 425-638-7001; Email: rrt@we-worldwide.com; Website: https://www.microsoft.com/en-us/industry/health/microsoft-cloud-for-healthcare

Iowa Medicaid expansion enrollees who participated in the Iowa Medicaid Healthy Behaviors Program (HBP) had substantial reductions in their utilization of hospital-based care. Compared to the non-participants, HBP participants from 2014 through 2017 were less likely to visit an emergency department; the likelihood was 9.6 percentage points lower. The HBP participants were also less likely to be hospitalized, at 2.8 percentage points lower. However, the HBP participants had total spending $1,594 higher than non-participants’ spending.

HBP is a mandatory program for Iowa Medicaid expansion enrollees. They must complete an annual wellness exam and health risk assessment. Those who fail to complete the exam and assessment must pay monthly premiums to avoid disenrollment.

These findings were reported in “Iowa’s Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012–17” by Brad Wright, Youn Soo Jung, Natoshia M. Askelson, Elizabeth T. Momany, and Peter Damiano. They analyzed Medicaid data from 2012 through 2017, and HBP from 2014 through 2017 for a sample of beneficiaries who were continuously enrolled in IowaCare for at least one year before and after Medicaid expansion. The goal was to evaluate how HBP changed utilization and spending.

The full text of “Iowa’s Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012–17” was published in the May 2020 issue of Health Affairs. An abstract is posted online at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01145.

For more information, contact:

  • Brad Wright, Director of Health Services and Outcomes Research, Department of Family Medicine and Associate Professor, Health Care Economics and Finance, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 590 Manning Drive, CB #7595, Chapel Hill, North Carolina 27599; 984-974-4536; Email: brad_wright@med.unc.edu; Website: https://www.med.unc.edu/fammed/directory/brad-wright-phd/
  • Sue Ducat, Senior Director of Communications, Health Affairs, 7500 Old Georgetown Road, Suite 600, Bethesda, Maryland 20814; 301-841-9962; Email: sducat@projecthope.org; Website: https://www.projecthope.org/

On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) urged Medicare Advantage organizations and Part D sponsors to halt their usual prior authorization requirements during the coronavirus disease 2019 (COVID-19) public health emergency. Absent a disaster or emergency, Medicare Advantage organizations and Part D sponsors have had flexibilities to waive prior authorization requirements at any time to facilitate access to services with less burden on beneficiaries, plans, and provider organizations. The relaxation or waiver must be uniformly provided to similarly situated enrollees who are affected by the disaster or emergency.

Additionally, the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act directed Medicare Advantage organizations to make changes specific to COVID-19 for clinical laboratory tests to detect or diagnose the virus and administration of vaccines. Medicare Advantage organizations are not permitted to impose any prior authorization or other utilization management requirements with respect to the coverage of these services when those items or services are furnished on or after March 18, 2020 and during the applicable emergency period. The plans are also not permitted to charge cost sharing (including deductibles, copayments, and coinsurance).

Medicare Advantage organizations must follow already outlined requirements for disasters and emergencies to ensure access to benefits. They must cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities that have participation agreements with Medicare. They must waive, in full, requirements for gatekeeper referrals where applicable. They must provide the same cost-sharing for the enrollee as if the service or benefit had been furnished at a plan-contracted facility.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/.

On May 22, 2020, the federal Centers for Medicare & Medicaid Services (CMS) finalized its proposals for Medicare Advantage related to increasing access to telehealth. CMS also finalized requirements to expand access to Medicare Advantage for beneficiaries diagnosed with end-stage renal disease (ESRD). CMS finalized its proposal to phase out Medicare Advantage dual eligible special needs pan (D-SNP) look alikes.

Plans will be able count telehealth clinical professionals in certain specialty areas (such as Dermatology, Psychiatry, Cardiology, Ophthalmology, Nephrology, Primary Care, Gynecology, Endocrinology, and Infectious Diseases) towards meeting CMS network adequacy standards. The goal is to encourage plans to enhance their benefits to give beneficiaries access to the latest telehealth technologies and increase plan choices for beneficiaries residing in rural areas.

Previously, beneficiaries with ESRD were only allowed to enroll in Medicare Advantage plans in limited circumstances. Starting in 2021, due to changes made by the 21st Century Cures Act, all beneficiaries with ESRD will have the option to enroll in a Medicare Advantage plan, which CMS anticipates will give them access to supplemental benefits such as health and wellness programs, transportation, or home-delivered meals that are not available in Medicare fee-for-service. The cost of kidney acquisition for Medicare Advantage members with ESRD will be covered fee-for-service, and the costs will be excluded from Medicare Advantage benchmarks. CMS will offer a more flexible approach to meeting network adequacy standards for outpatient dialysis than the current pre-determined time and distance requirements.

D-SNP look alikes have similar levels of dual eligible enrollment as D-SNPs but avoid the related regulations and contracting requirements of a D-SNP. The Bipartisan Budget Act (BBA) of 2018 required CMS to establish additional requirements related to Medicaid integration for D-SNPs. CMS intends to phase out D-SNP look-alikes. A plan considered a D-SNP look-alike has 80% or more of members who are entitled to Medicaid. The phase-out timeline is as follows:

  • Beginning for the 2021 plan year, D-SNP look-alikes will be able to transition their membership into a D-SNP or another qualifying zero-premium plan offered by the Medicare Advantage organization.
  • Starting for the 2022 plan year, CMS will not contract with any new Medicare Advantage plan, other than a SNP, that projects in its bid that 80% or more of total plan members will be entitled to Medicaid.
  • Starting for the 2022 plan year, CMS will not contract with any new Medicare Advantage plan, other than a SNP, that project it will be a D-SNP look-alike. Starting in 2023, CMS will not contract with a renewing plan, other than a SNP, with enrollment meeting the definition of a D-SNP look alike, unless the plan has been active for less than one year and has enrollment of 200 or less at the time of determination.

CMS released the finalized requirements in “Medicare Program: Contract Year 2021 Policy & Technical Changes To The Medicare Advantage Program, Medicare Prescription Drug Benefit Program & Medicare Cost Plan Program.” CMS finalized a subset of the proposed policies in advance of the June 1, 2020, Medicare Advantage and Part D bid deadline for the 2021 plan year. The remaining proposals will be finalized later in 2020; they will apply to the 2022 plan year.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/.

On May 8, 2020, the Pennsylvania (PA) Clinical Network announced that it entered a value-based contract for Aetna’s Medicare Advantage members in Pennsylvania. The organizations is a physician-led clinically integrated network. The contract calls for PA Clinical Network to enhance care coordination and increase quality for Aetna members.

According to Jaan Sidorov, M.D., chief executive officer for Pennsylvania Clinical Network, the arrangement provides incentive payments for meeting “a basket of quality metrics and utilization targets” during calendar year 2020. The incentive payments are designed to drive team-based improvement across the continuum of care. The benchmarks align with industry-wide standards and are configured to link increasing performance in patient care with increasing rewards. Aetna and the Pennsylvania Clinical Network are meeting regularly to monitor progress toward goals.

PA Clinical Network currently works with over 50 private practices with 150 advanced practice clinical professionals. Each practice is independent, but all have joined the clinically integrated network to pool their resources to serve their assigned Aetna members. The organization is supported by the Pennsylvania Medical Society and its Care Centered Collaborative.

Under the contract, PA Clinical Network will provide team-based and physician-led care management in addition to the HealthEC population-health data analytics platform. PA Clinical Network and Aetna will work through a Joint Operating Committee to monitor progress in a cycle of continuous improvement.

For more information, contact:

  • Jaan Sidorov, M.D., Chief Executive Officer, Pennsylvania Clinical Network, 777 East Park Drive, Harrisburg, Pennsylvania 17111; 866-441-2392; Email: jsidorov@patientccc.com; Website: https://www.pennsylvaniacin.com/
  • Ethan Slavin, Communications, Aetna, 2777 North Stemmons Freeway, 13th Floor, Dallas, Texas 75207; 214-200-8056; Email: SlavinE@Aetna.com; Website: https://www.aetna.com/
  • Laura Porto, Director of Marketing, HealthEC, 343 Thornall Street, Suite #630, Edison, New Jersey 08837; 732-271-0600; Email: laura.porto@HEALTHEC.COM; Website: https://www.healthec.com/

During the first quarter of 2020, $576 million in equity funding worldwide went to mental health startups, rising 400% from $115 million during the last quarter of 2019. There were 44 recorded deals involving mental health startups during the first quarter of 2020, up 18.9% from 37 in the last quarter of 2019. During the first quarter of 2019, there were 42 recorded deals in this sector with a value of $210 million.

Some of the companies involved in the first quarter 2020 investments were as follows:

  • Lyra Health received an investment of $75 million in March. The company offers a mental health platform based on evidence-based treatments.
  • Modern Health received an investment of $31 million in January. The company offers a suite of mental health solutions comprised of digital programs, virtual coaching, and clinical therapy.
  • Spring Health received an investment of $22 million in January. The company provides a platform that emphasizes a data-driven approach to delivering individualized behavioral health care through exercise, digital cognitive behavioral therapy, individual therapy sessions, and medication
  • Oxford VR received an investment of $13 million in February. The company offers a clinically validated virtual reality platform to treat mental health disorders.
  • Psychological Treatment by VR received a seed investment of $1.1 million in January. The company offers a virtual reality platform for health care professionals, including those practicing in mental health. The current applications include treating anxiety, addiction, and eating disorders.

Globally across the health care industry, equity funding grew by 4% between the last quarter of 2019 to the first quarter of 2020. The investments rose from $14.1 billion to $14.6 billion. The number of deals dropped by 6% between quarters, from 1,228 to 1,156.

In the United States, the total number of health care equity investments increased by 4.4%, from 636 in the last quarter of 2019 to 664 in the first quarter of 2020. In the first quarter of 2019, there were 645 investments. The number of “mega-rounds” (investments of $100 million or more) rose by 257%, from 7 in the last quarter of 2019 to 25 in the first quarter of 2020. During the first quarter of 2019, there were 14 mega rounds.

These findings were reported in “State Of Healthcare Q1’20 Report” by researchers with CB Insights. The researchers analyzed equity investment into emerging health care companies. They verified the investments via various federal and state regulatory filings, direct confirmation with firms or investors, or press releases. These financing vehicles include convertible notes, seed, Series A, Series B, Series C, Series D, Series E+, private equity, growth equity, other venture capital, and other investment rounds. The analysis also includes funding for only private companies. However, the analysis excludes funding rounds raised by public companies, even if they received investment from a venture firm. For tranched investments, the analysis only includes the investment made in a particular quarter. Further, the analysis included only the amount of investment that had closed. The researchers defined “digital health companies” as those in the health care sector that use technology/software as a key differentiator versus their competition. The digital health sector includes technologies focused on disease diagnostics, technology-enabled health, and artificial intelligence-driven drug discovery.

The full text of “State Of Healthcare Q1’20 Report” was published April 28, 2020, by CB Insights. A copy can be requested at https://www.cbinsights.com/research/report/healthcare-trends-q1-2020/.

For more information, contact:

  • CB Insights, 498 7thAvenue, New York, New York 10018; 212-292-3148; Email: info@cbinsights.com; Website: https://www.cbinsights.com/.

About 87% of Medicare inpatient psychiatric facility (IPF) claims with outlier payments during 2014 and 2015 failed to meet the medical necessity or documentation requirements set by Medicare. During fiscal years (FYs) 2014 and 2015, the number of IPF claims with outlier payments increased by 28%. Total Medicare payments for the IPF claims with outlier payments rose by 19%, from $450 million to $534 million. The Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) estimates that Medicare overpaid IPFs by $93 million for stays that resulted in outlier payments, but were non-covered or partially non-covered because inpatient treatment was not medically necessary for all or part of the stay.

An audit of a random sample of 160 claims found that 142 had missing or inadequate medical record elements. Most were missing physician certifications. Of the 142 medical records, 12 did not clearly support that the IPF had protected the individual’s right to make informed decisions regarding care. Oversight by the Centers for Medicare & Medicaid Services was not adequate to prevent or detect the IPFs’ errors.

These findings were reported in “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” by the OIG. The audit covered 36,120 inpatient claims with nearly $1 billion in total Medicare payments. The goal was to determine whether IPFs complied with Medicare coverage, payment, and participation requirements for services provided in FYs 2014 and 2015 that resulted in outlier payments.

A link to the full text of “An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements” may be found at www.openminds.com/market-intelligence/resources/040820oigiptpsychoutliers.htm.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/

As of mid-April 2020, about 43% of community-based addiction treatment provider organizations in North Carolina lacked sufficient cash on hand to remain in business for the next 30 days due to financial constraints created by the coronavirus disease 2019 (COVID-19) outbreak and public health emergency. According to survey responses provided by 70 community-based addiction treatment provider organizations, in addition to the 43% that reported having no more than 30 days cash on hand to fund operations without receiving reimbursements, 10% reported having 31 to 45 days cash on hand, 13% reported having 46 to 60 days cash on hand, and 16% reported having 61 to 90 days cash on hand. The remaining 18% reported having more than 90 days cash on hand.

Across the state, addiction treatment provider organizations lost revenue as demand for treatment dropped during the public health emergency, while new expenses to acquire personal protective equipment (PPE) and to implement telehealth treatment increased. To respond to the financial stress, about 27% of the organizations have laid off staff or cut positions, and another 40% were considering staff cuts. About 33% were staffing as normal. More than half, 57%, have closed at least one program. About 10% of programs cannot admit new consumers. About 19% of the organizations said they were operating as normal without service disruptions.

These statistics are the result of a survey conducted by Addiction Professionals of North Carolina (APNC). From April 13 to 20, APNC surveyed 70 of its member addiction treatment provider organizations. APNC is a network of more than 650 provider organizations and professionals. The survey was sent to executives at its member organizations statewide. The respondents are representative of provider organizations across all regions of North Carolina in terms of revenue mix and consumer volume.

For more information, contact:

  • Sarah Potter, Executive Director, Addiction Professionals of North Carolina, 3373 National Drive, Suite 225, Raleigh, North Carolina 27612; 919-630-8134; Email: spotter@apnc.org; Website: http://www.apnc.org/.

On March 27, 2020, Kansas awarded its next correctional health care contract to Centurion of Kansas, LLC, a Centene subsidiary, replacing the incumbent Corizon, LLC. Centurion was awarded a two-year full-risk contract to provide comprehensive health care services in the Department of Corrections’ (KDOC) facilities. The contract is expected to commence on July 1, 2020 and run through June 30, 2022, followed by two additional two-year renewal periods. Centurion will provide medical, dental, behavioral health, and related support services for offenders in nine facilities across the state. The contract is valued at a maximum of $554 million if all options are exercised.

The Kansas Department of Administration released the request for proposals (RFP EVT0006973) on October 10, 2019. Proposals were due by January 10, 2020. The state’s procurement negotiating committee (PNC) considered five proposals. The responding bidders were Centurion of Kansas, LLC; Corizon, LLC; VitalCore Health Strategies, LLC; Kansas Health and Recovery Solutions PC/WellPath LLC; and Wexford Health Sources, Inc. After evaluating the technical and cost proposals, the PNC met with four bidders: Centurion of Kansas, LLC; Corizon, LLC; VitalCore Health Strategies, LLC; and Wexford Health Sources, Inc.

KDOC serves a current population of approximately 10,000 adult inmates and 165 juvenile offenders. It operates nine facilities and three satellite facilities. Specialized services may be provided through agreements with area provider organizations such as hospitals, clinics, medical specialists, laboratories, and other specialized services.

The RFP asked for the bidders to provide two cost proposals for scenarios in which the selected contractor would or would not be responsible for paying for hepatitis C (Hep C) medications. The KDOC offered opt-out testing for Hep C for the existing inmate population. That testing was implemented in October 2018 and concluded in March 2019. Opt-out Hep C testing continues to be offered at admission. KDOC estimates that about 500 offenders will require treatment annually thereafter.

The state’s PNC noted that Centurion had the second lowest pricing bid, but the proposal had other persuasive factors that led to its selection. A key factor was “a unique opportunity that no other vendor shares to partner with Sunflower Medicaid Provider in addressing discharge needs” which exists because Centene owns both Centurion and Sunflower, one of the state’s Medicaid managed care organizations. Additionally, Centurion demonstrated good understanding of physician recruiting, and offered to partner with the state to find the cheapest Hep C drug pricing including 340B and return any funds of the $7.5 million cap to KDOC.

For more information, contact:

  • Randall Bowman, Executive Director, Public Affairs, Kansas Department of Corrections, 714 Southwest Jackson Street, Topeka, Kansas 66603; 785-296-5656; Email: Randall.Bowman@ks.gov; Website: https://www.doc.ks.gov/

On April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) issued regulatory changes to further expand beneficiary access to telehealth services in their homes for the duration of the coronavirus disease 2019 (COVID-19) public health emergency. CMS is waiving limitations on the types of clinical practitioners and provider organizations that can furnish Medicare telehealth services, and is raising reimbursement rates for audio-only telephone services. CMS will reimburse for Medicare telehealth services provided by rural health clinics and federally qualified health clinics.

Prior to this change, only physicians, nurse practitioners, physician assistants, and certain others could deliver telehealth services. CMS will now allow physical therapists, occupational therapists, and speech language pathologists to provide telehealth services.

CMS will also allow hospitals to bill as the originating site for providing telehealth services to beneficiaries registered as hospital outpatients but who are staying at home. The beneficiary’s home can serve as a temporary “department of the hospital” where the beneficiary can receive counseling and educational service as well as therapy services via telehealth technology.

Reimbursement for audio-only telehealth services is increased to match the outpatient office rate, from a range of about $14 to $41 to about $46 to $110. The payments are retroactive to March 1, 2020.

In addition to raising reimbursement rates for audio-only telephone services, CMS also expanded the list of eligible audio-only telephone services to include many behavioral health and consumer education services. CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services because some Medicare beneficiaries may lack access to interactive audio-visual technology required for telehealth services. CMS also recognizes that some beneficiaries would choose not to use audio-visual telehealth services offered by their health care professionals.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) approved a Washington State Medicaid 1115 waiver that will allow the state to pay higher rates to home- and community-based services (HCBS) provider organizations to maintain capacity during the coronavirus disease 2019 (COVID-19) public health emergency. Most of the approved provisions affect long-term services and supports (LTSS). In particular, they extend HCBS flexibilities available under 1915 (c) to beneficiaries receiving LTSS through a state plan amendment.

Additional provisions will allow the Washington State Health Care Authority (HCA) to establish a COVID-19 Disaster Relief Fund. Under these provisions, HCA will be able to use Medicaid funds to stabilize provider organizations as they implement new and expanded care delivery sites while managing economic disruptions. The fund will help provider organizations access needed equipment, broaden access to COVID-19 testing and care, and respond to higher demand.

CMS approved the following additional provisions:

  • HCA can receive federal reimbursement for providing LTSS to beneficiaries, even if they are not timely, updated in the plan of care, or delivered in otherwise-allowable settings.
  • To reduce administrative burden on HCA and beneficiaries, individuals will be permitted to self-attest, or HCA could use an alternative verification of individuals’ income and assets, disability, and level-of-care to qualify for LTSS.
  • Delay initial assessments or annual reassessments for up to one year.
  • HCA can make retainer payments for many habilitation and personal care services provider organizations to maintain capacity during the emergency.
  • HCA can make retainer payments to those organizations that include personal care as a component.

The state had previously been approved for a 1135 Medicaid waiver on March 19, 2020. HCA submitted the 1115 waiver on March 24, 2020, two days after CMS announced the availability of such waivers.

The HCA waiver affects the independent “individual providers” who deliver personal care services but are not employed through a home care provider organization. It also affects an array of residential provider organizations, such as adult family homes, assisted living facilities, home care agencies, adult day health and adult day care programs. HCA also uses the term “provider” to refer to the clinic or hospital billing for the services delivered by an “individual provider.”

Retainer payments were available to be claimed as of May 4, 2020 for residential and adult day providers, along with the rate enhancements. They can claim retainer payments for up to 30 days at 70% of the individual consumer’s rate.

In Washington, payment and rates for residential facilities and individual providers are collectively bargained and ratified by the legislature. Any changes must be approved by SEIU 775 and the residential facility councils. As of May 11, 2020, an agreement had been reached regarding retainer payments for all residential facilities, but rate changes for “individual providers” and home care provider organizations were still pending due to Washington’s parity requirements

CMS was still evaluating HCA’s request for Medicaid expenditure authority to use the Disaster Relief Fund to cover costs associated with treatment for uninsured individuals with COVID-19, housing, nutrition supports, and other COVID related expenditures for states and individuals as well as retainer payments for more than 30 days for provider organizations. Several other requests are also under review. CMS denied HCA’s request to establish a temporary eligibility group for those with incomes 138% to 200% of the federal poverty level.

PsychU last reported on emergency waivers in “34 States Approved For Medicaid 1135 Waivers During COVID-19 Public Health Emergency,” which published on May 11, 2020. The article is available at https://www.psychu.org/34-states-approved-for-medicaid-1135-waivers-during-covid-19-public-health-emergency/ .

For more information, contact:

  • Amy Blondin, Chief Communications Officer, Washington State Health Care Authority, Post Office Box 45502, Olympia, Washington 98504-5502; 360-725-1915; Email: amy.blondin@hca.wa.gov; Website: http://www.hca.wa.gov/.

Editor’s note: this article was updated on May 12 to include clarifications from HCA about the retainer payments and rate enhancements. 

During the coronavirus disease 2019 (COVID-19) national public health emergency, behavioral health provider organizations can accept donations of mobile devices and data plans to facilitate telehealth treatment, according to the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS). Such an arrangement during the public health emergency would not violate federal anti-kickback regulations on providing inducements to beneficiaries. The OIG posted its opinion on April 23, 2020.

The OIG maintains an online document with its feedback on a variety of questions submitted by provider organizations seeking guidance on arrangements to facilitate provision of services during the COVID-19 public health emergency. The feedback explains the application of OIG’s administrative enforcement authorities as applied to arrangements in existence solely during the time period subject to the public health emergency. This feedback is different than an OIG advisory opinion, which is a legally binding decision between the OIG and the requesting organizations.

One or more behavioral health provider organizations asked if they could accept donations of mobile devices, data plans, or both to facilitate telehealth treatment during the COVID-19 disruption for consumers who are financially needy and who do not own their own cell phone. The OIG’s response made the following points:

  • Normally the provision of valuable technology and services to federal health care program beneficiaries for free or at a reduced cost likely implicates the federal anti-kickback statute and beneficiary inducements civil money penalty (CMP).
  • In the context of the COVID-19 outbreak and in light of flexibilities in coverage for various telehealth and other virtual services payable by federal health care programs, the provision of a mobile device, service or data plan, or both by a behavioral health provider organization to a consumer likely presents a sufficiently low risk of fraud and abuse if safeguards are implemented.
  • The safeguards include a good-faith determination that an established consumer is in financial need before the telecommunications technologies are provided and that the consumer needs the technologies to access medically necessary services related to behavioral health treatment. The services must be medically necessary to reduce the risk of overutilization or inappropriate utilization. The third-party funding must be used only for telecommunication technologies.
  • The provider organization must not market the telecommunication technologies or offer/provide free phones to generate business.
  • The devices must be returned and the data plans canceled at the end of the COVID-19 Declaration.

The OIG noted that under certain circumstances, such as the Federal Communications Commission (FCC) distributing grants to certain provider organizations to fund telecommunications technologies, the remuneration from the donor to the provider organization would not trigger federal fraud and abuse laws. However, under other circumstances, arrangements between the donor and the provider organization, or indirect financial relationships between the donor and the consumer, could present risk under the federal fraud and abuse laws. The OIG advised provider organizations to separately assess any fraud and abuse risks that may arise with respect to any direct or indirect financial relationships between the donor and the provider organization, or consumer.

The clarifications were posted at https://oig.hhs.gov/coronavirus/authorities-faq.asp.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7thStreet, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: Donald.white@oig.hhs.gov; Website: https://oig.hhs.gov/

On April 30, 2020, Molina Healthcare announced a definitive agreement to acquire the Magellan Complete Care (MCC) business line from Magellan Health, Inc. for $820 million. Molina intends to fund the purchase with cash on hand. The acquisition will enable Molina to enter three new states—Arizona, Massachusetts, and Virginia—and expand into New York City. The transaction is expected to close in the first quarter of 2021, subject to federal and state regulatory approvals.

MCC, with revenue of over $2.7 billion in 2019, manages full-service Medicaid and Medicare health plans. As of December 31, 2019, MCC served approximately 180,000 members through the following plans:

  • Magellan Complete Care in Arizona, Florida, and Virginia
  • Senior Whole Health in Massachusetts and New York
  • TMG by Magellan in Wisconsin

With the addition of MCC, Molina will serve more than 3.6 million members in government-sponsored health care programs in 18 states. Pro-forma 2020 revenue after the acquisition closes is projected at over $20 billion. The transaction is expected to add approximately $3 billion in revenue by 2021 and presents an opportunity to significantly leverage Molina’s fixed cost base.

Molina believes that the acquisition of the MCC assets represents a strong strategic fit with its portfolio of core Medicaid, high-acuity, and duals businesses. The acquisition also creates new markets for growth opportunities in Medicare and Marketplace in an expanded Medicaid footprint.

Molina’s President and Chief Executive Officer, Joe Zubretsky said, “Acquiring MCC expands our geographic footprint in our core businesses of managed Medicaid, dual eligibles, and long-term services and supports. We believe it will allow us to scale our enterprise-wide platforms and benefit from both operating and fixed cost leverage.” He said, “We will also intensely focus on maintaining the continuity of care for MCC’s members and stability for its state partners.”

PsychU last reported on Molina in “Navajo Corporation Plans To Contract With Molina Healthcare For A New Mexico Medicaid Indian Managed-Health Care Entity,” which published on February 24, 2020. The article is available at https://www.psychu.org/navajo-corporation-plans-to-contract-with-molina-healthcare-for-a-new-mexico-medicaid-indian-managed-health-care-entity/.

For more information, contact:

  • Caroline Zubieta, Director of Public Relations, Molina Healthcare, Inc., 200 Oceangate, Suite 100, Long Beach, California 90802; 562-951-1588; Email: Caroline.Zubieta@molinahealthcare.com; Website: https://www.molinahealthcare.com/members/common/en-US/abtmolina/compinfo/newsmed/Pages/newsmed.aspx
  • Lilly Ackley, Vice President, Corporate Communications, Magellan Health, 5 Nod Road, Avon, Connecticut 06001; 860-5071923; Email: ackleyl@magellanhealth.com; Website: https://www.magellancompletecare.com/

Between January 2013 and December 2016, the Iowa Medicaid program may have failed to adequately document about half of claims paid to health home provider organizations. Iowa’s health home provider organizations did not document core services, integrated health home outreach services, diagnoses, and enrollment with provider organizations. In addition, the health home provider organizations did not maintain documentation to support higher payments for intense integrated health home services and did not ensure that beneficiaries had full Medicaid benefits.

A review conducted by the Office of the Inspector General (OIG) for the federal Department of Health and Human Services (HHS) considered documentation of 130 health home payments selected at random. For each payment, the OIG reviewed the documentation submitted by the health home provider organization and the beneficiaries’ medical records. For 62 of the 130 payments, documentation was inadequate to support the claim. The OIG concluded that Iowa improperly claimed federal Medicaid reimbursement.

During this period, the state paid 795,000 health home claims totaling $107 million, with $92 million as the federal share and the remainder covered by state funds. Based on the improper payment rate in the sample, the OIG recommended that Iowa return $37.1 million. The state disagreed with most of the findings, but did say it was improving its monitoring of the health home program and that it was revising the state Medicaid plan.

These findings were reported in “Iowa Inadequately Monitored Its Medicaid Health Home Providers, Resulting In Tens Of Millions In Improperly Claimed Reimbursement” by the OIG for HHS. The goal was to determine whether Iowa’s claims for Medicaid reimbursement for payments made to health home providers complied with federal and state requirements.

During 2016, Iowa’s health home reimbursements accounted for 3% of the entire federal total nationwide, although Iowa’s population represents only 1% of the national population. For federal fiscal year 2016, nationwide, states claimed federal reimbursement of Medicaid health home services totaling $750 million, with the federal share at $431 million.

For more information, contact:

  • Don White, Public Affairs Specialist, Office of Inspector General, U.S. Department of Health and Human Services, Federal Building, 90 7th Street, Suite 3-650, San Francisco, California 94103; 202-528-5254; Email: white@oig.hhs.gov; Website: https://oig.hhs.gov/
  • Matt Highland, Public Information Officer, Iowa Department of Human Services, 1305 E Walnut Street, Hoover Building, 1st Floor, Des Moines, Iowa 50319-0114; 515-281-4848; Email: mhighla@dhs.state.ia.us; Website: https://dhs.iowa.gov/ime/providers/integrated-health-home.

A recent survey of medical practices found that practices report a 55% decrease in revenue and 60% decrease in health care consumer volume since the beginning of the Coronavirus Disease 2019 (COVID-19) crisis. Overall, 97% of practices have experienced a negative financial impact directly or indirectly related to COVID-19.

At the same time, 48% of medical practices have furloughed staff since March 13, 2020, when the national public health emergency due to the Coronavirus Disease 2019 (COVID-19) pandemic was declared. Many practices that had not yet implemented staff layoffs or furloughs at the time of the study would consider doing so if conditions persist over the next 30 days. The survey respondents estimate that by May 8, 2020, 60% of medical practices will be forced to furlough staff, and 36% will be forced to lay off staff if, and 36% will be forced to lay off staff if conditions continue as they were during the survey.

These findings were reported in “COVID-19 Financial Impact on Medical Practices” by Medical Group Management Association (MGMA). On April 7 and April 8 of 2020, MGMA conducted a survey of medical practices across the United States. The survey included responses from 724 medical practices, of which approximately 75% of respondents were part of independent medical practices and employ less than 50 full-time equivalent (FTE) physicians. The goal was to gauge the economic impact of COVID-19 on the health care sector.

The full text of “COVID-19 Financial Impact on Medical Practices” was published on April 10, 2020, by Medical Group Management Association. A copy is available online at https://mgma.com/getattachment/9b8be0c2-0744-41bf-864f-04007d6adbd2/2004-G09621D-COVID-Financial-Impact-One-Pager-8-5×11-MW-2.pdf.aspx?lang=en-US&ext=.pdf.

For more information, contact:

  • Terri Pollock, Associate Director of Public Affairs, Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112; Email: tpollock@mgma.org; Website: https://www.mgma.com/

The last decade has brought myriad innovations to digital technologies within the health and human services market. Health care payers and providers often turn to tech to boost access, improve adherence, and to provide cost-effective care. This trend holds true for both physical and mental health markets. However, as seen with previous tech waves, behavioral health providers’ adoption continues to trail behind physical health providers’ tech adoption.

For many, tech innovation offers a way to reach remote, often resource- and provider-limited settings to improve patient access and outcomes. Given the widespread, sustained workforce and access issues inherent in the current behavioral health field, why is mental health tech adoption still lagging? What is the hesitation to implement tech as a strategy to improve outcomes? Is the evidence base lacking? Are the research outcomes insignificant? Or is it a case of the unknown—a lack of storytelling about the effectiveness of the currently existing tech? Maybe the field just hasn’t taken stock of the ways that providers are, in fact, successfully utilizing tech across the globe to address disparities in mental health.

In an attempt to fill this knowledge gap, authors Nadi Nina Kaonga and Jonathan Morgan released their recent article, “Common Themes and Emerging Trends for the Use of Technology to Support Mental Health and Psychosocial Well-Being in Limited Resource Settings: A Review of the Literature,” which was published in Psychiatry Research.  In the study, the authors take the pulse of behavioral digital health by examining 67 articles, all focused on positive progress in resource-strapped locales. Their findings are specific to eMental health, a sub-category within the digital health market focused on providing web-, internet-, or telephonic-based mental health services and education to patients, caregivers, and providers.

The Positive Market “Pulse”

The authors spent two months in 2019 scouring three databases of peer-reviewed journal articles with topical search terms. Eligibility of identified research rested upon seven factors. Research had to:

  1. Be original.
  2. Focus on mental health and illness, substance abuse, or mental well-being. For the researchers this included measures of psychosocial well-being such as emotional distress or social issues.
  3. Utilize digital technology as a support mechanism for treatment or education.
  4. Report outcomes.
  5. Focus on settings with resource scarcity. The researchers defined “resource-limited settings” in two ways: (1) using the World Bank’s classifications for lower income countries; and (2) in cases where original studies identified locales as “’rural’, ‘low-income’ or ‘marginalized’”
  6. Be recent. For the authors this meant published no earlier than 2005.
  7. Report full-text English or French.

To cross-compare study results, the authors used qualitative mixed-methods text analysis and synthesized results to report on prevalent themes. The 67 studies included in the review spanned 19 countries, though approximately 35% were focused within the United States. The majority of implementation settings were community-based. Sample size of original research varied from 3 to 17,000 participants. The authors discussed their findings in terms of mental illness supported, type of tech intervention, service/education delivered, and common lessons learned from implementation.

Mental Illness Use Case. Search results indicated eMental Health tech was focused on two main use cases: depression (37%) and general mental health (31%). Other behavioral health issues were supported much more infrequently. They included (ordered by frequency): substance use, posttraumatic stress disorder, anxiety, attention deficit/hyperactivity disorder, autism, psychosis, adjustment disorder, bipolar disorder, personality disorder, and somatoform disorder. The authors indicated that approximately 9% of the previous research studied multiple mental health uses.

eMental Health Tech. Research analysis found an even division among tech types included in previous studies. Approximately one-third of the studies used short messaging service (SMS), another third used the web- or internet-based approaches, and the final third used other methods like telephone calls, smartphone apps, or audio recordings. Interestingly, the majority of the web- and internet-based interventions focused on video teleconferencing (74%).

Services/Education Delivered. Almost half the studies focused on delivering mental health services (47%), including interventions focused on behavioral change. Though much more infrequently mentioned, data collection, training, and diagnostic uses were also mentioned in the literature. Application use coalesced around six main themes:

  1. Treatment Adherence – Studies focused on adherence were more likely to utilize telephone or SMS interventions to provide appointment and treatment reminders. The one exception was a pilot SMS intervention used as supplemental intervention alongside cognitive behavioral therapy provided face-to-face. The main outcome assessed across studies was improved engagement.
  2. Real-Time Assessment – Previous research analyzed included five studies using SMS or telephonic interventions to collect self-reported momentary assessment data. This data allowed health workers to track and assess patient behavior and symptoms in real time. The main outcome assessed across studies was improved patient adherence.
  3. Daily Mood Improvement – Five studies focused on SMS and telephonic interventions that promoted well-being by sending encouraging, supportive messages to participants at set time intervals. The main outcome assessed across studies was patient perceptions of support and feelings of hope.
  4. Health Care Education – A total of nine analyzed studies included health education for either patients/caregivers or health care providers. The main outcome assessed across studies was evidence-based knowledge among participants.
  5. Telemedicine – Unsurprisingly, due to its increasing rates of adoption, telemedicine by phone, videoconferencing software, or SMS was included in more than 40% of studies analyzed (n=28). Many of the studies focused on cognitive behavioral therapy, and outcomes assessed varied from drops in no-show rates to perceptions of safety to cost-effectiveness.
  6. Machine Learning – Recent innovations in machine learning was evidenced in search results, which included five topical studies within the last three years. In the majority of studies, machine learning was coupled with neuroimaging to predict risk/outcome, analyze brain regions, or attempt to diagnose mental illness.

Lessons Learned – Finally, 18% of studies recommended considerations for eMental Health tech adoption and implementation, including ethics (e.g., informed consent), privacy (e.g., data protection), and quality control (e.g., maintaining the therapeutic relationship).

Field Diagnosis

This literature review provides an overview of the demonstrated positive outcomes associated with eMental Health tech for individuals in low-resource areas across the globe. However, limitations of this qualitative study (e.g., variable methodology, lack of long-term outcome measures, and lack of analysis on return-on-investment) reveal the need for additional, long-term trials and analysis to improve the reliability and generalizability of its findings.

The authors’ research was supported by REPSSI. The authors have no competing interests to declare.

This summary was developed independently of the authors.

The Centers for Medicare & Medicaid Services (CMS) project that aggregate payments to skilled nursing facilities (SNFs) will rise by 2.3% during federal fiscal year (FY) 2021, according to statements in the proposed rule updating the SNF prospective payment system (PPS). The proposed rule was issued on April 15, 2020. It makes changes to the case-mix classification code mappings used under the SNF PPS. The proposed rule also includes minor administrative proposals related to the Skilled Nursing Facility Value-Based Purchasing (VBP) Program that affects Medicare payment to SNFs. Comments are due by June 9, 2020.

Aggregate payments to SNFs during FY 2021 are projected to be $784 million higher than payments in FY 2020. The estimated increase is attributable to two PPS components: a 2.7% market basket increase factor with a 0.4 percentage point reduction for multifactor productivity adjustment.

The proposed changes to case mix classification code mappings are in response to stakeholder feedback about the Patient Driven Payment Model (PDPM), which went into effect on October 1, 2019 (the start of FY 2020). Under PDPM, SNF payment is linked to beneficiary characteristics, rather than volume. The PDPM uses International Classification of Diseases, Version 10 (ICD-10) codes to classify Medicare SNF beneficiaries into case mix payment groups. The unadjusted federal per diem rates are divided into six components, five of which are case-mix adjusted components: physical therapy, occupational therapy, speech-language pathology, nursing, and non-therapy ancillaries. The last is a non-case-mix component.

The SNF VBP program began distributing incentive payments on October 1, 2018. It scores SNFs on a single all-cause claims-based measure of hospital readmissions, and then adjusts Medicare fee-for-service payments under the SNF PPS. The goal is to reduce unplanned hospital readmissions. Under this program, payments to all SNFs are reduced by 2% to create a distribution pool. CMS redistributes between 50% to 70% of the pool to SNFs as incentive payments. CMS estimates that the SNF VBP program will reduce aggregate SNF payments by $199.54 million for FY 2021.

For FY 2021, CMS is not proposing to make any changes to the measures, SNF VBP scoring policies, or payment policies. The proposed administrative changes would apply the 30-day Phase One Review and Correction deadline to the baseline period quality measure quarterly report and establish performance periods and performance standards for upcoming program years.

Send comments to:

  • Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1737-P, Post Office Box 8016, Baltimore, Maryland 21244-8016.

On March 30, 2020, the Centers for Medicare & Medicaid Services (CMS) announced temporarily expanded access to telehealth services for Medicare beneficiaries nationwide to permit them receive services where they live, including residents of nursing homes or assisted living facilities, and those receiving home health or hospice benefits. If a physician determines that a Medicare beneficiary should not leave home because of a medical contraindication or due to suspected or confirmed COVID-19, and the beneficiary needs skilled services, the beneficiary will be considered homebound and will qualify for the Medicare home health benefit to receive telehealth services at home. During the COVID-19 public health emergency, Medicare is allowing telehealth to fulfill many face-to-face visit requirements for clinical professionals to see beneficiaries in inpatient rehabilitation facilities, receiving hospice services, or receiving home health.

With the goal of preventing the spread of COVID-19, Medicare will cover more than 80 additional services provided via telehealth technologies, and in some cases the services can be provided via telephone. Eligible services include:

  • Emergency department visits;
  • Initial nursing facility admission and discharge visits; and
  • Home visits.

Medicare still requires that the services be delivered by a clinical professional permitted to provide telehealth services. During the public health emergency, beneficiaries can use commonly available interactive apps with audio and video capabilities to visit with their health care professional. Previously, Medicare covered telehealth services only for beneficiaries in rural areas; they had to travel to an approved site to receive the services because homes were not an approved site.

The expansion will permit home health provider organizations to offer more services to beneficiaries via teleheath, as long as the services were part of the beneficiary’s plan of care and the telehealth services do not replace needed in-person visits ordered in the plan of care. Hospice provider organizations can offer Medicare beneficiaries routine home care through telehealth, a long as it is feasible and appropriate to deliver services in that way.

Physicians will be permitted to conduct Medicare Virtual Check-In services (brief check-ins) by audio or video devices for new and established consumers. Previously, the Virtual Check-In service was reserved only for consumers with an established relationship with the physician. Further, clinical professionals can provide remote monitoring services and collect vital sign data via devices to manage symptoms of a chronic condition or COVID-19.

PsychU last reported on this topic in “New Federal Coronavirus Bill Waives Medicare Telehealth Restrictions,” which published on March 16, 2020. The article is available at https://www.psychu.org/new-federal-coronavirus-bill-waives-medicare-telehealth-restrictions/.

For more information, contact:

  • Office of Communications, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-260-1462; Website: https://www.cms.gov/

Health care navigators, or “patient navigators,” cut emergency visits and hospitalization for high-risk health care consumers, according to an analysis of a navigator program implemented by Texas Tech University Health Sciences Center (TTUHSC). Among consumers who were assigned a navigator, emergency room visits dropped from 3.1 visits per person per year to 1.1 visits per person annually. Hospital admissions dropped from 1.5 per person annually to zero. Nearly three-quarters (74.9%) of those assigned navigators decreased both hospital and emergency room utilization. The effects of the navigator program persisted across various insurance types, and whether or not the person had a primary care physician.

The estimated value of the net reduction in hospital admissions and emergency department among those who were assigned a navigator was $1.2 million. Net estimated hospital admission savings attributable to the navigator program were $963,900, plus another $707,427 for emergency department visits resulted in total savings of $1.6 million. The cost of the TTUHSC navigator program averaged $404,754 with net savings of $1.2 million. Over three years, the navigator program cost an estimated $1.2 million to implement and produced estimated avoided costs of nearly $3.8 million.

These findings were reported in “An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System” by Charles F. Seifert, Pharm.D., FCCP, BCPS; Taylor J. Horyna, Pharm.D., BCPS; Dolores Buscemi, M.D., FACP; and Rosalinda Jimenez, Ed.D., APRN, FNP-BC, PMHNP-BC, and Linda McMurry, DNP, RN, NEA-BC. The researchers analyzed results generated by 11 Medicare Coordinated Care Demonstration programs, which showed that coordinated care resulted in an 8% to 33% decrease in hospitalization among high-risk Medicare beneficiaries.

For the TTUHSC navigator program, the researchers recruited 364 low-income individuals age 50 and older with health conditions that put them at high risk of frequent hospitalization or emergency department visits. Their median age was 59 years. About 75% were enrolled in Medicaid or Medicare. About 70% had mental health issues. Most reported relying on a hospital emergency room for their primary care because they believed the best physicians worked at a hospital or they were skeptical of care provided outside a hospital. The goal of the TTUHSC program was to determine whether a navigator intervention had a positive effect on hospital and emergency room visits.

The program employed four navigators once fully implemented. Each navigator worked with an average of 150 individuals. The participants were required to host one home visit where they made face-to-face contact with the navigator. During home visits, navigators checked blood pressure, conducted medication adherence checks, and performed a home environment scan. The navigators were able to collaborate with nurse practitioners to arrange for education during a home visit if the participant did not understand the purpose of prescribed medications.

The full text of “An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System” was published in the January- February 2020 issue of Journal of Healthcare Management. An abstract is available online at https://journals.lww.com/jhmonline/Abstract/2020/02000/An_Evaluation_of_Interprofessional_Patient.11.aspx.

For more information, contact: 

  • Charles F. Seifert, Pharm.D., FCCP, BCPS, Professor of Pharmacy Practice, Health Sciences Center, School of Pharmacy, Texas Tech University, 3601 4thStreet, Lubbock, Texas 79430-8162; 806-743-7639; Email: charles.seifert@ttuhsc.edu; Website: https://www.ttuhsc.edu/pharmacy/default.aspx

On March 25, 2020, Metrocare Services announced it had reached a contract agreement with the North Texas Behavioral Health Authority (NTBHA), following a contract dispute about payment rates. The two entities had been in a dispute because NTBHA proposed reducing Metrocare’s contract rate by about $600,000 annually because NTBHA seeks to equalize its support to all of its contractors (about 24 organizations) that provide similar services, which would reduce how much state funding is directed to Metrocare. However, the new agreement allows for continuation of services without a reduction in funding through August 31, 2020, the end of the state fiscal year. The announcement did not disclose the contract amount or terms of the agreement. NTBHA opted to continue the contract under its previous terms to avoid disruption during the current COVID-19 public health emergency.

About 16% of the Metrocare budget had been from NTBHA. Metrocare said its funding should remain at the same level because it serves the most at-risk population in Dallas County. The situation was discussed at the NTBHA Board of Directors meetings on January 8, 2020, and February 12, 2020. According to the meeting minutes, the issues included the following:

  • Metrocare believes that the proposed contract with NTBHA “is so bad that if they were a private entity, they would walk away and that it actually costs them to do NTBHA business.”
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