What You Should Know; 

– Highmark Health and Spring Health today announced their collaboration to expand the number of access points to behavioral health care by 40 percent for Highmark insurance members, including children and teens. 

– Highmark’s Mental Well-Being powered by Spring Health will offer multiple levels of support: digital capabilities for daily wellness, one-on-one care navigation, deeper clinical care through in-person or virtual therapy, medication management, and 24/7 crisis support. 

Global Mental Health Solution

Mental Well-Being is powered by Spring Health, the most comprehensive global mental health solution for employers and health plans, and provides members with access to therapy and medication management appointments in an average of three days or less. Spring Health has helped nearly 70 percent of users reliably improve their mental health, with an average time to remission of just 5.9 weeks, as shown in a peer-reviewed study published by JAMA. With Spring Health’s best-in-class technology, Mental Well-Being uses a proprietary assessment screen for acuity across more than a dozen conditions, including generalized anxiety disorder, major depressive disorder, bipolar disorder, substance use disorders, post-traumatic stress disorder (PTSD), adult attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), post-partum depression, and eating disorders. Each member is recommended a personalized care plan tailored to their assessment results. Members can book appointments with providers in real-time and filter by condition, specialty, gender, ethnicity, and language. 

“Spring Health’s precision technology is changing the mental health paradigm,” said Adam Chekroud, PhD, president and co-founder, Spring Health. “There is a false narrative that increasing access will dramatically increase cost. But third-party-validated results demonstrate that Spring Health has been successful in lowering total health plan spend per participant in the first six months of engagement, especially those with costly chronic conditions. We’re thrilled to partner with Highmark Health as they recognize that providing access to Spring Health’s Precision Mental Health services will help members develop an understanding of how to incorporate behavioral health into their personal healthcare journey in a meaningful way—with proven clinical and financial results.” 

Availability
Mental Well-Being powered by Spring Health will be available to health plan members through the My Highmark member platform. My Highmark is a digital front door to a holistic experience that guides members through individualized health journeys. By creating a pathway that suits each member’s needs and interests, it’s easier to engage in and take the right steps to manage physical, mental, and social health, which ultimately improves outcomes and overall population health.

In the current digital landscape, the impact of social media on youth mental health is becoming an increasingly pressing concern. Dr. Vivek Murthy, the U.S. Surgeon General, recently issued a call to action, urging tech companies and lawmakers to take immediate steps to safeguard the mental well-being of our children and adolescents. 

This timely request is certainly necessary, but it only scratches the surface of a complicated issue.

From my perspective as a psychologist, addiction expert, and researcher who has worked with adolescents in a clinical setting, the narrative becomes even more complex. And, as a mother of three, I’m also personally invested in the well-being of our youth in a world where social media is a ubiquitous presence. 

In joining my personal interest in these issues and my professional experience, I hope to provide a multifaceted perspective to this topic. Understanding the unique challenges faced by today’s youth is the first step toward bringing about change that can help end the mental health crisis they currently face.

What the Data Says

According to the Pew Research Center, as many as 95% of U.S. teenagers aged 13-17 report using a social media platform. This is virtually every teen in America. 

The Pew research also shows that 35% of teens say they use one of the top five platforms (YouTube, TikTok, Instagram, Snapchat, and Facebook) almost constantly. This has troubling implications, as a 2019 research study published in JAMA Psychiatry found that people who spend over three hours a day on social media are more likely to develop mental health problems. 

Digital World, Physical Harm

Many of the negative effects of youth social media use involve issues of body image and identity. This is likely because social platforms offer countless opportunities for young people to compare themselves with others. And, as a consequence, they may experience feelings of alienation when they feel they don’t meet popular standards for physical appearance.

Numerous studies have reported a correlation between social media use and body dissatisfaction, dieting behavior, and eating disorders among young people. This isn’t just a response to passive viewing of the seemingly perfect lives and bodies cascading endlessly down social media feeds; more troublingly, this is part of an active conversation as young people create and respond to content promoting disordered eating. 

Social media is also where cyberbullying happens. According to the Pew Research Center, 46% of teens aged 13-17 have been bullied or harassed online, often over their physical appearance. These online attacks can have severe psychological impacts, leading to depression, anxiety, and low self-esteem.

The Complexity of Adolescence

Adolescence has always been a challenging phase of life, with or without social media. It’s a period fraught with physiological changes, emotional turbulence, and identity formation. As CDC data shows, mental health conditions like depression and anxiety often first surface during this phase of life. The existence of these conditions isn’t just a product of social media; they’ve been long-standing challenges for adolescents. However, social media may be a factor in the record rates of youth depression and suicide we’ve seen in recent years.

Generational trauma and societal pressures compound the challenges of adolescence. Our youth are navigating an environment where the strains of academic achievement, future uncertainties, and societal expectations loom large. Research indicates that these pressures can contribute to stress, anxiety, and other mental health issues among teens. Many teens even take to social media to discuss trauma, and while this can be therapeutic, it can also have an amplifying effect on the trauma itself. 

Loneliness has also recently been highlighted by the Surgeon General as a serious harm to health and well-being in our nation, and loneliness is especially complex in young people. Loneliness can lead to both emotional and physical harm. 

Despite the many ways in which social media allows us to connect with others both near and far, the nature of those interactions can lead to more disconnection than connection. As Dr. Murthy states, “There can be an assumption that because you’re virtually connected through social media, email or text that somehow that protects you from loneliness. Sometimes it can, but not always.”

Harnessing the Positive Potential of Social Media 

Despite the issues that can arise, we must not forget that social media also has transformative potential. Social platforms can be positive places for fostering connections, encouraging empathy, and promoting social activism. For example, many young people use social media to find communities that support their interests, identities, and causes. 

However, the key is to ensure that social media usage is healthy and balanced. To do this, we need a comprehensive approach that combines education, digital literacy, mental health support, and community intervention.

The Crucial Role of Caregivers

Caregiving, especially for the youth grappling with mental health issues, requires a profound understanding of the challenges young people face and the right set of tools to address their needs. Digital tools, such as youth-oriented mental health apps, can offer round-the-clock access to resources and support; this can include self-help guides, meditation and mindfulness activities, or direct access to licensed therapists. 

Caregivers need to be equipped with knowledge about recognizing signs of mental distress, understanding the impacts of excessive social media use, and learning effective intervention strategies. This includes understanding the signs of cyberbullying, identifying changes in behavior that may indicate social media addiction, and being aware of the potential for social media to distort perceptions of reality. 

Digital literacy education for caregivers is also essential; it’s important for caregivers to understand the online environment that young patients spend so much time in. This can help caregivers provide supportive conversations about social media use, establish healthy boundaries, and introduce alternatives to online interaction.

It Really Does Take a Village

A truly effective approach to supporting youth mental health is the “It takes a village” approach, which underscores the importance of a supportive community in nurturing the well-being of young individuals. 

Schools are in a unique position to spearhead this effort by integrating mental health and digital literacy education into their curricula. Beyond education, tech companies have a crucial role to play in creating safer online environments. The Surgeon General has also urged enhanced privacy settings, effective content moderation, and tools that can promote well-being to help make social media a more constructive space for young people.

Similarly, lawmakers have a responsibility to create supportive legislative frameworks. These might include policies for stricter regulation of online content, increased public investment in youth mental health services, and legislation that promotes responsible digital behavior. Community support is another essential part of this endeavor; and this includes online communities. The presence of supportive adults and peers in a young person’s life can significantly mitigate the effects of social media. 

A Comprehensive Approach to a Complex Problem

The issue of social media and youth mental health is not a one-dimensional problem. It’s a multifaceted challenge, intertwined with broader societal issues and generational narratives. It calls for a comprehensive approach that recognizes these complexities, fosters community support, and places education at its core.

As we navigate this new digital era, it is our collective responsibility to ensure that our young people are equipped with the resilience and skills to thrive, both online and off.

About Lindsay Oberleitner

Lindsay Oberleitner, Ph.D., is a clinical psychologist who has worked at the intersection of addiction, trauma, and chronic health conditions. Lindsay is SimplePractice’s Education Director. Before joining SimplePractice, she worked as an Assistant Professor at Oakland University William Beaumont School of Medicine, Yale University School of Medicine, and Western Connecticut State University. She also served as Associate Director of the Yale Forensic Drug Diversion Clinic, where she worked to increase access to care and recovery for underserved populations and advance equitable and inclusive treatment through a community engagement approach.

What You Should Know:

– Cartwheel, a platform helping schools tackle the student mental health crisis by delivering affordable, evidence-based telehealth services with no waitlist raises $20M in Series A funding led by Menlo Ventures. Reach Capital joined the round, as did earlier investors General Catalyst, BoxGroup and Able Partners.

– The funding will allow Cartwheel to expand mental health services to hundreds of thousands of new students in current service areas, as well as school districts in new states.

Evidence-Based Mental Health Support

Founded in 2022, Cartwheel has quickly become a trusted mental health partner to schools. The founding team, which includes Chief Medical Officer, Juliana Chen, MD, a board-certified child, adolescent, and adult psychiatrist, had collectively spent decades working in schools and community mental health clinics and felt the need for stronger school-community partnership to improve accessibility, quality, and financial sustainability of mental health care.

Today, when a school district partners with Cartwheel, school counselors can refer students for clinical mental health services with no waitlists. Cartwheel’s in-house team of licensed clinicians delivers evidence-based telehealth services, including 1-1 therapy, group therapy, parent guidance, and medication support – all as an in-network benefit covered by the family’s insurance. Operating year-round, Cartwheel allows students to see a licensed clinician at home or at school and during evenings, weekends, school breaks, and summers.

“By combining funding from school districts and health insurers, we’ve helped superintendents ensure the long-term financial sustainability of these services,” added Daniel Tartakovsky, Co-Founder and COO of Cartwheel and previously a mental health policy advisor to the U.S. Surgeon General. “We believe our model will become a blueprint for districts across the country on how to build a long-term school-community partnership, especially as school budgets tighten with the expiration of federal COVID relief dollars.”

Throughout care, Cartwheel works hand-in-hand with school staff and families to ensure the student is appropriately supported. A clinically licensed Program Manager supports school administrators on student cases, parent engagement, and staff training throughout the year; and bilingual Care Coordinators help families with scheduling, insurance, and referrals for additional services. Parents can also schedule weekly guidance sessions with a licensed clinician to discuss ways to support their child, even if their child isn’t interested in therapy themselves. Parents can also join educational workshops on timely mental health topics, ranging from school avoidance to social media use.

In a society where so many want more—more money, more time off, more adventure—few stop to question the logic of insatiably wanting “more.” Perhaps, no place does the consequence of wanting more negatively impact people than with healthcare treatments. Medication use, for example, shows clear dose-response curves, where over-use can have fatal consequences; negative consequences and death also can result from too much chemotherapy, radiation, antibiotic use, or complications from unnecessary surgical procedures. Within behavioral healthcare, negative outcomes have been across all populations and treatment interventions. Patients receiving cognitive behavioral therapy, for example, who fail to show significant change within an expected number of sessions have an incredibly low likelihood of achieving clinical behavior change making further therapy a misallocation of resources and potentially harmful if it prevents the patient from finding a more effective treatment. As a result, medical and behavioral health treatments often have well-defined standards of care that outline minimum and maximum levels of treatment to optimize effectiveness, with one exception -autism spectrum disorder (ASD). Here’s why stakeholders need to figure it out… 

The prevalence of autism has continuously risen over the past 20 years along with a continued shortage of Board Certified Behavior Analysts (BCBA) to provide Applied Behavior Analysis (ABA) treatment, the only evidence-based, empirically proven therapy for ASD. In a rush to meet the resulting access issues, the elephant in the room that people look past, however, is the lack of standardization and high variability for recommending treatment intensity individuals with autism clinically need. The result is a system where treatment recommendations can range from focused to comprehensive, from 5-to-40 hours per week, and for between 18 months to 5 years—often under the assumption that more hours will always translate to more progress. But is the old adage that “more is better” uniquely applicable to ABA? 

There is not a “one size fits all” approach within ABA and it’s important to consider various factors which may lead to some undesirable effects that comprehensive treatment may have on families. Recommendations of 30+ hours/week pose a lengthy list of flags, questions and concerns including the financial impact on the family, coordination of care and transition planning.  Having a therapist in your home for several hours every day is seen by many as an intrusion of privacy. It also takes away precious time for other social/community involvement, reduces a parent’s ability to work, and can lead to the deterioration of parent-sibling and marital/couple relationships. Children receiving ABA in clinics have added impact from the time driving back and forth, limited parental insight into what their child does all day, and their treatment gains may not generalize to other environments. In short, therapy-life balance is important for the child in treatment, their parents, and their siblings. 

More controversially, several pieces of evidence suggest some autistic individuals have better treatment outcomes with fewer hours directly contradicting the “more is better” assumption from above. The key component here is that treatment recommendations are individualized relative to each patient’s baseline skill levels (skillset prior to receiving treatment) and target skills that the providers believe to be most important to improving the child’s quality of life. For example, if the goal is to optimally increase communication skills, comprehensive services may be the answer. If the goal is to reduce general ASD symptom severity and parental stress, more ABA may not be the answer. Finally, research examining dose-response relationships suggests the duration of treatment has a stronger impact than intensity on outcomes (here’s another example for adaptive skills, motor skills, and executive functioning). 

The ask and answer: Individualize treatment tailored to optimize ABA effectiveness for each child! No more blanket business models at 35 hours/week for every child. No more requesting excessive hours “just in case” of cancellations and school vacations. No more requesting hours to substitute for school enrollment. Instead, services should be outcome-based and guided by clinically validated data to drive hours of recommendations and treatment to best meet individual goals. Providers have good intentions but also have conflicts of interest. Let’s use patient characteristics, goals, skill sets, and historical data on how ABA actually improves the lives of each unique client to determine precise, individualized treatment intensity recommendations that optimize outcomes and pay providers accordingly. Examples of how this can be done already exist here, and here, and here. All it takes for all individuals with autism to benefit is to start questioning the assumption that “more is always better.”

About Dana D’Ambrosio, MS, BCBA, LBA

Dana D’Ambrosio leads Clinical Development for RethinkFutures. She is a New York state-licensed and Board-Certified Behavior Analyst. She brings over a decade of clinical knowledge, with experience spanning from direct patient care in various treatment settings to utilization and care management within the payor realm. She specializes in the creation and enhancement of technology solutions utilized by providers and health plans, to ensure best practice, high quality, coordinated care and streamlined review processes for all parties. 

What You Should Know:

– Banner Health forms a strategic partnership with Phoenix-based evolvedMD to place mental-health providers at Banner’s primary-care clinics, making it easier for people to receive mental health services they may need.

– The integration of mental health services in primary-care settings will be phased in at Banner Medical Group sites throughout metro Phoenix, starting in the East Valley at Banner’s East Mesa and Queen Creek locations.

– Under the program, a licensed behavioral therapist works with the patient’s primary care providers to provide mental health expertise, psychiatric consultation, ongoing clinical support, case management and insurance support and navigation.

What You Should Know: 

– Headspace, a comprehensive digital mental healthcare provider, and Castell, Intermountain’s value-based care subsidiary, have signed a value-based care (VBC) mental health partnership designed to improve health outcomes through a personalized care experience for members.

– The VBC mental health partnership will provide members with access to Headspace’s clinical offerings including their self-guided content, behavioral health coaching, and therapy in an outcomes-based payment model. This is a notable expansion of VBC for Headspace and is Castell’s first and only digital mental health provider in their network.  

Addressing the Growing Mental Health Crisis

The collaboration between Castell and Headspace aims to address the growing mental health crisis by engaging patients – wherever they may be on their mental health care journey – with robust behavioral health care offerings. The partnership will integrate Headspace’s offerings into Castell’s value-based model of care, which aims to improve clinical outcomes at a population level while reducing costs across the healthcare continuum.

Refer Eligible Members to Behavioral Health Coaching & Therapy

The partnership will allow Castell to refer eligible members directly to Headspace for behavioral health coaching and therapy. Those members will then have access to a team of behavioral health coaches, who respond to outreach in two minutes or less and provide care in the moment of need. Headspace’s coaches help to build coping skills and manage day-to-day stressors, and its licensed therapists are trained in a variety of clinical specialties and treatment modalities for more acute clinical care. Headspace’s care model is built to meet people where they are in the care spectrum and allows members to step up to higher levels of care or adjust over time, as their needs and preferences evolve.

“Our goal with patients is to help them have the most holistic view of their health. Being able to better address and integrate a patient’s mental health status is critical to treating the whole person and elevating the quality of care they receive,” said Jay Zerwekh, CEO of Castell. “We are thrilled to partner with Headspace to give patients access to behavioral health coaching and tools that can be tailored to meet their individual needs.”

Far too often, substance use disorder (SUD) is viewed as an “acute condition,” one that can be “cured” with short-term treatment, such as a week-long stay in a detox facility. This could not be further from the truth. The failure to understand the science behind addiction leads individuals who are undertreated or inappropriately treated to return to use again and again.

SUD is not a moral failing. It is not a behavioral issue. It is not a choice. The leading health organizations around the world agree―based on a multitude of scientific research―SUD is a chronic brain disease rife with biological underpinnings. As such, the genetic component of SUD should not be a surprise. If you have addiction in your family, you are approximately 50% more likely to be affected, too.

SUD can be managed very successfully―and for a lifetime―if individuals in treatment, in need of treatment, and in recovery (along with their loved ones) fully understand the need to manage it as a chronic disease. When individuals harbor misconceptions about what addiction is, they may not seek treatment, they may not seek the right treatment, or they may not continue in treatment. Self-detox is not a viable option and, in some cases, can be fatal.

When viewed as a behavioral issue or a choice, there is a stigma surrounding SUD that can prevent individuals in need of treatment from seeking care. According to the 2021 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), 46.3 million Americans are struggling with substance use disorders, but only a small fraction—6%—receive treatment.

For those who do seek treatment, many expect SUD to be remedied with a “one and done” approach, which is not realistic. Individuals in recovery then internalize that thinking and let their guard down, assuming it is not necessary to continue daily practices that support long-term recovery. The National Institutes of Health reports the relapse rate for SUD is between 40 and 60%.

In addition to understanding recovery is a long-term process, we must also recognize that clinical treatment alone is not enough. Individuals with SUD need ongoing psychosocial support from their families, their communities, and their employers. Recovering from addiction requires rewiring and retraining the brain, and it takes hard work and a significant amount of effort. Acknowledging this better serves patients and families going through the early stages of recovery, as well as in managing this disease long-term.

In the ideal world, unhealthy substance use would be identified early on, and intervention by a family member or healthcare provider would be delivered with compassion and without judgment. Too often the opposite is true, and when people seek medical or mental healthcare, they do not feel cared for.

While it may take many years for society to fully understand and identify SUD as the chronic condition it is, there is a particular treatment component―one that too few are providing or utilizing―that we can leverage immediately to support more individuals in their recovery journey. That component is the integration of peer support into every level of care.

The presence of peers throughout the recovery journey―peers who have overcome SUD and mental health challenges themselves and can inspire hope, offer compassion, and provide guidance along the way―is a complete gamechanger. This manner of support, especially during the most challenging moments, can mean the difference between recovery and return to use. The outcomes, which are clinically evident, are extraordinary.

It is frequently touted that “connection is the opposite of addiction.” And that feeling of connectedness is essential to long-term recovery. My hope is to build greater awareness and implementation of this peer support component in our collective mission to combat our country’s SUD crisis, and to ensure every individual has access to the tools needed to achieve lifelong recovery.

About Hans Morefield

Hans Morefield is Chief Executive Officer at CHESS Health, proudly leading a team that brings innovative and evidence-based solutions for addiction management and behavioral health to healthcare providers, health plans, and the public sector. CHESS Health’s platforms help get more patients into treatment for substance use disorder, increase adherence to treatment plans, reduce the rate and severity of relapses, and lower the total cost of care. Prior to joining CHESS Health in 2017, Morefield served as Vice President of 

Population Health and Care Coordination at Experian, where he led the team delivering the successful CareCertainty Platform to ACOs, health plans, and risk-bearing health systems nationwide. He previously served as Senior Vice President of Strategic Development at SCI Solutions, responsible for product management and strategic partnerships. Morefield earned his BA from Kalamazoo College, where he has served on the Board of Trustees for over 15 years. He also serves as a volunteer on the Community Relations Committee for Stepping Stones, the Historic Home of AA and Al-Anon Founders Bill and Lois Wilson.

As behavioral health claim volumes continue to increase, there’s a growing need for health plans to be vigilant in spotting fraud, waste and abuse. Today, the complexity and cost of these schemes necessitate a proactive, preventative approach.

Nearly four out of five psychologists say they are seeing increased volumes of patients experiencing anxiety, while two out of three reported an increase in symptom severity in 2022, an American Psychological Association survey shows. High volumes, combined with new modes of care delivery approved during the pandemic such as audio-only services for behavioral health, make these services especially vulnerable to fraud, waste and abuse by bad actors.

Some health plans—typically larger plans with greater resources—have large in-house special investigations units with the expertise to review behavioral health claims data for suspicious activity. One investigation detected more than 40 dates of service for which a provider billed more than eight hours of services a day, often on consecutive days, including major holidays such as Thanksgiving, Christmas and New Year’s Day. A closer look at the documentation revealed inconsistencies in the member’s identity, age, gender, health history and sexual orientation. These were signs that services might not have been provided or that records were being cloned, with either scenario leading to inappropriate payment. Without this investigation, the health plan could have overspent as much as $115,000 annually on just one provider’s claims.

But not every plan has access to a large SIU to combat fraud, waste and abuse in behavioral health. That’s why knowing how to decrease the risk of inappropriate claim payment—preferably before the claim is paid—is an important step toward improving payment integrity.

Behavioral Health Schemes Are Increasing

The potential for lost revenue is high in an environment like the one health plans found themselves in during the COVID-19 pandemic when the need for services like behavioral health dramatically increased, but opportunities for in-person care suddenly shrank. 

The relaxations in telehealth delivery that occurred during the pandemic, for example, created additional avenues for bad actors to exploit members who badly needed mental healthcare. Suddenly, Medicare members could access behavioral health via telehealth using audio-only communication platforms, from the point of the first visit. They could also access care via telehealth from providers across state lines, whether in their homes or in rural health clinics or federally qualified health centers. Many of these changes became permanent for Medicare, such as enabling beneficiaries to receive behavioral telehealth services in their home. Others have recently been extended for several months beyond the expiration of the COVID-19 public health emergency (PHE), such as flexibilities that enable providers to prescribe controlled medications via telehealth. 

Individual psychotherapy sessions are another area that is ripe for fraud, waste and abuse. Among claims processed by Cotiviti, 60-minute individual therapy sessions comprised nearly two-thirds of behavioral health procedure codes in 2022. One example of potential waste and abuse is when a higher-than-average percentage of claims are billed as 60-minute sessions compared with a provider’s peers, warranting a closer look. Then there’s applied behavior analysis services for people with autism, an area where disreputable providers have submitted false claims, upcoded claims, or billed for one-on-one therapy rather than a group session. In one instance, the U.S. Attorney’s office recovered more than $2 million from an autism therapy provider for false claims. 

Yet many plans are hesitant to pursue suspected issues with behavioral health claims. There is a tendency to treat these claims more sensitively than other types of claims, partly due to fears of upsetting members who need mental health care and partly due to a lack of in-house expertise—from clinicians to coders—to review these claims. Moreover, patients who are most often targeted in these schemes include those least likely to review or understand their claims—such as the elderly—as well as those who suffer from addiction and those whose claims are fully covered by insurance.   

Detecting Behavioral Health Schemes Faster

When behavioral health claims look suspicious or outright wrong, the right defense helps plans protect themselves as well as their members—and prevents these cases from continuing to proliferate. Here are ways health plans can shore up efforts to prevent and detect behavioral health fraud, waste and abuse.

1. Become well-versed on the changes in behavioral health service delivery that will become permanent. This includes knowing which telehealth flexibilities continue to be extended following the expiration of PHE—and in what circumstances. This will help in educating providers, members and staff on what has changed in the plan’s coverage of remote behavioral health services. It will also position payers to take the first steps toward optimizing prepay claim editing.
2. Take a proactive approach to data mining, looking for trends in behavioral health spending. Examine trends in behavioral health spending prior to the pandemic and compare them to the types of claims the health plan is seeing now. Look at providers that are rendering much of their services in a telehealth setting and that are expanding their geographic coverage area. This data offers a basis for flagging providers that warrant immediate investigation.
3. Go beyond a traditional outlier analysis. Outlier analysis can position plans to pick the low-hanging fruit, such as providers who are billing extremely high volumes. But with these schemes becoming more sophisticated, health plans should also examine trends such as clustering—when a group of providers in a geographic area provides similarly high volumes of behavioral health services. They should also compare providers’ activity levels to those of their peers, regionally and nationally. Doing so can help pinpoint providers that are flying under the radar and merit a second look. Today, the addition of artificial intelligence algorithms and machine learning is assisting health plans in moving from retroactive, “pay-and-chase” review toward early detection of inappropriate claims.
4. Adopt a collaborative approach to front-line detection of suspicious claims. For small and medium-sized plans in particular, talking with other plans about the trends they are seeing in the same geographic area can uncover regional trends that deserve greater focus. This gives health plans a better basis for determining where to devote resources for strengthening prevention and recovery. It also increases staff productivity by empowering them to catch bad billing behaviors before payment is made.
5. Add prepay and postpay integrity solutions to your revenue integrity toolkit. This not only enables plans to detect behavioral health schemes faster, but also positions them to use the learnings from their investigations to optimize prepay claim editing moving forward.

Prevention Starts with a Change in Mindset

The sophistication of behavioral health billing schemes calls for health plans to let go of their fear of pushing back on behavioral health claims and arm themselves with actionable data and expert guidance. Such an approach empowers plans to more effectively detect and analyze suspicious claims, catch red flags and follow up on potential patterns of abuse, protecting vulnerable members.

About Erin Rutzler

Erin Rutzler is vice president of fraud, waste and abuse for Cotiviti. As vice president of fraud, waste, and abuse (FWA), Erin is responsible for the oversight and strategic direction of Cotiviti’s FWA solution suite. In her role, Erin has been integral in the development of Cotiviti’s FWA solutions over the past eight years. Serving as the company’s primary subject matter expert in investigations and FWA for compliance, client training, sales, and marketing activities, she regularly represents the company at industry conferences such as the National Health Care Anti-Fraud Association’s (NHCAA) Annual Training Conference (ATC).

What You Should Know: 

• Artificial intelligence (AI)-powered mental health screening pioneer Aiberry (pronounced “I” + “berry”) unveiled a new version of the Aiberry platform specifically designed to meet the needs of corporate wellness platform users. 
• Easily integrated with all leading corporate wellness platforms, Aiberry uses an AI-powered therapeutic assistant, “Botberry,” to conduct a conversation to detect mental health disorders by analyzing what is being said, the speech patterns being used and even subtle changes in facial expressions. New analytics capabilities introduced as part of the Aiberry corporate wellness platform enable corporate wellness program administrators to track utilization of the platform as well as employee wellness over time.

Platform Expansion into Corporate Wellness

Aiberry for corporate wellness builds on a solid foundation of use in clinical settings including leading national recovery centers. These facilities have seen assessment accuracy and patient well-being improve measurably since the platform was implemented. Futures Recovery Healthcare found that the percentage of clients receiving an official diagnosis for a depressive disorder rose from 24% to 46% after Aiberry implementation, due to the system’s ability to detect depression in cases in which completion of self-reporting forms such as the Patient Health Questionnaire (PHQ-9), currently the gold standard, did not. Futures found Aiberry to be more sensitive than traditional screening methods, as 45% of clients who scored in the severe range for depression on initial Aiberry assessment scored only “moderate” or “mild” when completing the PHQ-9.

“The expansion of the Aiberry platform into corporate wellness brings the benefits of AI-powered mental health assessment to a critical population, American workers, which is massively underserved by currently-available behavioral health resources,” said Aiberry Co-Founder and Co-CEO Linda Chung. “This delivers on our mission to offer objective, reliable, and scalable solutions via the power of AI, making behavioral healthcare accessible to all, and helps bring our vision, to empower patients and providers with the tools to effectively and efficiently assess behavioral health, to reality.”

What You Should Know: 

• Today, Affect Therapeutics – a McLean, VA-based company reimagining alcohol and drug addiction treatment with smartphone apps that put an integrated treatment program into the pocket of its members raises $16M in Series A funding led by ARTIS Ventures. The funding also included additional participation from previous investors AlleyCorp and CityLight, as well as new investments from LifeArc Ventures, Samsung Next, and What If Ventures. 
• Founded in 2020, Affect Therapeutics offers clinically intensive treatment that is all-digital, accessible, and cost-effective.

Supporting Entire Recovery Journey

Affect has established a scientifically-proven program that supports the entire recovery journey, and is the first company to reward healthy behavior with financial incentives, known as contingency management, to drive motivation resulting in increased retention and more durable sobriety. This is coupled with counseling, medical oversight, and case management, delivering a comprehensive program based on decades of research. Affect has already treated thousands of patients with results that are proven to be twice as effective as traditional treatment models by key metrics insurance and medical partners value most. More importantly, these outcomes change peoples’ lives and lead them to manage the chronic disease of addiction into lasting remission.

In its short time in market, Affect has already treated thousands of patients with results that are proven to be twice as effective as traditional treatment models by key metrics insurance and medical partners value most. More importantly, these outcomes change peoples’ lives and lead them to manage the chronic disease of addiction into lasting remission. 

Availability

Affect currently holds outpatient treatment licenses in 20 states and aims to serve a majority of the U.S. population by the end of 2023. The company partners with the largest health insurance payers in the country, including UnitedHealthcare, Aetna, Humana, Molina, and Centene. The company plans to use the funding to advance their program initiatives in more states, as well as engineering innovation in its platform. The Affect app is free to download on the Google Play Store or Apple App Store.

What You Should Know: 

• TELUS Health today released its monthly Mental Health Index which revealed that workers who collaborate with others in the workplace have a better mental health score than those who work exclusively independently. 
• The Index also showed that the mental health scores of workers who do not feel supported in their mental health and wellbeing by their employers scored 10 points below the national average.

Collaboration aligns with better mental health

• Nearly two in five (37 percent) workers report needing to collaborate with coworkers all the time; this group has the highest mental health score (72.9), five points higher than workers who do not need to collaborate for their roles (67.8) and nearly two points higher than the national average (70.9).
• Nearly two in five (38 percent) of those surveyed reported that they would prefer to work alone most of the time; the mental health score of this group is more than four points below the national average.
• The mental health sub-score of isolation is the lowest among employees who prefer to work alone most of the time, nearly 12 points lower than employees who don’t prefer to work alone.

Employer mental health and wellbeing support

• The mental health score for workers who do not feel supported by their employer for their mental health and wellbeing needs is 10 points below the national average. Employees who feel less supported now versus early in the pandemic have an even lower mental health score (57.3) than those who never felt supported in the first place (60.6).
• Fifteen percent of workers surveyed indicated that their employer has improved the level of mental health support; this group has a mental health score of 71.5.
  • Laborers are 40 percent more likely than service industry workers, and 30 percent more likely than office workers, to report their employer has improved the level of support.

We all know the stark reality: rates of mental illness, substance use, and developmental disorders continue to rise in the U.S. and estimates show that 1 in 44 children are diagnosed with autism spectrum disorder (ASD). 

Add to that the ongoing efforts to reduce stigma and it’s no surprise that the increased demand is overwhelming existing resources. 

Improvements in both the efficiency and effectiveness of care and treatment are critical in addressing the crisis.

Doing so will require both better data and better insight into that data. 

The result will be improved access and quality, including through pay-for-performance and value-based care initiatives. 

Historically, behavioral health has lagged behind physical health in the adoption of such strategies due to the lack of data collection on both treatment and outcomes. 

Yet, just like physical health, ​​behavioral health overall has widely accepted and clinically validated treatments and outcome measures for the vast majority of conditions but measuring it has been a challenge. 

In the last decade, however, there have been significant advances in behavioral health measurement and data, as both public and private payors roll out successful pay-for-performance and value-based-care efforts. 

A number of players have also started to use very large data sets, modern data science, and AI to further understand and improve behavioral healthcare. 

This is true across behavioral health conditions and levels of care. 

Except, that is, when it comes to autism.

Multiple factors make autism care complex

Many children with ASD have varying levels of severity and multiple comorbidities such as intellectual deficits, mental health conditions, and medical disorders. Taking a holistic approach to any behavioral health treatment is no easy feat, and the complexity of ASD further complicates measurement, diagnosis, treatment, and outcomes monitoring.

Treatment and behavior change processes also occur over time and trained behavior analysts or therapists must work with—and observe—behavior across a variety of settings to understand why certain behaviors develop, stabilize, or change.

Without the ability to observe, measure, track, and oversee patients in all settings throughout the week, however, it’s difficult to develop the most appropriate interventions and to deliver them in a consistent way for the duration of time needed and to make a lasting impact.

The push to value-based care in behavioral health and autism

Successful value-based systems in primary and specialty care have evolved to where they are because of robust evidence-based practice literature that directly ties data on a healthcare system’s structure to its processes and in turn, to data on patient outcomes.

Behavioral health historically has been slower to aggregate and analyze such data, but within the last five years, we’ve seen a significant shift in the marketplace as major payors have implemented wide-ranging pay for performance and value-based care arrangements.

The U.S. government, in particular, has introduced comprehensive quality measures, from outcomes to the required use of evidence-based practices in mental health programs. 

Yet autism and developmental disorders have not benefited from these changes, despite the fact that developmental disorder diagnoses have reached 17% and rates of ASD have tripled. 

Further, the cost for intensive behavioral interventions such as Applied Behavioral Analysis (ABA) therapy is significant: between $40,000 to $60,000 per child per year. 

Today, mandates for ABA in all 50 states dramatically impact both public and private payors, as costs increase rapidly but uncertainty remains about how to forecast spending.

Compounding this uncertainty and further increasing costs is a historical lack of consensus around how to measure the quality of ABA services, but this too is changing.

For example, in 2021, the International Consortium for Health Outcomes Measurement (ICHOM) published a set of global standard outcome measures to enhance care for individuals with ASD. The same year, the Behavioral Health Center of Excellence (BHCOE) also published the ABA Outcomes Framework for individuals with ASD. 

The time has come to make significant moves to drive improved quality and access and rationalize the economics in autism care, making value-based care models critical.

Bringing advanced data to autism care: an industry-wide call to action

We cannot make necessary progress without profoundly upgrading our use of data. 

Data tells us how much therapy, and the characteristics of therapy, that a patient is receiving. 

It also tells us for whom certain types of therapy are most effective and which providers are better or worse at providing therapy. 

In the near future, data collected around patient demographics, symptoms, behaviors, treatment sessions, skill sets, and other variables must be used to identify evidence-based patient clusters. 

Analysts making use of these larger datasets should also start to build predictive models to recommend the right dosage, skill areas, and the type of therapy that a patient needs based on their unique and individual situation. 

Much like precision medicine, this data-based approach ensures appropriate care. 

It also allows providers and payors to collaborate around what the data indicates, as opposed to existing processes and procedures that rely more on the expertise of a few people making utilization management decisions which are fraught with issues of inter-rater reliability. 

Such transparency and refocusing on what the data says will allow providers and patients to work together more efficiently which can help to reduce patient wait lists. 

In addition to streamlining current interactions between providers and payors, large structured datasets will allow us to see things we previously weren’t able to. 

As previously stated, behavior is complex, but large datasets with objective data on behavior can be captured and analyzed over time. 

What’s more, recent advances in technology and computing increasingly make it easier to understand the complexity around medical and behavioral comorbidities, familial and social factors, and the unique characteristics of each patient. 

The result is a holistic view of each patient’s condition that enables interventions to be designed for an individual’s unique needs.

Additionally, when tied to outcomes data, patients can be tracked over time to determine the quality of care they are receiving, whether they’re achieving their treatment goals and whether treatment may need to be modified.

As we continue to stare down the supply and demand crisis, we must ensure patients receive quality care and treatment that is evidence-based. 

Adopting value-based care models for autism care alongside those for other health and behavioral health conditions is an industry imperative and will be a game changer in how care is delivered and paid for, and in the quality and effectiveness of the care patients receive, but it will require the right data. 

It is incumbent on stakeholders at all levels of the system—providers, payors, and the private sector—to rapidly execute the new data strategies necessary to enable this crucial evolution.

About Daniel Etra 

Daniel Etra is the Co-founder and Chief Executive Officer of RethinkFirst, a global behavioral health technology company offering industry-leading software and solutions for autism services.

HealthJoy, Teladoc Health Launch Virtual Primary Care

HealthJoy, a benefits navigation platform that amplifies employer benefit strategies expands its partnership with Teladoc Health to introduce virtual primary care. HealthJoy Virtual Primary Care, powered by Teladoc Health, provides a fully integrated primary care experience that supports members throughout their entire healthcare journey. The solution will further enhance HealthJoy’s comprehensive suite of virtual care offerings that already includes adult and adolescent mental health, chronic care management, dermatology, employee assistance program services, musculoskeletal therapy, nutrition, tobacco cessation, and urgent care.

Lifesum and ŌURA Partner to Connect Nutrition and Sleep

Lifesum, the leading global healthy eating platform, has unveiled a sleep tracking feature in partnership with ŌURA, the company behind the smart ring that delivers personalized health data, insights, and daily guidance, which will allow its users to understand how their dietary choices impact their sleep patterns—and vice versa. The partnership will build on their integration of Health Connect by Android to give Lifesum users another important layer of health data to track. The sleep tracker function will be offered to Lifesum Android users who opt in to the open beta, and the company will roll out the service to all Android users in the coming weeks.

Neuronic and Santa Clara University Partner to Develop Next-Gen Neurotech for Photobiomodulation

Neuronic, a multi-national company focused on light therapy technology, and Santa Clara University (SCU) in Silicon Valley announced a partnership to develop a research project to study photobiomodulation (PBM) guided by real-time brain activity, which will be led by Dr. Julia A. Scott and Dr. Sally Wood.  To address this concern, the research team plans to improve the efficacy of PBM delivery, a non-invasive therapy that uses near-infrared light to pass through the skin and activate molecules that improve blood flow, reduce inflammation, and increase cellular energy.

The researchers hope that their findings will pave the way for more conclusive evidence regarding the effectiveness of PBM for brain injury and neurodegenerative conditions. Further, they envision a future where clinicians can tailor treatments to the individual needs of each patient through the use of real-time electroencephalogram (EEG) data, thereby optimizing results. To achieve this goal, the team will conduct small-scale studies of the device on healthy adults to assess the effects of PBM on brain activity and evaluate protocol designs.

Patient Discovery Partners with AmerisourceBergen for Cancer Care Equity

Patient Discovery Solutions joins global healthcare company AmerisourceBergen’s Trusted Vendor Program. The collaboration enables community oncology practices, hospitals, and health systems nationwide access to Patient Discovery’s Equitable Care Platform, allowing care providers to proactively identify and address social determinants of health to better inform providers and help improve outcomes for cancer patients. AmerisourceBergen’s Trusted Vendor Program is comprised of a portfolio of cutting-edge operational and clinical care solutions. As a partner, Patient Discovery’s Equitable Care Platform will seamlessly integrate within a participating practice’s current systems, helping to improve information exchange for delivering equitable care across multiple sites of care.

Opus EHR Partners with Aroris to Revolutionize Behavioral Health Practices

Opus EHR, an innovative behavioral health solutions provider partners with Aroris, a contract negotiation company, to provide cutting-edge technology solutions that help behavioral health practitioners save time and money while managing payer relationships more effectively. The partnership aims to equip both current and prospective clients with all the necessary tools and features to grow and scale their practice, optimizing profitability from their business efforts.

Doceree Further Expands Global Footprint With Partnership With Hello Health Group 

Doceree, a global platform building unprecedented solutions for HCP programmatic marketing with proprietary data tools, today announced its long-term partnership with Hello Health Group, a leader in health & wellness content development that drives consumer and patient engagement. The latest collaboration will accelerate growth for both companies by combining the world-class HCP targeting and reach capabilities of Doceree with Hello Health’s leading patient and consumer reach and engagement solutions, and strong geographical presence in the South East Asian region. The partnership further establishes Doceree’s presence in eight key markets – Vietnam, Indonesia, Malaysia, Cambodia, Myanmar, Singapore, Philippines and Taiwan.  

West-Com Nurse Call Systems, Vitalchat Partner to Bring AI-Enabled Virtual Care Solutions to Healthcare Facilities Nationwide

West-Com Nurse Call Systems and Vitalchat partner to provide hospital systems and other healthcare facilities nationwide with virtual care solutions using artificial intelligence to meet the needs and demands of patients, caregivers, providers and IT leaders. Together, these solutions increase patient and caregiver safety, improve clinical collaboration, enable specialty access and provide for off-site family connection and engagement. They are available through a network of more than 70 active distributors around the country.

What You Should Know:

• Emory Healthcare (EHC) today announced a partnership with NeuroFlow to support and improve the delivery of psychiatric services for both patients and providers at their Brain Health Center and several sites across Georgia.
• NeuroFlow, which offers a cloud-based registry and enterprise platform to help facilitate collaborative care, will support EHC clinical services’ data-driven approach to patient care, with a sharpened focus on improving communication between care teams, including primary care providers, behavioral health specialists and care coordinators.
• The implementation of NeuroFlow in Emory Healthcare’s primary care clinics will begin in May 2023, with plans to expand to additional clinics throughout the year.

Increasing Access to Behavioral Health Services

The strategic partnership will seek to complement and scale Emory’s new collaborative care model (CoCM) within its primary care clinics. The CoCM is part of Emory’s Integrated Behavioral Health (IBH) Program, which was formed by the Department of Psychiatry and Behavioral Sciences to help meet significant access demands for behavioral health services in the EHC network. CoCM is embedding licensed specialists called behavioral health care managers (BHCMs) to work in EHC primary care clinics alongside primary care clinicians to provide psychotherapy onsite and serve as liaisons with psychiatric consultants.

Through NeuroFlow, Emory patients are given 24/7 access to self-directed content that reinforces psychotherapy guided by the program’s BHCMs and provides care teams with frequent measures of patient progress. This engagement between office or telehealth visits supports traditional care and can lead to faster recovery, better overall outcomes and fewer readmissions.

“This collaboration introduces the type of technology needed to assist our healthcare providers and patients in bridging the gap between mental and physical health,” says William McDonald, PhD, chair of Emory’s Department of Psychiatry and Behavioral Sciences. “While our teams already practice collaborative, integrated care, this partnership serves as a driving force to expand and enhance these endeavors throughout the Emory ecosystem, ultimately resulting in improved outcomes and reduced costs.”

What You Should Know:

• Operational and financial pressures drove mergers and acquisitions in the healthcare sector in Q1 2023, according to a new report from Kaufman Hall. In total, there were 15 announced transactions in Q1 resulting in $12.4 billion in total transacted revenue.
• The trend of fewer but larger transactions that characterized 2022 was maintained—the average size of the seller or smaller party in Q1 was $827 million, just below last year’s historic year-end average of $852 million.

1. Insights on a New Wave of Mergers

Prior to the COVID-19 pandemic, smaller independent hospitals and health systems were pursuing partnership opportunities to ensure their continued strategic and financial viability in an environment where high fixed costs, downward pressure on payments, and increasing competition for outpatient services were creating an increasingly difficult operating environment, one which has intensified over the past three years.

The pressure on the frontline staff at the height of the pandemic resulted in early retirements, which alongside moves to non-clinical positions, drove up the labour demand and costs. Currently, however, volumes in key service areas—including emergency department admissions and inpatient surgical procedures—remain below pre-pandemic levels. Investment losses in a volatile market have limited opportunities to mitigate negative operating margins, which more than half of the hospitals providing data for Kaufman Hall’s National Hospital Flash Report are experiencing.

Currently, in the aftermath of the pandemic, mid-sized regional health systems seek partners while remaining in positions of financial strength, whereas some seek to balance their desire to influence local healthcare delivery with utilising the resources of much larger health systems. Similarly, the new realities of the operating environment also appear in announcements of new transactions. The CEO and president of Flagler Health, which announced a merger with UF Health in Florida, noted that the system was “facing new and evolving industry headwinds” and needed “access to additional resources” to support key community-focused service lines, including behavioral health and women’s health.

2. Trends in Cross Regional Partnerships

Health systems are increasingly moving beyond the traditional constraints of geography to find partners. This quarter, New Mexico-based Presbyterian Healthcare Services and Iowa-based UnityPoint Health announced their intention to merge. According to the report, this type of activity is expected to not only continue, but to intensify.

Transactions of this nature typically involve large, regional health systems. While the traditional rationale of pursuing opportunities for savings as the partners centralize and combine administrative functions may apply, the main drivers are broader in nature. Even more apparent in the largest system transactions is the intent to combine, expand, and optimize complementary capabilities. Presbyterian Health Services, for example, has longstanding experience with a provider-based health plan, and UnityPoint’s CEO noted in an interview with Modern Healthcare that this experience could help it bolster its Medicare Shared Savings Program and accountable care organization offerings. The report also notes that need to think beyond traditional boundaries to seize opportunities for greater efficiencies and enhanced capabilities will remain compelling in the months and years ahead.

3. For-Profit Portfolio Realignment

A trend since 2017—the realignment of for-profit health system portfolios—showed continued strength in Q1 2023, particularly for hospitals that are, and have historically been, high financial and operational performers. Pertinent examples are as follows:

1. Community Health System announced the sale of two North Carolina hospitals to Novant Health,and the sale of Plateau Regional Medical Center in West Virginia to Vandalia Health. 
2. Steward Health Care announced the sale of its Utah care sites, including five hospitals and more than 35 medical group clinics, to CommonSpirit Health/Centura Health. 
3. Tenet Health announced that John Muir Health would become the sole owner of San Ramon Regional Medical Center, buying out Tenet’s 51% ownership stake (John Muir acquired a 49% ownership stake in 2013). 

These sales represent for-profit health systems’ ongoing efforts to focus their resources on core markets with good growth potential. For-profit systems are facing the same operational and financial headwinds as not-for-profit systems, and these headwinds are affecting decisions on which assets should remain in the portfolio.