Nancy Klotz MD

Nancy K. Klotz, MD, MBA, FACP, is chief medical officer at Brighton Health Plan Solutions, where she is responsible for clinical strategy across the company's various business segments. Previously, she served as chief clinical officer at HealthCare Partners, and Heritage NY Medical, PC.

Nancy Klotz, MD

Contributed Content: Why Preventive Care at No Cost Is Smart Regardless of What the Courts Say

Nancy Klotz, MD, September 26, 2023

We strongly urge our customers to cover preventive services because it makes sense from a medical, health, and financial perspective, and that it’s critical to maintain these services and offer access that’s as easy as possible to members.

Editor's note: Nancy K. Klotz, MD, MBA, FACP, is chief medical officer at Brighton Health Plan Solutions.

There’s a lot of news from the courts these days. So you may have missed a decision in late March by a U.S. District Court judge in the Northern District of Texas that struck down a provision of the Affordable Care Act requiring most private health plans to cover a range of preventive services at no cost to the member. That ruling has been stayed, but should it be upheld, over time, many millions of people might lose access to services proven effective at improving health.

Recently I spoke on a HealthLeaders panel about this issue and the potential problems it could create if organizations are not required to continue to provide free or discounted preventive services. If they’re not required to, they may decide not to.

Because we provide TPA services, our customers are not required to abide by the provision because it applies only to fully insured plans. Despite this, many if not most of our customers choose to provide a wide array of preventive services at low or no cost. After a detailed analysis of their population during onboarding, we advise them to provide a robust suite of preventive services their members can access without co-pay or charges against their deductible. Why? Because our analysis shows in great detail how to tailor those programs to each customer’s member population, and how they pay off. Here’s how you can do the same.

Design benefits for long-term health

Benefit design varies from organization to organization. When onboarding a new benefits partner, work collaboratively and make recommendations for prior authorization requirements, allowing certain preventive services at low or no cost and decide whether and how much of a copay should be involved. Everything from high-cost drugs, chemotherapy, drug benefits, behavioral health benefits, diabetes management, and more should be considered.

Indeed, preventive services do exactly what their name says they do—they prevent more debilitating and expensive costs down the road and keep employees healthy and available to work. Make sure your benefits partner can make detailed recommendations based on a deep analysis of your previous claims, and identify what could have been prevented under a robust set of services aimed at better managing the chronic conditions that, unmanaged, can lead to catastrophic health outcomes.

Tailor preventive services to your population

Insist on an analysis of the high-cost diseases that might have been avoided had preventive services in those areas been previously available. For example, good control of diabetes is important in improving cardiac outcomes. So, designing your program around the services likely to have prevented past escalations is a good place to start. Work with your benefits partner on pharmacy design as well. For example, using a mail-order pharmacy helps avoid missed doses. For behavioral health, it’s often worthwhile to deploy a case management team that can access contracted preferential rates for members and expedite and even reserve appointments for members.

In addressing each population based on what they need, borrow from NCQA and use its guidelines to inform recommendations on preventive care. These recommendations are aimed at managing those who do have a chronic disease like diabetes, or cardiac issues or kidney problems to make sure their disease does not progress to the point it affects their ability to function. Part of preventive care may include screenings to identify pre-diabetics or cancer screenings based on age and sex to identify cancer in its early and treatable stages. Also manage the drug formulary to maximize preventive care and encourage recommended immunizations at no cost.

The recent court cases are concerning because since the ACA passed, the waiving of cost sharing has led to an increase in preventive care services being administered. The reality is given the barriers around access that may include factors such as cost, transportation, and lack of time to go to appointments, most people will avoid these activities if there’s a cost involved. If they don’t feel sick, they don’t go to the doctor, and that’s a problem no-cost preventive care can help solve.

3. Achieve better outcomes

For those who recognize the value of preventive care, the resolution of this court case probably won’t have much of an impact on them. We continue to strongly urge our customers to cover preventive services because it makes sense from a medical, health, and financial perspective, and that it’s critical to maintain these services and offer access that’s as easy as possible to members.

But providers are used to providing care on an individual level. Now, at a system level, we’re asking them to administer population health, of which preventive health strategies are a critical aspect. To operate that way, practices need to change. That’s difficult to do when covered preventive services are all over the map. If, however, preventive services are widely covered and your practice is rewarded for, say, keeping your diabetics managed to a certain level, you might hire a nurse practitioner to manage the population to ensure those optimal outcomes. Covering preventive services at no cost is a way to give providers the tools they need to structure incentives and achieve better outcomes. Widespread preventive coverage is part of what we need to fully realize the transformation from providing sick care to truly providing healthcare.

Care to share your view? HealthLeaders accepts original thought leadership articles from healthcare industry leaders in active executive roles at payer and provider organizations. These may include case studies, research, and guest editorials. We neither accept payment nor offer compensation for contributed content. Send questions and submissions to Erika Randall, content manager, erandall@healthleadersmedia.com.

Why It's Time to Integrate Behavioral and Physical Health

Nancy Klotz, MD, September 12, 2022

Plan sponsors, payers, and third-party administrators owe it to our members and physician partners to encourage further behavioral/physical health integration in our practice networks.

Editor's note: Nancy Klotz, MD, is the chief medical officer at Brighton Health Plan Solutions.

If the pandemic has taught us nothing else, it's the importance of mental and behavioral health to overall well-being. The World Health Organization says the global pandemic triggered a 25% increase in the prevalence of anxiety and depression worldwide. In 2020, the latest data available, U.S. deaths associated with alcohol, drugs, and suicide reached 187,673, and substance misuse deaths reached their highest level ever, according to the Trust for America's Health.

Based on these statistics alone, it's clear that behavioral and physical health go hand in hand and poor mental health has recently contributed to physical suffering and death on an unprecedented scale. So why do we continue to treat behavioral and physical maladies as independent of each other?

Where the behavioral and physical intersect

Even though the Mental Health Parity and Addiction Equity Act requires health plans to offer behavioral health benefits on par with medical and surgical benefits, patients obtain these services in discrete ways. With few exceptions, physical and behavioral health care are not integrated.

The reasons behavioral and physical health services are so separate are complex and too numerous to highlight here, but they begin with the now-antiquated notion that patient disorders in thinking, emotion, and behavior are an indicator of moral weakness or that they result from poor personal decision-making. In other words, this thinking goes, while physical health problems are out of the patient's control, they bear some responsibility for their behavioral or mental issues. Never mind that science and the general public relegated this overly simplistic view of mental health to the dustbin years ago; how practices are traditionally organized is its legacy and inertia is a big hurdle.

The evidence is compelling that change is needed. As noted in the statistics above, physical health is often a predictor of mental health and vice versa. Physical maladies such as cancer, or chronic illnesses such as heart disease and diabetes contribute to the risk of physical injury or death. Mental illnesses contribute to worsening of physical problems through substance abuse or apathy due to depression, for example.

Parity should encourage new models

Patients don't fall neatly into the "physical" or "behavioral" health classification. Rare is the patient who has only physical or behavioral needs. In fact, up to three-fourths of primary care visits include behavioral or mental health components, including behavioral factors related to chronic disease management, substance use (including tobacco), and exercise, just to name a few examples. But these are often addressed in an unsystematic way by professionals whose practice is aimed at physical health. Primary care physicians often don't feel equipped or properly compensated for tackling mental health issues beyond making a referral outside their practice.

But new practice models that integrate behavioral health and primary care have shown promise and the benefits accrue to both patients and their physicians.

One primary care integration model uses a behavioral health consultant—whether a psychologist, licensed clinical social worker, or other behavioral health professional—as a member of the healthcare team. In such models, behavioral or mental healthcare is not referred outside the practice. Rather, the patient is guided to a behavioral health professional "co-located" at the practice, who then works directly with the primary care physician in support of the patient's broader health goals. Another collaborative care model incorporates a behavioral health specialist as part of the team managing individual patients. In some states, advanced practice nurses can practice psychiatry on their own, offering another opportunity for integration for health systems.

Finally, options for better integrating behavioral health are widening beyond the physician office. The social isolation the pandemic required contributed to behavioral issues as well as encouraged the development of virtual behavioral health. Patients are migrating to fast-growing companies in the telehealth arena that pledge to integrate both physical and behavioral health. Many patients prefer to receive mental or behavioral health care virtually already—perceiving it as more discreet.

While payers, plan sponsors, and health plans may wish to avoid dictating how physicians should organize their practice, it's past time for them to encourage practice changes that facilitate the integration behavioral and physical health services. This can be done via incentives to the practice to add these capabilities or by steering patients toward practices that have implemented them.

Integrating physical and behavioral health is also better for physicians. According to a study that surveyed physicians about integrating a behavioral health specialist in primary care, 93.8% believed integrated care improves patient care, and 90.1% said integrating a psychologist in their practice reduced their personal stress level. And they'll likely support employer or payer efforts to help them integrate behavioral health. Eight physician organizations recently issued a call to action supporting such integration efforts.