Latest / The Mental Health Evolution / Ep 20: Inside Behavioral Health Systems with Cathy Gilbert

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Ep 20: Inside Behavioral Health Systems with Cathy Gilbert · The Mental Health Evolution

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  (Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick Podcast Network.
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  Learn more at ListenFrederick.com.
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  Welcome to Mental Health Evolution, a podcast about what's changing in mental
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  health and why it matters.
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  I'm your host, Rachel Harrison, inviting you into honest conversations with
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  people from all perspectives in the field, clinicians, tech founders,
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  investors, insurance companies, and all the folks in between.
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  Let's explore what's working, what's not, and what's next.
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  Welcome back, everyone, to the Mental Health Evolution podcast, where we are
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  talking today about mental health care systems.
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  We want to dig in to look at things like what are
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  themes in payer relations, contract negotiation, and network provider
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  relations.
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  Our guest today, Kathy Gilbert, currently works as a consultant to providers,
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  but she has a history of working with big insurance groups, working
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  with provider network development and operations.
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  Kathy has supported behavioral health provider organizations in areas like
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  payer relations, contract negotiation, compliance review, and program
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  consultation.
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  She has also been on this podcast before.
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  She had so much to say that we invited her back for
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  a new topic.
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  So welcome back, Kathy.
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  Wow.
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  Nice to be back.
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  Yeah.
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  So I want to get us started with looking at a couple
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  of things that seem to be happening with insurance payers in particular.
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  So we're going to give our listeners a little picture of some
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  of what's happening in the news, and then we'll dive into some
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  conversation.
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  The first is the concept of value-based care.
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  And while this has been slower to roll out in behavioral health,
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  it is here and it is rolling out.
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  And there are both pros and cons to this, noted in the
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  EverNorth study, which was a look at the progress toward value-based
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  care in mental health.
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  And this article talks about how technology and systems seem to be
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  a heavy lift for a lot of mental health practitioners, but it
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  also talks about better outcomes for patients.
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  So that's one idea that I want to kind of dig into
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  a little bit more.
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  The other is the idea of insurance companies creating their own care
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  clinics, such as creating a mental health treatment center or a medical
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  facility.
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  There was an article about medical facilities that are run by insurance
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  companies from Times Union titled, Congressman Pat Ryan Releases Optum Health
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  Survey Results.
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  And it really reveals the declining care, increase in prices and poor
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  quality offered based on survey ratings of the Optum clinics that have
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  opened to provide direct medical care.
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  And then there are these other models, too.
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  There's CVS clinics, there's Humana clinics opening in Walmart and various
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  models for treatment in places that are not typically medical health practices.
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  So I want to make sure that we can dig into that.
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  But with a little bit of background, let me get some of
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  your perspective, Kathy.
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  How would you describe the state of value-based care implementation
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  specifically in behavioral health?
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  It's really slow.
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  I've been talking about it, let's see, probably close to 20 years
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  and how to implement it.
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  OK, so it's very slow and there are some challenges in value
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  -based care.
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  First is, how do you measure mental health care improvement and mental
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  health?
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  Now, I would say now there are two measures, the PHQ-9
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  and the GAD-7, which means your depression and anxiety that have
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  almost become table stakes at health plans that they want clinicians to
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  be doing those measures.
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  They want to see improvement.
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  But the only data they have, and I think we used to
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  be able to have a little more data, it changed and I
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  think it was a good change where they discontinued authorization requirements
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  for outpatient behavioral health services.
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  It's something that you can access under parity very easily.
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  I think that's very important.
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  But the change that made from the plan side and being able
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  to measure outcomes is when the only data that plans really have
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  is what comes in on a claim, on somebody's outpatient care.
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  So they get data when somebody goes inpatient because they're doing a
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  clinical review or a higher level of care.
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  So the data that health plans really have ends up becoming flat
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  on what's happening in an outpatient practice.
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  So that I think that in some ways slowed down a move
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  towards value-based programs because you just had less data to be
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  able to build that and how a practice was performing.
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  So that being said, I have seen several plans implement kind of
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  a report that they give to providers based on the data they
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  have available.
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  Some of it that outpatient providers wouldn't have, like hospital admits and
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  our higher levels of care, history of care, you know, plans still
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  have that information.
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  An individual provider may not.
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  So that's one piece.
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  And then the other thing is a lot of it from claims
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  data.
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  But knowing that kind of they've started to implement some programs, they're
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  very early stage value-based.
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  They're kind of like they set a report card and have metrics.
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  And if you meet certain metrics, there's an opportunity to participate in
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  a bonus pool for those providers.
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  The other thing they've done is some incentives for things like access
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  to appointments, early appointment availability, and to have, you know, they
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  incentivize some of those things.
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  There have been more value-based things at the higher levels of
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  care and behavioral health because they have more information.
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  It's a little easier to measure.
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  They can do those things.
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  So I think that's part of it.
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  The other piece in behavioral health that makes value-based a little
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  bit challenging because part of value-based care is having enough data
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  from any one plan and enough members to really be able to
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  have any concrete outcomes and figure out what's going on.
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  So, as you know, in behavioral health, unlike the medical world, the
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  behavioral health side, there are still many, many more single shingle, small
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  group practices in behavioral health than there are in the medical world.
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  And they move around more because you don't need a lot of
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  equipment to provide a behavioral health service.
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  So it's easier to set your practice up or move it.
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  So just in general, and then if you have a small group
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  practice, you only have capacity for, you know, maybe say 40, you
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  can see 40 patients a week in behavioral health if you're a
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  therapist.
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  And even that's pushing it because it's very intense for a therapist
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  as well.
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  That's, that's tough.
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  So, you think about all of that, even having the volume of
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  data in behavioral health for outpatient, especially, is very challenging.
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  So what needs to happen, and this is what, and I think
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  technology is going to get us there, is all behavioral health care
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  being measurement-based care, which is focused on the outcomes.
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  You know where the member is.
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  You're getting that feedback loop.
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  And there are, you know, there are platforms and EHRs that are
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  designed for those individual and small group practices, actually specifically
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  designed for behavioral health measurements.
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  So, and they can help with those outcomes and help a practice
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  kind of know where they stand.
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  So that's, that's all part of the picture to get there.
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  So I think it's starting.
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  And there's more measurement, especially with the tools that are now available.
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  And those can be available electronically and with electronic health records.
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  I think it's coming, but it can also, there's a cost factor
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  to implementing that in a small practice.
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  So, so kind of figuring out all of those pieces.
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  But it's coming slowly, but it's, I mean, I would call it,
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  it's, you know, it's young, it's very young and we're finally getting
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  the tools to be able to do it.
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  I've seen a couple not implemented on a national basis with a
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  national plan, but in certain markets for national payers that are more
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  market-specific, smaller programs.
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  And so I've seen some of those slowly be implemented.
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  One has, like I said, they have a couple of them have
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  programs where they incentivize different things that are outcomes-based,
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  access, equipment availability, even things that are measured are, you know, if
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  you're seeing somebody outpatient, how many of your patients were admitted to
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  a higher level of care, you know, and I think, and tell
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  a provider that, you know, provider may not be able to help.
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  So, or ER visits, those kinds of things that, you know, if
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  a mental health provider knows about it, can help somebody troubleshoot things
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  and maybe prevent some of those admissions and visits.
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  Yeah.
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  So, but it's, it's challenging.
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  It is.
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  I think this, this piece too, you've mentioned like increasing, like access
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  to care is one of the things that practices would be rated
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  on.
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  And I think that's particularly difficult in mental health, though it's needed.
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  You mentioned the limitation, right?
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  Of seeing maybe 40 clients a week, but that's high for a
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  lot of what people are doing.
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  And so it's not like a doctor's office where you see someone
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  once every six months, if you're seeing somebody daily, you're full when
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  you're full, you know?
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  So I'm, I'm curious how, or if you've had any chance to
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  dive into how outpatient can make accessibility better.
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  You know, there's a variety of ways.
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  One is having a way for plans to, or the online scheduling
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  so people can see your appointment availability, because honestly, most
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  providers, I mean, they actually have midday availability where they're,
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  they're booked early morning and evening appointments, or if they happen to
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  offer weekends, those are, those are always full.
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  So it's, you know, figuring out how to, you know, how people
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  realize, you know, take those midday appointments.
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  The other piece is, and that online scheduling also addresses another piece
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  in a small practice.
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  You may not have a receptionist to answer the phone.
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  So when you're in session, you can't pick up the phone if
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  somebody's calling.
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  Right.
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  So, so some of those technology pieces can really help a small
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  practice.
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  One, save those phone calls because that's when you may not get
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  a patient or, you know, or somebody who really, one of your
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  current patients who really needs to reach you in an emergency can't
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  get through because you're in session and you should be focused on
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  your session.
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  Right.
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  With that individual and, you know, reimbursement rates don't always allow for
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  providers to have somebody to answer their phone all the time.
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  Yeah.
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  Yeah.
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  In a small practice, just realistically.
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  So it's thinking about some of those things that probably technology can
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  help and cost-effectively help.
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  Some of those integrated practice management systems have the online scheduling
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  built in.
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  Yeah.
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  Yeah.
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  So that they'll help you with that.
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  So looking for those kinds of things that makes it available.
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  And then health plans are starting to connect to people's online availability
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  in their provider directory.
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  So if you have it and they can connect it into your
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  profile in their directory.
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  Oh.
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  That, all of those little pieces.
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  And then if, you know, so I'm thinking, you know, as you
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  think about the technology and then when we talk about outcomes, some
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  of those systems can even push out a PHQ-9 or a
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  GAD-7 pre-session so that you can get that feedback.
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  I will say that most of the digital providers that I work
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  with in our virtual care, that is part of their app or
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  their program is that they push out those, the appropriate assessment tools
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  to the member and then do post-session surveys and they push
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  that, those out to the member and it's kind of part of
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  their program and that's how they're able to demonstrate their outcomes, which
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  is leading some of those digital programs to get to value-based
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  care because they have it built in to their reporting.
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  Yeah.
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  Yeah.
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  That makes a lot of sense.
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  That's great.
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  Food for thought.
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  Yeah.
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  So if we dive into some of these other trends that we're
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  seeing to insurers opening their own behavioral health clinics, and I
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  understand there's kind of been a shift in this over the last
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  few years and that that's kind of shifted.
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  Some people are shifting away from it, but you still have Humana
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  with Walmart and some things like that.
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  I would love to hear some of your thoughts about that trend
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  and about what you're seeing happening and how that's impacting care for
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  people in general, the public, and how that's impacting providers.
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  One of the things I mentioned is Access and the idea behind
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  those programs like Humana and Walmart and others, Carillon's done some of
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  those things as well, is it gets the services to where people
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  are.
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  So it helps people get to care, find care easier.
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  I'm thinking even for an example, nowadays, I mean, you get all
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  of your vaccines, you get them at CDS.
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  I mean, you don't get them from your doctor's office.
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  That's a convenience.
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  I mean, I would even ask, I'd even ask my doctor about
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  something.
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  It doesn't happen in pediatrics typically, but for adults, that it takes
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  away the challenge that practices may have, especially if it's in a
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  practice where they do a limited number of vaccines other than maybe
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  the flu vaccine in their practice and a primary care practice of
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  storage of those vaccines and monitoring all of that, and it also
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  makes it easy access when I need, you know, I go to
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  CDS to pick up a prescription, I go stop to pick up
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  something else, you can get your vaccine, right, if it's something that's
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  due.
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  And I think that also came as a part of COVID too,
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  when they were trying to get everything out, but then they realized,
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  oh, this kind of makes sense.
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  And that way, I think it's a positive because it brings the,
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  it brings access to medical care, and if you think about it,
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  into rural areas, because there's a Walmart in almost every small town.
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  Yeah, that's true.
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  There's a CDS or a pharmacy.
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  So it brings care to areas where maybe care was hard to
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  access.
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  So for some pieces, I think I see that, I see the
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  point and I see why plans do it.
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  But what I say it doesn't do, it doesn't give you a
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  net new providers.
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  It doesn't help that there are not enough behavioral health providers in
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  the country for the demand.
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  We know there are, you know, in large metropolitan areas, you can
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  access care for the most part, you can find someone available, but
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  as you get into rural areas, it's not there, there's not enough
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  people providing the care.
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  So in that sense, I think it's good to bring it to
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  the people, but it doesn't really bring net new providers.
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  So I think that's something we need to focus on in this
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  country is, you know, how do we attract people to healthcare professions,
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  to behavioral health?
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  I mean, you know, I know even when I went into social
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  work eons ago, people were like, are you sure you want to
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  do that?
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  You're not going to make any money.
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  And I'm like, well, that wasn't the point.
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  Yeah, that's not really the point, right?
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  So, right.
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  So as for quality, I think that goes back a lot of
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  like I read through the article with Congressman Pat Ryan, a lot
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  of it is impacted by provider shortage and then a shortage also
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  of people to simply answer phones.
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  There are not enough, probably when in his article with the one
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  Optum took over, it probably increased the volume to that clinic because
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  then anybody who had Optum United coverage, they would want to send
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  to their clinic.
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  It increased volume.
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  And then do you have enough people to answer the phones?
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  Because it's not just the healthcare professionals, it's all the support staff.
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  So when you look at that whole picture and not that that
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  was a good thing, I mean, we've got to address it, but
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  those programs don't create more providers and get, they may attract somebody
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  who was in private practice and was looking for something to just
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  be more steady and have set schedule and hours.
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  But that still doesn't get, but you lose that private practice.
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  So it's not in that new providers.
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  Yeah.
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  So I think that, I think it's a vicious circle.
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  There's, there's pros and cons to it and they're not addressing all
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  the issues.
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  Yeah, that's an interesting thought when you talk about that circle, because
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  I think there are so many more people coming into the field,
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  there are tech companies, there are MSOs, there are all these people,
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  the insurance-based clinics, and it is the same providers maybe cycling
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  through those at the end of the day, right?
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  So we're not really, we're not building a network of providers.
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  Right.
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  Well, you should think about it as the baby boomers, and I'm
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  that last tail of that baby boom generation.
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  As providers retire, we have the next generation's more willing to access
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  behavioral health care.
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  Fewer of them going into behavioral health care.
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  You have boomers, we're still around and we probably still need behavioral
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  health care and there, there's more, there's more behavioral health providers
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  retiring every year than are coming out of schools.
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  And that's especially true with psychiatry, which is another huge problem.
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  Oh, wow.
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  It's not even just therapy, it's psychiatry.
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  And, and people coming out of medical school aren't choosing psychiatry.
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  It's not as sexy as, say, cardiology or cancer treatment.
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  Those are very challenging, or surgery, neurology, all those are very
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  fascinating, much needed fields as well.
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  Yeah.
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  But we still need, you know, maybe if there were a few
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  more psychiatrists and now health professionals treating people, we would catch
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  things sooner.
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  People would be more aware and we'd have less of these other
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  issues because they'd be more compliant with other, other areas of their
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  lives, like diabetes and diabetes management and it helps people work through
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  those types of things.
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  So there's all of those pieces.
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  It's all one system and you need all of those.
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  Yeah, you do.
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  So, so, you know, yes, it's terrible what Congressman Ryan found, but
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  you have to look at multiple underlying issues within our society and
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  our structure.
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  I love that perspective and seeing the bigger picture because, yeah, I
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  think everywhere I see that even a change.
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  And when I'm accessing any kind of medical care, there are clearly
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  shortages and longer waits and all of that.
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  Mm-hmm.
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  Mm-hmm.
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  Right.
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  Well, and that was one of the reasons when I did my
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  thesis, national healthcare, three years ago, is the biggest challenge to
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  national healthcare in the U.S. is our culture.
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  We want the best care.
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  We want it now and we want it cheap.
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  I mean, bottom line.
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  Yeah.
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  Yeah.
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  I mean, that is what we want.
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  If you look at other countries that have national healthcare, for the
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  most part, people are okay to wait.
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  They understand the wait and the prioritization and, you know, elective versus
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  must have now.
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  And so there is that, but it, to me, it, it does
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  a lot of times come back to our culture, you know, it's
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  the Walmart, Amazon idea.
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  Yeah.
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  We want the lowest cost, but the best.
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  Well, the lowest, but the best.
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  And we want it right now.
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  You know, if I can get it delivered in an hour, I'm
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  great.
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  Yeah.
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  We are pretty spoiled in that way in a lot of areas.
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  We, we almost quickly, all of that.
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  Yeah.
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  Yeah.
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  So when you think about that whole concept, it's like, okay, so
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  how can, what, what do we have to change?
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  It's not just the healthcare system, which I totally agree means change,
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  but we have to think about it in terms of what people
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  will accept.
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  Right.
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  Right.
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  And so what do you advise to people that are looking for
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  care to overcome some of these barriers?
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  One is look for the virtual care options because that does stretch
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  capacity.
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  And, and so you can do that.
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  And they also have things that I think there are a lot
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  of things that are going to become more self-serve.
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  And then as more complex things will be escalated to individuals.
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  So I think that's, you know, all, so, you know, kind of
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  playing a little bit with the virtual care where, where you can
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  to, to check that out because it's, but always, you know, you
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  look for, do your research on the providers.
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  So you find one that kind of matches because it's also hard
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  when you do, you know, doctor shopping and you take an appointment
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  and decide you don't like that and want to go to somebody
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  else.
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  So I think do your due diligence ahead of time.
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  It's easier to do that nowadays to find a match for what
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  you need.
• 22:56
  And that can be, you know, your primary care doc can help
• 22:59
  you with that.
• 23:00
  You know, anybody, you know, in the community use, for kids, talk
• 23:05
  to the school's counselors, then they'll know who in the community might
• 23:09
  be a good fit.
• 23:10
  But, you know, look at what you have available and health plans
• 23:14
  are trying to make things available.
• 23:16
  You really are.
• 23:17
  And so, you know, kind of see what they have.
• 23:21
  If you have a health plan, not everybody does and not everybody
• 23:25
  wills in the near future, but yeah, they'll have, you know, preferred
• 23:29
  providers or providers that really are meeting some of those outcomes and
• 23:34
  quality measures that you're looking for.
• 23:36
  You can find those in your health plan.
• 23:38
  They have preferred networks, they have digital providers that they've
• 23:41
  contracted with and think are a good value and are getting meeting
• 23:46
  patients' needs and, you know, I think sometimes it's knowing that you
• 23:52
  don't always need that specialist because a lot of times the wait
• 23:54
  is for that specialist.
• 23:56
  So somebody will think in behavioral health, it may be, you'll probably
• 24:00
  be able to get an appointment with a therapist, but you may
• 24:02
  not be able to get a psychiatrist, well, starting with the therapist
• 24:05
  may be okay.
• 24:08
  And for the most part, people can get into their primary care
• 24:11
  doc.
• 24:12
  So start with primary care.
• 24:15
  You don't necessarily always need the specialist because that's where the long
• 24:19
  waits are.
• 24:21
  And if you're working with your primary care or with a therapist
• 24:26
  and you do need that specialist, they may have the connection to
• 24:31
  get you in quicker with somebody because they have a preferred providers
• 24:36
  that they work with and they can make that referral and help
• 24:40
  you get into that care.
• 24:42
  So it's, you know, really looking at the system and using the
• 24:46
  tools that are out there, like, yeah, so yeah, there will still
• 24:54
  be challenges.
• 24:55
  That's not going to change.
• 24:56
  There will still be challenges, but, you know, try to use the
• 25:00
  tools that are available for someone who is trying to access care.
• 25:03
  Yeah, that's awesome.
• 25:05
  Well, Kathy, thank you again for giving us some very concrete things
• 25:10
  to think about and to do with this whole, all the systems
• 25:14
  changes and things that we see happening in the mental health industry.
• 25:19
  I appreciate you being here.
• 25:20
  No, no, thank you.
• 25:22
  I enjoyed it and you know, if there's ever any questions, feel
• 25:26
  free to reach out.
• 25:27
  I appreciate that.
• 25:28
  Thanks everybody for being here.
• 25:30
  Join us next time to take a look at all the changes
• 25:34
  in landscape and different perspectives in the mental health industry.
• 25:38
  Bye for now.
• 25:41
  Thanks for listening to the Mental Health Evolution podcast.
• 25:45
  Join the conversation, find us on social, send us your thoughts and
• 25:49
  tell us what you're seeing in your corner of the mental health
• 25:52
  world.
• 25:52
  Until next time, stay curious and keep evolving.
• 26:04
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• 26:09
  .com.