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Inside PsychPlus: Scaling Behavioral Health Nationwide · Becker’s Payer Issues Podcast

0:00
Hi, everyone. This is Lucas Voss with Becker's
0:02
Healthcare. Thanks so much for tuning in to
0:04
the Becker's Healthcare podcast series. It's great to
0:06
have you. I'm excited to welcome doctor Fasseltide
0:09
back to the podcast. It's great to have
0:11
him. He's a board certified psychiatrist and founder
0:13
of Psych Plus. He completed a psychiatry training
0:16
at the University of Iowa where he served
0:18
as president of the graduate medical education program
0:21
overseeing more than 800
0:23
residents and fellows. During his residency,
0:26
he began developing an EHR specifically designed for
0:29
mental health, and today, he leads Psyc plus
0:31
strategy
0:32
to scale across all 50 states through a
0:34
vertically integrated care model. His work also centers
0:37
on advancing value based care and population health
0:39
by leveraging data technology
0:41
and clinical infrastructure to improve patient outcomes, enhance
0:44
care quality,
0:45
and reduce total costs across diverse populations.
0:50
Doctor Tai, welcome back to the podcast. So
0:52
great to have you.
0:54
Good to have you as well.
0:56
Lucas,
0:58
excited to be here. Yeah. We have a
1:00
a lot to talk about again. I always
1:01
feel like we do, when we have you
1:03
on.
1:04
Unfortunately, we're still in a spot where we
1:06
have to talk about behavioral health as one
1:08
of the fastest growing cost drivers for health
1:10
plans. That's likely not going away, unfortunately, in
1:13
the near future.
1:14
Network adequacy and psychiatry
1:16
remains a major challenge.
1:18
Still,
1:19
from your perspective,
1:21
what's
1:22
still driving that gap between demand and access?
1:25
And, again, what does that scalable value based
1:27
solution look like from where you're at from
1:30
plants trying to improve outcomes while also managing
1:33
that total cost of care?
1:35
So this is
1:37
an interesting
1:38
question
1:39
and I think a fallacy in this space.
1:43
I'll give you a personal story. There was
1:45
a health plan that
1:47
we were in network with
1:49
in Texas,
1:51
and they were
1:53
also they had lives in Florida and Nevada.
1:56
And I knew the health plan president personally,
1:59
and we found out that they didn't put
2:02
us in network in Nevada and Florida.
2:05
So I was planning to go out to
2:07
Nevada where their headquartered office is anyways for
2:09
some other work. So I ended up grabbing
2:11
lunch with him and his team,
2:14
and he was very surprised. He didn't understand
2:16
why we were not allowed in network.
2:20
And so we met with the with the
2:21
VP of contracting,
2:24
and she said, well, we have so many
2:26
providers
2:27
that we didn't think we needed any more
2:29
providers. Well, anyways, obviously, I knew him, so
2:32
we got over the hump. But the more
2:33
questions I asked,
2:35
I asked them a simple question. I said,
2:37
if you guys have so many providers, then
2:38
why does the CMO keep reaching out to
2:40
me to get their patients into the to
2:42
see a psychiatrist or a therapist?
2:44
Well, the contracting people had no
2:46
idea why they're still needing to call me.
2:50
And and the problem is because what you
2:52
get in health plans is you have tons
2:54
of solo providers in this space. Right? And
2:57
the interesting thing about psychiatry is it's not
2:59
like other medical specialties.
3:01
You don't need a lot of infrastructure.
3:03
You can put a shingle
3:05
in a house, and that can be your
3:07
office. And so you have armies of therapists
3:10
and psychiatrists that are out there that are
3:11
trying to provide this care,
3:13
but they can't get to the patient. And
3:16
that's the problem. Right? And so
3:19
it's fragmented.
3:20
It's in a disarray.
3:22
It's like saying
3:24
that we don't have enough drivers to drive
3:26
Uber
3:27
prior to Uber coming out. Well, obviously, we
3:30
don't
3:31
because there's no technology connecting them. Right? And
3:33
then after Uber comes out,
3:36
you could have a guy living down the
3:37
street from your house now taking you to
3:39
the airport that you didn't even know existed.
3:41
Right? And so what the technology did for
3:44
that space was it reduced the traction between
3:48
a driver and a customer
3:50
so that
3:51
the the customer can access that driver rapidly.
3:54
Right? You're you weren't gonna go walk down
3:56
the street and knock onto a random guy's
3:58
house to take you to the airport. That
4:00
would be bizarre, but the technology fundamentally allowed
4:03
you to do so.
4:04
And I think what's
4:06
the problem in the psychiatry space and the
4:08
mental health space is, yes, we can have
4:11
more providers,
4:12
but I don't think the problem is that
4:14
we don't have enough providers. The fundamental problem,
4:16
in my opinion,
4:18
is that they're not
4:20
on
4:21
a singular or similar platforms.
4:25
They're out on their little islands, and there's
4:27
no true way for patients to actually connect
4:30
to that care,
4:31
go from one level of care to the
4:33
next level of care, even if you are
4:35
able to find a psychiatrist. Okay. You need
4:37
group therapy.
4:38
You need
4:39
exposure response therapy. Maybe you need to go
4:42
inpatient to a detox program.
4:45
There's no connection. You can't actually
4:47
the psychiatrist is gonna tell you to go
4:49
Google this stuff or maybe they're gonna refer
4:52
you to another program, but there's no actual
4:54
handoff. And so there's a lot of drop
4:56
balls. There's a lot of bad outcomes.
4:58
And a lot of it stems from
5:00
fragmented
5:02
provider base that exist in this
5:04
ecosystem.
5:06
And, really, what we are trying to change
5:08
is trying to bring them onto a singular
5:10
or similar platforms
5:13
where it really becomes like an Uber for
5:15
mental health where providers can coexist with patients
5:19
and patients can get active care, but that's
5:21
not it. When in fact the patient needs
5:24
to get referred to a different service
5:26
that the technology
5:28
and the platform can actually facilitate and own
5:32
that delivery of care and bring you to
5:34
a different provider, whichever you need at that
5:37
moment in time.
5:38
So all of these examples that you just
5:40
mentioned are are very telling because they apply,
5:43
again, from a consumer perspective to
5:45
how does all of this then we talk
5:47
about access. We talk about coordinating all of
5:50
this as you've just mentioned in your in
5:51
your examples. Right? How does all of this
5:54
then influence total cost of care at scale?
5:58
Well, I I think there's a lot of
6:01
issues with not being on a singular platform
6:04
or platforms not talking to each other. Right?
6:07
So I don't know if you're aware, but
6:09
at some point, the hospitals
6:12
the medical hospitals were required
6:14
to be on an EHR or electronic health
6:17
record system
6:19
or Medicare was gonna penalize them. And they
6:22
had some reimbursements that were tied to that.
6:25
I don't think most people are aware, but
6:27
mental health hospitals were not part of that
6:30
initiative.
6:31
So even we we today
6:34
cover over 200 plus mental health hospitals and
6:37
facilities.
6:39
I will tell you this.
6:41
Majority of them are not on an electronic
6:44
health record. Majority of them are on paper
6:46
charts,
6:47
and this is 2026.
6:49
Right? I mean, to me, that is insanity.
6:51
That is not part of the Medicare initiative
6:54
to somehow incentivize or penalize
6:57
health systems for moving into an electronic health
7:00
record. And you can imagine
7:03
there there is no capturing of that of
7:05
that data. Right? That's not intelligent data. There's
7:07
nothing we can do with it.
7:09
Patients get multiple
7:11
medications that are the same, multiple labs that
7:13
are the same.
7:15
There's no actual handoff at discharge with an
7:18
outpatient provider.
7:20
You know, outpatient provider information gets on their
7:22
discharge summary. The patient ball gets dropped.
7:25
When they discharge, the phone numbers are wrong.
7:28
The emails are wrong. So you can't really
7:29
get hold of these patients at the outpatient
7:31
side. But there's really no owner
7:35
in delivering that care or owning that care.
7:38
Right? Every person is solving for that their
7:40
little silo,
7:42
but none of it is talking to each
7:44
other. And so the amount of redundancy and
7:46
the amount of waste that's happening in this
7:48
space
7:50
outside of even the cost of the medical
7:52
system. Right? Just the waste in mental health
7:55
is significant.
7:56
And I think
7:57
building pathways
7:59
where the care is being
8:02
facilitated from one provider to another provider, but
8:05
on
8:06
a unified platform, it reduces
8:08
a lot of redundancy,
8:11
or wastage
8:12
in this space
8:14
and perhaps improves outcomes because you now know
8:17
exactly what happened with this patient in the
8:18
hospital,
8:19
in their group session, in their residential,
8:22
a facility where they may have been admitted
8:24
in the PHP IOP program.
8:26
And and so the idea is to connect
8:28
all the dots together.
8:31
Now connecting the dots, we are connecting the
8:33
dots. Right? When we're evaluating that impact now
8:37
from an organizational perspective and a cost perspective
8:39
and a financial aspect to this, right,
8:43
What are the metrics that you're prioritizing
8:46
to actually make sure, okay, there is performance
8:49
and there is ROI across the organization from
8:51
some of these initiatives?
8:54
That's a very good question.
8:56
We track
8:57
a decent amount of data.
9:00
We also
9:01
look at metrics and how we're performing in
9:04
other value based care plans.
9:06
We're in a in a few value based
9:08
care plans. One, that's a famous one that
9:10
some of the health plans utilize, which is
9:13
when a patient discharges from the hospital,
9:15
what percentage of them are actually to show
9:18
up to an appointment
9:19
within the next seven days of hospitalization? And
9:21
it's a HEDIS measure.
9:23
And our
9:25
percentage,
9:27
for conversion is over seventy five percent.
9:30
National average for a Medicaid patient is about
9:33
twenty percent.
9:35
And so we
9:36
have three hundred percent higher chance of getting
9:39
that patient in
9:40
to be able to be seen by a
9:42
provider post discharge, which has a tremendous impact
9:45
on their rehospitalization
9:47
and then continuing in the community,
9:50
with that care. In terms of total cost
9:52
of care, we've been able to show repeatedly
9:55
about 18 to 20% deduct reduction on their
9:58
total cost of care
9:59
when they when they're following
10:01
or within our platform.
10:05
Overall, I would say the metrics
10:08
in this space are not very well defined.
10:12
There's a lack of tremendous leadership in the
10:15
mental health space in what value based care
10:17
looks like.
10:19
I I I commonly talk about mental health,
10:21
especially in the seriously mentally ill population,
10:24
is as much as a homelessness problem as
10:26
it is a medical problem.
10:29
And I think
10:30
there's not enough infrastructure
10:32
or investment in enough infrastructure
10:35
in the community to actually solve some of
10:37
these problems. And so I think if you
10:39
really want to change
10:41
how we operate, we have to be able
10:43
to invest in the right infrastructure
10:46
and not keep adding more hospital beds because
10:49
I don't think that's a solution.
10:51
Speaking of infrastructure,
10:53
and that's a very good point that you
10:54
just made. I I I wanna touch on
10:56
something that often comes up or comes up
10:58
in almost every conversation about behavioral health right
11:01
now, which is again that these gaps that
11:03
we're seeing
11:05
often manifest themselves in higher ED utilization,
11:08
right, as you just highlighted, avoidable inpatient stays,
11:12
poorly managed comorbidities,
11:14
quite frankly.
11:15
What do you think about the downstream
11:18
cost implications, again, of that delayed psychiatric care
11:21
at a population level? I know you just
11:23
touched on it, how important this is for
11:25
communities as well.
11:28
It it is pretty significant. Right? And so
11:31
when you actually look at a dollar
11:34
of mental health cost,
11:37
more than fifty percent of it is ED
11:39
visits,
11:41
which is insanity to me. Right? Like, it
11:43
it's not even inpatient or outpatient. Majority of
11:47
the cost is emergency room visits.
11:49
And what's interesting is you would think that
11:52
a lot of the hospitals like to have
11:54
ED patients because it adds revenue to their
11:57
bottom line.
11:58
And the answer is you would be surprised
12:01
no.
12:03
Emergency room visits
12:05
5% of total emergency room visits in the
12:08
country are mental health visits.
12:11
But 35%
12:12
of the bed capacity in the emergency rooms
12:15
today
12:16
is being used up by mental health patients
12:19
or psych patients or substance use patients. Right?
12:22
Which is
12:23
so
12:25
significant
12:26
in terms of the gap. Right? So an
12:28
emergency room is like a
12:30
is like a restaurant. Right? That's a fast
12:32
moving restaurant. The more tables that turn, the
12:35
more you generate.
12:36
Person sits on a table for two hours
12:38
versus thirty minutes, but you could have moved
12:40
that table around four times over instead of
12:43
keeping someone there for two hours.
12:45
Emergency rooms are not much different. Right?
12:47
When they get clogged,
12:50
most of the time, it is because a
12:52
mental health patient is
12:53
keeping the bed occupied for twelve, twenty four,
12:56
thirty six hours, and they can't move that
12:59
patient out. Right? Whether that's into another psych
13:01
hospital,
13:02
whether that's into a outpatient appointment,
13:05
nonetheless, but that care coordination
13:08
and that rapid triaging of patients and rapid
13:10
access to care is missing.
13:12
And so
13:14
medical hospitals don't necessarily like psych patients sitting
13:18
in their hospitals for two, three days. Right?
13:20
They can be disruptive,
13:22
especially if you're in a in a nicer
13:24
part of town. They may be worried about
13:26
other patients may not coming in. Right? A
13:28
lot of these patients are not
13:31
they're they have bad odors. They're not cleaning
13:33
themselves. They're not bathing.
13:34
They may be breaking furniture. They may be
13:36
punching holes in the wall. They may be
13:38
using a lot more staff time. And so
13:42
a lot of our strategy
13:43
as a community
13:45
needs to go around figuring out how to
13:47
divert
13:48
mental health patients from going into the emergency
13:51
room. Right? Could they be rediverted to psych
13:53
hospitals? Could psych hospitals have a crisis unit
13:56
that can function as a triage? Could they
13:58
be rediverted to psychiatric urgent cares or rapid
14:02
appointments?
14:03
I think there is a tremendous potential there
14:07
of us reducing that
14:09
number of ED visits for psych patients by
14:12
at least twenty to thirty
14:14
percent, which would be a good start in
14:17
the right direction.
14:19
Now are those
14:20
as you mentioned, the those factors to redirect
14:22
folks, right, from the ED, are those
14:25
the performance standards that you want to see
14:28
health partners be accountable for? Right? And and
14:31
and what are some of the other ones
14:32
that you think are important to mitigate some
14:34
of these risks that you just outlined?
14:36
I
14:37
I think that is the number one cost
14:40
bucket today that I think somehow we need
14:43
to build the infrastructure
14:45
to reduce that cost.
14:47
I don't see
14:49
enough
14:51
provider groups being incentivized
14:53
in ways to engage with patients to actually
14:56
deliver better care. Right?
14:59
And so tons of tons of health plans
15:01
ask us, well, what are we doing today?
15:04
How are we changing
15:05
the way
15:06
we operate around these mental health patients? And
15:09
the reality is we're not doing much because
15:11
there is no way to actually pay for
15:12
it. Right? So, yes,
15:15
I could put a psychiatrist twenty four seven
15:18
in my clinic to see them or even
15:20
virtually,
15:22
but
15:23
there's no reimbursement
15:25
for me to get a patient in or
15:26
high reimbursement for me to get a get
15:28
a patient in within four hours of them
15:30
contacting us. Right? And so
15:34
but there's a cost to it. For me
15:35
to get be have someone available to see
15:37
someone that rapidly,
15:39
I would have to pay pay them some
15:41
proprietary or urgent fee.
15:43
There's no way for me to get paid,
15:44
so the only way for me to run
15:46
that program would be at a loss
15:48
while the patient would rather just go to
15:50
the ER and run up a $3,000
15:52
bill. But I think there is a balance
15:55
somewhere,
15:56
But I think it needs to be reimagined
15:58
and redesigned.
15:59
I think the way we're operating,
16:01
there's no true incentivization
16:03
for anyone
16:04
to actually do this correctly.
16:08
And I will say this,
16:10
mental health is not like the physical health
16:12
of the world. Right? I mean, in in
16:14
medical
16:15
world, you have a stroke, you have a
16:17
heart attack,
16:18
you have a pretty short window to actually
16:21
to actually show up to the ER
16:23
because of the equipment they need to actually
16:25
make sure you're alive.
16:26
Mental
16:27
health, you actually have some time.
16:30
Right? When patients
16:32
are are feeling worse,
16:34
it's it's a slow brewing process. So if
16:37
you can actually get them in within the
16:39
next four to six hours to see a
16:40
provider,
16:42
you may actually prevent a hospitalization
16:44
or an ER visit.
16:46
And even if you need to hospitalize them,
16:48
you could save them two or three days
16:50
being stuck in the ER
16:52
and directly send them to a psych hospital.
16:55
But, again, not only do you have to
16:57
incentivize the providers, the providers have to be
16:59
part of a system that is actually connected
17:02
to the hospitals to ensure
17:04
that that delivery happens. Right? And it so
17:06
boils down to the same question,
17:08
right, incentivization
17:10
and infrastructure
17:12
or a platform that's actually getting
17:15
getting incentivized
17:17
to ensure
17:18
that the delivery of care is happening correctly
17:21
and no balls are dropped in that process.
17:23
Right?
17:24
And I think
17:26
that vision, that mindset is just missing in
17:29
this space today.
17:31
Is that where organizations need to start right
17:34
now? If you were talking to somebody and
17:37
said, hey. We wanna improve this. We want
17:39
we wanna redesign this process completely.
17:42
Is that factor that you've just highlighted the
17:44
one that you want them to start at?
17:46
And, again, what can they do? What are
17:48
those partnerships that organizations
17:51
can strive for, can look for to be
17:52
able to say, okay. We've redesigned this process.
17:55
We are improving here.
17:57
I think the best
17:58
thing that payers can do is find ways
18:01
to incentivize
18:03
organizations
18:03
that have the ability and the infrastructure
18:06
to actually deliver that care.
18:09
And I think the other thing that I
18:11
would caution against, which is very typical in
18:14
this space,
18:15
is a lot of neat solutions. And a
18:17
lot of niche solutions don't actually provide
18:21
vertically integrated care work, which reduces wastage. Right?
18:24
So you may have a platform that only
18:27
provides and not that
18:28
we we don't need those platform platforms, but
18:31
you have a platform that only provides substance
18:33
use care. Well, in my fifteen years of
18:35
practicing as a psychiatrist,
18:37
I have yet to see patients that only
18:39
have strictly
18:40
substance use issues and no amount of health
18:42
issues that they need to treat.
18:44
Right? Or you may have a platform
18:46
that's only treating anxiety
18:48
while
18:49
anxiety is very comorbid with depression,
18:53
right, and other mental health issues. And so
18:56
you you need platforms
18:58
that are able to treat the vastness and
19:01
are also connected. Right? So you're you have
19:03
platforms
19:04
that focus mostly on hospitals or mostly focus
19:08
on clinics or mostly focus on schools.
19:12
Well, it that's all well and good, but
19:14
what happens when you have someone at school
19:17
or someone at an employer campus
19:19
that actually needs a higher level of care?
19:21
Where are you sending them to the ER?
19:23
Well, that doesn't help either. Right? And so
19:25
so,
19:27
you know, I think the only solution and
19:29
maybe I'm biased about this, right, because that
19:31
is how I built my company.
19:33
But the only true solution would have to
19:35
be diverse in how it treats the pathology,
19:39
and it has to be vertically integrated
19:41
where it can actually treat multiple levels of
19:44
care
19:44
so that the patient doesn't get lost
19:47
in in that forest.
19:49
Unfortunately, there's no easy button here.
19:51
Never has been in this space, and it's
19:54
going to take some time. Doctor Tai, again,
19:56
thank you so much for your time and
19:57
insights today. It's, great to have you again.
19:59
Appreciate it. Thank you, Lucas. We also want
20:02
to thank our podcast on Recycling Plus. You
20:04
can tune in to more podcasts from Becker's
20:06
Healthcare visiting our podcast page at @beckershospitalreview.com.