Latest / The Mental Health Evolution / Ep 29: Crash-Testing AI for Mental Health with Shirali and Arul Nigam

Transcript

Ep 29: Crash-Testing AI for Mental Health with Shirali and Arul Nigam · The Mental Health Evolution

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  (Transcribed by TurboScribe. Go Unlimited to remove this message.) All right.
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  And then Rachel, the only thing is just make sure you're projecting
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  your voice into that microphone.
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  Okay.
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  And then other than that, you guys are all set.
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  Okay, sounds good.
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  Is it decent on the video, Jenny?
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  Can you see or can you not?
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  I can't see myself on the video, which is fine.
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  But does that mean it's not recording my video?
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  Okay.
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  I don't know where the setting is.
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  I probably should have had Lydia come back.
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  It's probably still recording me, even though I can't see my face,
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  right?
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  You look great.
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  Yeah, it's coming through on my end.
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  Yeah.
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  Okay.
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  What do you think?
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  I think it's just probably an issue.
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  It says stop video, so I think we're good.
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  Okay.
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  All right.
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  So we have actually switched to recording in a studio, but this
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  is a newer switch for us.
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  So forgive the technical difficulties.
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  And we're finding that we have to work with everybody else's schedules
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  and they're like, oh, I'm running behind.
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  And so.
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  Yeah.
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  No, it makes sense.
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  No, it's great.
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  Great to be here.
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  Yeah.
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  All right.
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  Well, any questions before we get started?
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  No, it feels good.
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  Yeah, I'm ready.
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  Let's dig right in then.
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  All right.
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  Well, welcome back everyone to the Mental Health Evolution podcast, where we
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  are talking about how the landscape is quickly evolving in the mental
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  health industry.
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  And today we're taking a look at what has changed with payers,
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  specifically insurance companies, in the landscape of venture capitalist
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  partnerships, value-based care, tech companies, all of these things that are
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  changing how payers are paying on their contracts and how this is
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  impacting the market overall.
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  So for some background, our guest today, Jeremy Zug, is someone I
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  met at Meet You in Kentucky, which is a conference for group
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  practice owners.
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  And he and I started a conversation.
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  We dove right into talking about the trends in our industry and
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  what he's seeing from his lens.
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  And I think he's going to give you some really great things
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  to think about in this evolving market.
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  So I can't wait to dive into that conversation.
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  But before we do, I want to give you a little background
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  here to set the stage of some kind of topics and trends
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  happening so that you can understand where we're talking from as we
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  start digging into the conversation.
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  So in Indiana, for those that may or may not know, January
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  1st, 2025, Anthem Blue Cross sent out a letter notifying providers that
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  they were delegating care management to the company Carillon.
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  But nothing would change for members and providers.
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  And then June 27th, behavioral health providers got a notice that they
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  would now be paid based on Carillon reimbursement rates and not Anthem
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  rates, which was about a 40 to 57 percent decrease in provider
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  pay.
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  So there's been a lot of hubbub about that, as you can
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  imagine.
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  So that's a piece of data that's important to know as background
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  to this conversation.
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  Also, just some other articles I've been reading from Becker's Behavioral
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  Health.
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  There's a flurry of M&A that continues, 22 deals to know.
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  And if you're not familiar with the term M&A, it stands
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  for mergers and acquisitions.
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  And it's an article looking at the continuing push of venture capitalist
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  companies to acquire mental health and behavioral health companies.
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  This is increasing their market share in the mental health industry, and
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  they're happening all around us all the time.
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  If you're not watching, knowing that there are 22 deals recently happening,
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  that's a lot happening in terms of mergers and acquisitions here.
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  And one more piece of Fierce Healthcare reporting that Octave nabs $52
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  million in the expansion of network therapy services to all 50 states.
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  This is back in 2024.
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  So that was already happening.
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  But in this article, they are discussing merging Alma and Hedway.
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  Most people have heard of Alma and Hedway to provide in-network
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  services at higher rates to therapists due to their venture capitalist funding.
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  So this is, again, like merging Alma and Hedway, that brings up
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  all kinds of questions about who's covered, what are the rates.
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  And so this is all of the kind of thing that we
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  want to dig in and be talking about today.
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  So let me tell you a little bit about Jeremy.
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  He is the co-founder and partner at Practice Solutions, LLC, which
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  is a medical billing and revenue cycle management company dedicated to serving
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  mental and behavioral health providers.
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  His experience working directly in group practice billing and operations has
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  shaped his mission to create a service that empowers therapists to understand,
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  manage, and improve their billing policies and processes.
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  So thanks for being here, Jeremy.
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  That's amazing.
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  Yeah.
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  Thanks, Rachel.
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  That's great context, by the way.
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  Yeah.
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  Thank you.
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  Yeah.
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  I feel like if we're going to dive in, people need to
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  know a little bit about where is this coming from?
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  And we will attach the articles and references to the show notes
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  too for people if you want to dig into that more.
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  So let's talk about all of this.
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  I'd love to start by just asking you, what are the patterns
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  you see in the work that you're doing?
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  Yeah.
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  So there's a few patterns that we track on a regular basis.
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  So, and I think the Carillon example is a really good example.
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  These shifts happen all the time.
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  So if you're in private practice, probably up until this point, you
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  haven't needed to be aware of what's going on.
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  But the big therapy, my good friend Brent likes to call the
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  big MSOs, big therapy, you know, oftentimes providers come in to these
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  big MSOs, they try it for a little bit, and they think
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  that the guarantees that were sold to them are sort of the
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  golden goose of private practice.
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  They come in, they get EHR light, maybe some administrative stuff is
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  done for them.
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  But what they find is that the hands-off value proposition of
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  joining a big MSO like that is not quite what they're looking
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  for.
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  So one trend that we're seeing a lot of are providers going
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  into those organizations, they try it out, they realize it's not quite
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  what they're expecting for, and then they decide that doing the uphill
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  work of starting a private practice is really what they want to
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  do.
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  And that's an exciting trend that the independent private practice owner and
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  that idea is having a little bit of a reemergence from the
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  COVID era, from four years ago.
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  And so that's an exciting one.
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  We're noticing that the insurance conversations with the big therapy providers
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  are changing.
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  So those big MSOs were able to come...
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  Can you describe MSOs just for people that are maybe not familiar?
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  What MSO is?
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  Yeah.
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  Managed service organization.
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  And so those companies are the almas and headways of the world.
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  The other term that people like to assign those companies are aggregators,
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  because they take a bunch of NPIs, they aggregate them together to
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  form one very large organization.
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  That's a great clarification, Rachel.
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  Thanks.
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  There's a lot of acronyms floating around the billing world.
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  So I got to be a little slower.
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  To you, right?
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  It's just everyday conversation.
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  Everyday conversation.
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  Certainly for listeners.
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  Yeah.
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  And during COVID, those organizations had a lot of sway because all
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  of a sudden they had tens of thousands of new therapists that
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  they could offer to the insurance company network.
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  The insurance company executives also went to Ivy League schools and got
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  pretty decent grades.
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  And what they realized is that those organizations are not adding net
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  new NPIs or providers to the network.
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  They're actually just borrowing NPIs or providers to the network that were
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  already there.
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  The only organizations that are adding net new providers are the independent
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  private practices.
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  And that's the value proposition that practice owners have now, is that
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  we're actually adding new providers to the network and MSOs are just
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  reshuffling what's already here.
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  And so the NPI, the new provider piece, when you're talking private
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  practice, are you talking solo practitioners?
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  Are you talking group practices?
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  Or are you talking both?
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  Both.
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  Yeah, both.
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  Because groups, independent groups, attract folks from grad schools all the
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  time.
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  And those providers have the choice of going to community mental health.
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  They could start their own practice.
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  They can join an MSO.
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  And so oftentimes they join the independent group practice for a huge
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  range of reasons.
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  I mean, the value proposition there for a new clinician is giant
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  versus a CMH, for example.
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  So those practices are adding more providers to the network.
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  But then you have this other M&A pattern.
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  Optum and insurance companies at large buy practices all the time.
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  They could approach your practice and say, Rachel, we want to buy
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  your practice.
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  And they could offer you some kind of deal.
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  I have a friend who has a friend whose practice owner sold
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  to Optum because of this exact kind of swirly deal that they
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  offered.
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  And a year later, that deal was not as attractive as it
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  was said to be.
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  And no judgment.
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  I don't own a practice.
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  And I don't know the pressures that that particular practice owner was
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  facing and the huge range of reasons why you'd want to do
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  that.
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  But practice owners are going to get approached by insurance companies.
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  They have a lot of money.
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  They have a lot of options.
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  And you got to look at those deals very carefully.
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  So it's really important here that a practice owner notices these trends.
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  They know the players.
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  They know the game board.
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  And they're able to make the best decision they can, even if
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  it feels a little bit like attrition.
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  You're going to stay in your trench for as long as you
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  can hold out for.
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  Because generally, the normal vicissitudes of life will play out in your
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  favor.
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  Interesting.
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  It's interesting to hear the leverage of group and solo private practitioners
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  because I think insurance companies are coming out and saying, hey, your
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  rates are going to be decreasing.
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  Your it takes longer to get credentialed than, say, an Alma or
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  Hedway.
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  There are all these sort of ways that they are maybe reducing
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  the service to private practitioners.
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  Do you see that across the board, across the country as well?
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  Yeah, that's a good question, Rachel.
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  It's not a typical trend across the board.
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  Because our health care system is like broken pieces of ice floating
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  on the ocean.
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  They don't all jive and work together.
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  They don't move.
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  They're not correlated with each other.
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  And so you have some states that that's not the case and
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  some states where it is the case.
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  Here's what I'll tell you.
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  The research is pretty clear that, at least in the mental and
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  behavioral health space, clients are four times more likely to go out
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  of network with their provider than find an in-network provider.
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  So Caroline can come along and they can cut the rate by
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  half.
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  And then you've got to think.
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  If you're not going to make a panicked decision, which I don't
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  recommend, don't make a panicked decision.
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  Go, OK, they're going to offer me half.
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  Let's say, just for round numbers sake, that that's $50 a session.
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  I would be willing to wager that a client who has a
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  good therapeutic rapport with their therapist is going to follow them out
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  of network for the same rate or more cash.
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  Because you're not going to find the same therapist somewhere else.
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  It's not like another medical specialist.
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  It's not like a pharmacist who can just do it.
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  It's very relational.
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  Rapport matters.
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  So what I would say is leave the network.
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  Leave the network.
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  Maybe charge $5 more than what they were going to offer you.
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  That $5 difference per session makes a huge difference.
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  So providers have a lot of options in terms of what their
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  response can be to this.
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  But you can't panic.
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  That's that's the first thing for sure.
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  I love that.
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  I love that.
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  And so if you could kind of predict the future, which we
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  know you can't, I'm just asking you to use that part of
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  your brain, right?
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  But what do you think will change with the tech companies, which
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  with venture capital backing insurance companies, backing the tech companies in
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  our industry?
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  What do you see on the horizon?
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  Yeah.
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  So I have a couple.
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  I really appreciate this question.
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  We think about this stuff all the time because this industry changes
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  so much.
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  So for tech companies specifically, one of the brighter pieces of news
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  or trends that I'm seeing is a renewed commitment from insurance companies
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  to change the prior authorization process.
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  That was something that you'll see on LinkedIn a lot or you'll
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  see in news releases that prior authorization has really become a sticking
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  point for a lot of folks for good reason.
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  But there is also, and this is kind of the interesting conversation
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  that you and I can have about this process, but prior authorization
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  is not all bad, right?
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  Sometimes prior authorization does prevent fraud.
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  So if you want to look at a case study from 2014,
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  North Carolina removed prior authorization wholesale.
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  They said no more prior authorization allowed.
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  And nine months later, they reversed course.
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  Why is that?
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  Well, what happened was a flood of bad actors came into the
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  market and fraudulently billed like crazy.
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  And I think the attorney general, from what I've read and understand,
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  is still dealing with those cases today.
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  So they had to roll that back.
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  They had a $500 million state budget deficit because of all these
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  bad actors.
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  And so you have to balance this system-wide change.
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  And this is my prediction, that tech companies are going to figure
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  out what the prior authorization process, a renewed one, looks like.
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  Because with it, as it exists today, you prevent care from people
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  that actually need the care, right?
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  Without it, you allow bad actors to come in and run up
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  a giant bill.
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  So you've got to figure out somewhere, some other system.
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  We've got to get off either or and find a new thing.
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  So that's one prediction.
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  The second is that insurance companies are not, and this isn't really
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  a prediction, this is currently happening, but insurance companies are not
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  giving the same rates to big therapy because they're not adding net
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  new NPIs.
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  So big therapy is either going to have to increase the session
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  count of therapists or they're going to have to decrease the amount
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  of pay.
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  Rachel, you and I both know either one of those is going
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  to be like a net negative for those companies.
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  So my prediction there is that if those companies, the MSOs, aggregators
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  start to decline, I think the insurance companies will just buy them
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  out.
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  I think they'll just adopt them as another service within their platform
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  of companies.
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  And then my last one is that Medicaid is getting cut.
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  We all know that.
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  That's kind of a new thing.
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  And so what does that mean, right?
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  That means for some of you listening, that's a loss of patience
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  and that's a loss of reimbursement.
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  And we don't really know what the impact of that is going
• 16:42
  to look like, right?
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  We think, well, the higher limit says 36 million people lose Medicaid.
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  The Congressional Budget Office says 10.4, 10.6. I think that's
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  a little low.
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  So I think somewhere between 10 and 30 million folks are going
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  to lose coverage.
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  So that's a lot of folks.
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  So you got to start planning for what that looks like too.
• 17:08
  Yeah.
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  And then in the industry, you have clinics, practices that are all
• 17:13
  Medicaid are primarily Medicaid clinics, right?
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  You have others that don't take it at all.
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  It'll be interesting to see how that affects other private insurance, I
• 17:23
  would think as well, and maybe even self-pay.
• 17:27
  For sure.
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  So like Centene is a really large publicly traded company that all
• 17:34
  of what they do generally is Medicaid and Medicare management.
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  And so that company is going to take a huge hit.
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  Humana also is another big one that manages Medicare and Medicaid.
• 17:47
  And then UnitedHealthcare also has quite a few Medicaid members.
• 17:51
  And so the folks running those companies, again, are pretty smart and
• 17:58
  they're not panicking.
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  They're thinking about their next step.
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  And I would encourage practice owners to have this same attitude, right?
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  If these things are true, what's my response, right?
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  So I would flip the question back on you, Rachel, which is
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  like, let's say all this stuff plays out and you were a
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  practice owner just starting, what would be your move?
• 18:23
  Well, I've definitely recommended to some people who are starting out in
• 18:27
  solo practice not to go with any of these MSOs because I
• 18:32
  think it's a gamble, right?
• 18:34
  I think having your own credentialing, having control of your own billing,
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  I think all of those pieces are going to be something you
• 18:42
  want control over for the long haul.
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  So it's sometimes a hard sell though, because they look at me
• 18:48
  and they go, yeah, but these people are going to do my
• 18:50
  credentialing and do my billing for me and all that.
• 18:53
  And I'm like, okay, I mean, do you.
• 18:55
  But if you're asking me my opinion, I would say steer clear
• 18:59
  of those organizations because of some of the volatility that you're talking
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  about.
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  There's going to have to be change there.
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  I look at it from the perspective of if a venture capitalists
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  are investing in these companies, right?
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  They're at the market grab part of this.
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  They're trying to get as much market share as possible.
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  So all the money is flooding in.
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  It's amazing.
• 19:23
  You could do all these things with all this money we can
• 19:25
  get.
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  But at some point the payback has to happen.
• 19:30
  That's right.
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  Or I think all of these changes are going to come is
• 19:34
  like, okay, we can ride this wave of you're getting more than
• 19:38
  you would if you were paneled individually.
• 19:42
  And what's going to happen when they reduce that?
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  And maybe there's something in there, reach your contract really well too,
• 19:50
  right?
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  Make sure you can actually get credentialed independently.
• 19:54
  And then how long is that going to take?
• 19:56
  And then do you patience in the meantime, right?
• 19:59
  There are all these risky things when you're not the one that
• 20:02
  owns those processes.
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  So that's part of what I see as well.
• 20:08
  For sure.
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  And I would highlight a bright spot in the M&A world.
• 20:13
  There's only from what I've been able to meet in this community,
• 20:18
  there's only one good one, like Fireside Strategic.
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  I don't know if you've heard of them, but they're looking at
• 20:24
  how do we do this M&A thing so that the clinicians
• 20:28
  benefit, right?
• 20:30
  That's their mission.
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  But they won't buy a practice that's within those big MSO companies,
• 20:37
  right?
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  Because it's not yours.
• 20:39
  I like exactly what you're saying.
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  And so you look at that too, and you look at a
• 20:45
  Fireside Strategic who I think is actually going to be a very
• 20:50
  good actor in this, like a good influence in this space.
• 20:54
  But it's not your practice if you're part of those big MSOs.
• 20:59
  And I'm probably like you, Rachel, I'm very independent.
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  And so I like the idea that you can steer the ship,
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  right?
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  If you're not in the helm, that ship gets steered for you.
• 21:12
  So I'd love to sort of talk about another piece on the
• 21:19
  side here, but it has to do with payers.
• 21:20
  I'm hearing all of this talk about value-based care and insurance
• 21:25
  companies requiring that of behavioral health and mental health providers.
• 21:29
  And I think it's been a much slower rollout.
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  I know they've already rolled this out in a lot of medical
• 21:34
  practices and for medical providers.
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  So I'm curious some of what you're seeing there, because you work
• 21:40
  with practices all over the country.
• 21:42
  So how much value-based care are you seeing being implemented?
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  How much is not?
• 21:48
  What are you noticing?
• 21:50
  Yeah, value-based care is here.
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  It has been much slower to roll out in the mental health
• 21:55
  space.
• 21:56
  But when you look at the MACRA and MIPS program within Medicare,
• 22:01
  and even for behavioral health providers within facilities have to report
• 22:06
  certain data measures that influence the reimbursement rate, there's already a
• 22:10
  template for this.
• 22:11
  The debate in the insurance companies is whether it's value-based care
• 22:17
  or whether it's value-informed care.
• 22:19
  And there's a big difference here.
• 22:21
  Value-based care is these are your outcomes and your reimbursement follows
• 22:28
  how much value you provide, right?
• 22:31
  So on paper, that makes sense.
• 22:33
  Value-informed care says that the outcome measures for the treatment you
• 22:39
  provide are a factor of the reimbursement.
• 22:44
  Now that matters in real life.
• 22:46
  So like I live in Detroit, there are some pretty wealthy suburbs
• 22:50
  around Detroit, and then there are some pretty poor areas in Detroit.
• 22:54
  Let's say, Rachel, you were practicing in a fancy suburb and I'm
• 22:58
  practicing in downtown Southwest Detroit, for example.
• 23:01
  There are some much bigger factors than just the care that are
• 23:08
  provided that influence the outcome of that care, right?
• 23:12
  Yeah.
• 23:13
  Value-based care says the better grade you get, the more reimbursement
• 23:17
  you receive.
• 23:20
  But you never had an essay, leave your office, and then go
• 23:25
  live its life somewhere and then have that impact your reimbursement.
• 23:29
  And that's the trouble in mental and behavioral health care, is you
• 23:32
  can be a very talented clinician, but you're dealing with people that
• 23:36
  make decisions, right?
• 23:41
  Contrast that to like a medical provider with, let's say, a population
• 23:46
  of folks that have diabetes, right?
• 23:49
  You can throw those folks on a medication, almost very little lifestyle
• 23:53
  change, and you're going to get better outcomes.
• 23:55
  You can't do that in the mental and behavioral health world.
• 23:57
  So the question has always become for like Kaiser and Optum, to
• 24:02
  what extent are we measuring the outcomes and how much are we
• 24:07
  weighting those outcomes, right?
• 24:10
  Medicare rolled out MACRA and MIPS, they're going to continue with that
• 24:14
  program.
• 24:14
  And you're going to continue to see payers play around and experiment
• 24:19
  with this idea, but it's eminently complicated in mental health care, given
• 24:25
  like geography, socioeconomic status, diet.
• 24:29
  There's like a million variables, right, that impact the outcome of treatment.
• 24:34
  And so insurance companies are aware of that, and they're trying to
• 24:37
  solve for that.
• 24:39
  That's kind of in my hunch about why it hasn't rolled out
• 24:42
  yet is like, what are we actually using to measure?
• 24:45
  What are we measuring?
• 24:46
  How do we know that that's a fair measure?
• 24:48
  All the things that you're saying.
• 24:50
  Yeah, that's right.
• 24:51
  And if you are in a poorer geography versus a wealthier geography,
• 25:00
  your outcomes will be different.
• 25:02
  And so do you want to penalize the clinicians that are in
• 25:07
  a poorer demographic?
• 25:08
  No, you don't because you want providers there.
• 25:12
  And if you punish them for where they are, they won't be
• 25:17
  there.
• 25:18
  So you have to figure that out.
• 25:20
  And the network has federal responsibility according to the quality
• 25:24
  associations to provide access to care.
• 25:27
  So that's not in their interest to do that either.
• 25:30
  So they're going to figure out a better system there.
• 25:34
  That makes sense.
• 25:35
  That's a good thing.
• 25:36
  I appreciate that perspective.
• 25:38
  So I'm curious about your business in particular.
• 25:41
  How is all of this impacting you?
• 25:44
  What do you see as changes for you or maybe changes in
• 25:47
  services that you're offering?
• 25:49
  What's the outlook?
• 25:51
  Yeah, we're pretty optimistic in the independent private practice world.
• 25:56
  I think therapists are pretty smart.
• 25:59
  I think they are independent.
• 26:01
  They represent a group of people that I greatly enjoy because of
• 26:05
  the qualities that they carry.
• 26:08
  For practice solutions, we only exist to empower providers to focus on
• 26:14
  their patient care by relieving the burden of billing.
• 26:18
  And part of how we do that is we educate a lot.
• 26:22
  And so we do this kind of thing.
• 26:24
  We're launching our learning hub in 15 days where if you're a
• 26:28
  new clinician and you have no clue what we're talking about, you
• 26:32
  can get our playbook, all of our downloadable tools and resources there
• 26:38
  within the learning hub.
• 26:40
  We published a book, Insurance Billing Basics.
• 26:43
  Our podcast is coming out this fall as well.
• 26:46
  So all of those resources, we want to educate providers on how
• 26:51
  to make the best decisions for their practice.
• 26:55
  We also offer done-for-you billing.
• 26:57
  I don't think...
• 26:59
  It would be shocking to me, Rachel, if private insurance in our
• 27:02
  country went away overnight.
• 27:04
  That would be a wild shift.
• 27:08
  It would definitely simplify our work.
• 27:12
  So there's always going to be an element of outsourced.
• 27:15
  We're a US-based company.
• 27:17
  All of our billers are here in the US and we serve
• 27:21
  independent practices that way.
• 27:22
  But if you're a big group, we also help build out billing
• 27:26
  departments nationally.
• 27:30
  So between all three of those, we really enjoy the work that
• 27:34
  we're doing.
• 27:34
  And we're kind of used to these changes, right?
• 27:36
  I mean, I feel like last year it was change healthcare getting
• 27:39
  hacked.
• 27:40
  So that was real exciting.
• 27:42
  This year it was Tricare West not paying a cent, Carillon.
• 27:46
  So these are normal changes that our leadership team sits down and
• 27:51
  we plan for as well.
• 27:52
  So we're right there with practice owners and thinking through, okay, well,
• 27:56
  what's the next thing?
• 27:58
  How do we help empower more practices to enter the marketplace?
• 28:03
  Because that's where I think the best care happens ultimately.
• 28:06
  I love that.
• 28:07
  I love that.
• 28:08
  We are about out of time and needing to wrap up, but
• 28:11
  I have one more question for you.
• 28:13
  If you could highlight just one critical piece of information for people
• 28:17
  to know, maybe practice owners, maybe people that are seeking care, just
• 28:23
  in general, what would that piece of information be?
• 28:26
  Oh, that's a good question.
• 28:27
  There's so many.
• 28:29
  The one I would say is ask for more, like negotiate higher
• 28:34
  rates, demand better from the insurance companies, for sure.
• 28:39
  Build good relationships there.
• 28:42
  I think there's more available than providers in practice think there is.
• 28:47
  And so the care you provide is worth it.
• 28:50
  I know sometimes that's a struggle for especially new therapists in the
• 28:54
  market, but the care you provide is eminently valuable.
• 28:58
  And so if you're not getting that value out of a partner,
• 29:01
  they're the wrong partner.
• 29:03
  So find a new one, but yeah, ask for more.
• 29:07
  I love that.
• 29:07
  That's great.
• 29:09
  Well, I want to thank you so much for your thoughts.
• 29:12
  Definitely gave us a lot to consider and think about, Jeremy.
• 29:16
  So thanks for being here and thanks for the work that you
• 29:18
  do.
• 29:19
  Thank you.
• 29:20
  Yeah, it was a pleasure.
• 29:21
  Thanks so much, Rachel.
• 29:22
  Yeah.
• 29:22
  Everyone else, we will see you back for a new episode to
• 29:26
  talk more about the changes in the mental health industry.
• 29:29
  Bye for now.
• 29:32
  All right.
• 29:34
  Amazing.