Latest / StartUp Health NOW Podcast / Making Behavioral Health Work in Primary Care: A Conversation with Indira Paharia, PsyD, of VIBEcare

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Making Behavioral Health Work in Primary Care: A Conversation with Indira Paharia, PsyD, of VIBEcare · StartUp Health NOW Podcast

• 0:00
  [on-hold music] Hello, my name is Unity Stoakes, co-founder at Startup Health.
• 0:07
  Today, we have a dynamic conversation to learn all about Vibe Care, and we're gonna be speaking with a really cool doctor-preneur, Indira Paharia, who is the founder and CEO of Vibe Care.
• 0:22
  They are focused at the intersection of really creating access to care for people who need mental health services.
• 0:29
  So we're gonna learn all about their platform and what makes them special, and really dig into what it's like to be building in the category of mental health and behavioral health today. Stick around. Uh, how are you?
• 0:41
  Hi. I'm good, Unity. How are you? So nice to meet you. Nice to meet you. I'm excited for our conversation. Are you in Colorado today, or where are you? I am. I'm in Denver, yeah. Yeah. Where are you based?
• 0:55
  I'm in Berkeley, and I'm gonna be in Boulder on Thursday. Ah, okay. My, my, my sister lives there, and I'm coming to celebrate her 50th birthday. Oh, very nice. Uh, yeah. Yeah. It's lovely to meet you.
• 1:08
  I'm looking forward to having a great conversation about Vibe Care. Yes, yes. And you and your background, which is- [laughs] Sure...
• 1:15
  I, I think is really extraordinary, and I know you're gonna be linking up with some other members of the team later- Yeah... later in the week.
• 1:23
  But after our conversation, we can dig in to any other questions you have or things you need. But I really wanted to get to know more about you as a health transformer- Mm-hmm... and doctor-preneur- [laughs]...
• 1:35
  and also about what you've been building and what you're building at Vibe Care, and anything else you'd like to talk about. Yeah, sure. That sounds great. Uh, maybe we start with you.
• 1:46
  Tell us, uh, you have a really dynamic background. Yeah. You're a clinician. You're a, uh, my favorite, doctor-preneur, because you're- [laughs] I love that term... building something.
• 1:57
  I've never actually heard that term before, doctor-preneur. Very nice. I think so many of the great innovations today come from people who've been practicing or building in the space, and then- Yeah...
• 2:09
  bring that wisdom to actually creating a new solution. But how did- Yeah... tell us about you. How did you get your start? Yeah, so I'm a clinical psychologist, and always knew I would be in healthcare.
• 2:23
  My parents were healthcare providers, and so that was just the path, right? Now, my parents were medical professionals. Father was a surgeon, mother was a trauma nurse. But I gravitated towards mental health.
• 2:37
  I was always really fascinated by people and how people think, and mental health issues. So that was my path that I went down, and I actually did my training here in Denver.
• 2:49
  So there, there's a whole, like I've lived in a lot of different places, and I've recently come back to Denver, so this is like a full circle for me. It's really interesting.
• 2:59
  The work that I specialized in, what I was training in when I was here in Denver, was what's called health psychology or integrated behavioral medicine, and it's really what it sounds like, integrating mental health and substance use treatment into medical services because of the comorbidities and the fact that behavioral health drives the majority of the total healthcare costs, right?
• 3:25
  And so that, at that time, in the '90s, was not really well understood.
• 3:31
  And very early in my career, I did a residency with a Department of Family Medicine at the University of Colorado, where I worked with the residency program as a co-located behavioral health provider.
• 3:45
  And so I've always knew that I wanted to somehow bridge medicine and psychology. But fast-forward, and I did end up leaving Denver and going back east. I'm originally from the East Coast.
• 4:01
  I continued down that road of I started in academia. I was teaching in behavioral medicine. I was conducting research and publishing,
• 4:10
  but I was getting really frustrated about why we couldn't get more financial resources for behavioral health.
• 4:18
  So when I get frustrated about things, I wanna do something about it, so I thought maybe I need to learn about healthcare finance and healthcare business.
• 4:30
  And so at the time, I was teaching at Temple University, and [laughs] I decided to go and get an MBA. It, in their... They were the only one in Philadelphia that had a part-time program.
• 4:43
  So at night I was a student, and by day I was a professor. It was very funny, the experience.
• 4:49
  I ended up doing my MBA in healthcare at, administration, and then I did an MS in healthcare finance, because I really liked finance. Unbeknownst to me, I was shocked.
• 4:59
  And so then it was like, okay, how am I gonna put all this together? I'm not a degree collector. That doesn't interest me.
• 5:08
  And people started talking to me about managed care, health insurance, and the sort of dark side of healthcare, so to speak. And I was intrigued. I'm like, "These are the payers.
• 5:19
  This is where all the financial decisions get made other than government, of course." But I thought, why not? So I ended up joining Blue Cross Blue Shield. I ran a four-state Blues plan for behavioral health.
• 5:32
  I then moved on to Medicaid and Medicare at Molina Healthcare and was a national VP for them.
• 5:39
  And eventually I ended up at Centene, which is the largest Medicaid managed care company in the country, and I was the COO and the acting CEO of behavioral health for over 16 million members across the country.
• 5:55
  So I had all this knowledge about behavioral health, now integrating m- businessAnd mental health or behavioral health. And I had a background in integrating medicine and behavioral health.
• 6:10
  And that's where the full circle comes in. So a very dear friend of mine from 30 years ago, Dr. David Brody, who actually was one of the cre- And this is your co-founder? Is this your co-founder? Mm-hmm.
• 6:22
  He's my co-founder, and I'd love for you to get to meet him at some point or just, you know, have him be more involved with Startup Health.
• 6:29
  But he was one of the original creators of the PHQ-9, which is a major assessment tool used for mental healthcare in primary care. And that was, like, 30 years ago.
• 6:42
  So he ended up relocating to Denver from Philadelphia, and he and a friend of his who's a tech guy and had done a lot of tech startup began creating this company and asked me if I'd like to be involved.
• 6:58
  And I thought, "This is really interesting. So you're bringing behavioral health into primary care, but you're gonna scale it and do it virtually and not try and co-locate people because that never really works."
• 7:12
  And so I got involved with them as a board member three years ago. And was this even before it was called Vibe Care? It had a- I changed that name, yes. [laughs] Okay.
• 7:22
  That was my- The previous incarnation of the company that's now called Vibe Care. That's right. And maybe to set the stage, just give a one sentence or how do you describe Vibe Care to the world today? Yeah.
• 7:36
  So it was originally Collaboration Care, which is a very painfully long multi-syllable name. [laughs] So I decided, what are we doing? What does Vibe Care do?
• 7:49
  And we virtually integrate behavioral care, and that's where the Vibe came from, right? It's an acronym for Virtual Integrated Behavioral Care. And I loved the, well, the, the connotations that you get with that.
• 8:05
  It's very positive and upbeat and the marketing around that's gonna be fun.
• 8:10
  And so I quickly said to David and Kirsten, who are my co-founders, I said, "I get that we're using the collaborative care model," which is an evidence-based model for integrating behavioral health into primary care, and it's why we were called Collaboration Care.
• 8:25
  I said, "But that's really a mouthful, and I think we can get across that that's what we do without that name." And so that's how we ended up changing the name. It's very recent.
• 8:35
  We went through changing our website, transitioning to a new domain name and all of that.
• 8:41
  But essentially what we do is the collaborative care model is a framework that was designed by experts at the University of Washington, who I actually have worked with and have known, and they do amazing work.
• 8:56
  And it's a best practice for how do you bring, uh, behavioral health successfully into primary care. And this model didn't exist in the '90s when I was a co-located [laughs] psychology resident.
• 9:09
  Yeah, I wanna dig to that in a second. Yeah. How things have changed since then to now. Oh, tremendously.
• 9:15
  I, I love the track you're on where you're just also describing Vibe Care and kinda how it works and how it integrates in with primary care, which I think is- Yeah... helpful.
• 9:27
  So the nice thing about the model is that it provides this sort of interdisciplinary framework, but what it doesn't do is it doesn't i- in- infuse evidence-based clinical practice in a way that's standardized and scaled.
• 9:43
  And it also doesn't come with a lovely platform and all of the automation that's needed and the billing that's a little bit complex. So our platform provides all of that.
• 9:55
  We have a proprietary technology platform that includes all of those features that are required to deliver this model, but we augmented the model with scripted evidence-based coaching that our behavioral health coaches can use with patients.
• 10:13
  And so it fulfills all the requirements of the model, but we're 100% virtual, so nobody's going into the practice.
• 10:20
  We can integrate, and we have interoperability with provider and practice EHRs so that we can do, like, electronic referral and send PCPs reports, and we can communicate back and forth.
• 10:33
  And, and that's what we do to really increase the access for behavioral health services, but do it in a way that scales standardized evidence-based care and measurement-based care.
• 10:46
  So we're doing, like, repeat measures over time with things like the PHQ-9 to make sure the patient's depression is actually reducing and so forth. So that's what we do.
• 10:58
  But going back to your other question around how it's changed, back then there was no way to pay for it. Mm.
• 11:05
  So the problem was you'd have these co-located social workers or psychologists or even psychiatrists, and, A, space is at a premium.
• 11:16
  A primary care practice builds a practice based on space allocation because they have to generate revenue per square footage, so to speak. So where do they put these people? How do we bill for these people?
• 11:29
  Because same-day billing had been historically an issue. And then nobody wanted to pay for an integrated service.
• 11:36
  So this collaborative care model really gained traction, I don't know, maybe 15 years ago, and then Congress approved these billable codes. And so now these codes, you can actually bill for them, and they're significant.
• 11:52
  Most commercial and all of Medicare pay for those codes.
• 11:56
  And then 36, uh, Medicaid plans pay for them now, and the 36th plan was Colorado on July 1st, this July 1st, which is very exciting for us 'cause we're a Colorado-based company. Right.
• 12:12
  So it's like we wanna help these primary care providers-... deliver these services to their Medicaid patients. So let- So there's all these inflection points happening.
• 12:22
  One, I think the most fundamental is there's now a payment mechanism where you're integrated- Mm-hmm... into how the billing system and money flows within healthcare. You- That's right...
• 12:34
  you describe this really interesting, I think, transformation of bridging medicine with behavioral health, and that seems to be- Mm-hmm... a really important leap forward in our world today compared- Yes...
• 12:47
  to, say, the '90s. Could you just talk a little bit about that, how we've, the progress maybe we've made in understanding how important that is, and I think that leads directly to what,
• 13:00
  why it's so important that you're linking directly right into primary care and making this type of care more accessible to- Yeah... patients everywhere. Absolutely.
• 13:10
  So like I mentioned in the '90s, that people weren't really understanding back then why is behavioral health so important in medicine.
• 13:22
  And so there was a limited understanding of people have medical conditions and they have mental health conditions. Okay, that's very simplistic.
• 13:30
  But over time, what we've understood is that these conditions bi-directionally, reciprocally impact one another, meaning chronic medical conditions worsen and exacerbate behavioral health conditions and vice versa significantly.
• 13:47
  A perfect example is somebody with diabetes or cancer, and the co-occurrence of depression or anxiety is very high. And when those things exist, you can't effectively manage diabetes.
• 14:03
  You can't effectively tackle or fight your cancer and go through chemotherapy. You have to treat both conditions.
• 14:12
  And so that, people started to understand that, the research started coming out more and more showing how these conditions impacted one another.
• 14:22
  And when COVID hit, I think it just sh- sh- shined a spotlight on all of this bec- now all of a sudden behavioral health was in, like, the national spotlight and everyday vernacular and people talking about their experiences.
• 14:40
  But then there's another layer to this which is a little more sophisticated, and this goes back to my very early training in behavioral medicine, which is that there are all kinds of psychological interventions that you can use to better manage and treat and even prevent chronic medical conditions.
• 15:01
  And so that's where I think we're starting to, like, the industry is starting to get that part.
• 15:07
  And then of course, the fact that the funding is there, but the reason the funding is there is because organizations like Milliman have done outstanding actuarial analysis showing that when you treat behavioral health conditions, there is a corresponding financial offset of the medical cost and the overall total cost of care.
• 15:32
  And when you can prove that, then it's like a light bulb goes on for the bean counters and the managed care business people going, "Oh, maybe we need to pay attention to these conditions and not just be subjecting them to utilization management and denial of care and all the rest."
• 15:51
  Mm. So I think those are some of the things that have begun to pave the way to making this possible.
• 15:59
  There's still tons of barriers [laughs] that we are dealing with, but I think there, there's just a lot more possibility because of these developments.
• 16:09
  So what's your sense, is it, is, is this kind of an understanding across the government, the payers and employers that there's an opportunity here to really drive costs down by intervening
• 16:23
  early and in these other ways with behavioral health that can then save tremendous amounts of money down, down the line potentially from these other health issues that develop? Is that...
• 16:36
  I- is it just the government that's figured this out? Is it the payers that have figured this out? Are employers also understanding this? What are you seeing today? Yeah.
• 16:44
  It's actually, I would say a lot of the knowledge comes out of actuarial science and then randomized control trial research. The payers are often the last to really buy into these things.
• 17:00
  So I would say after that, the government has really taken hold [clears throat] through the evidence base, through the research.
• 17:09
  And then at least with government-sponsored programs, companies like Molina, companies like Centene, then they start to take notice.
• 17:18
  Because if CMS is willing to pay for certain things, then there's a requirement that they have to pay for certain things.
• 17:26
  And if these codes get passed at the state government level, then by law, if the state mandates that these have to get paid for under a Medicaid contract, the managed care plan must meet that level of reimbursement.
• 17:44
  So they can always pay for more, but they can't pay for less than the state dictates.
• 17:50
  So I think absolutely, it's, it, it really is probably, at least for government-sponsored, it's state and federal government, then managed care.
• 18:00
  But for commercial plans and employer groups, like large ASOs, what we know and what we're seeing more and what they're understanding about behavioral health is it's not just cost, but it's absenteeism and it's presenteeism.
• 18:13
  It's things that really impact employee productivity as well that are the soft-costs that aren't as easy to sometimes calculate, but they have an appreciation for that too.
• 18:27
  So I think that they, they actually stand to save even more money. Um- Yeah, if people are calling out sick or not- Exactly... productive, that's a huge driver. That becomes, uh, the CFO's issue as well as anybody's.
• 18:41
  That's exactly right. And then, you know, why primary care... Like, over 70% of behavioral health is delivered in primary care. It's the front line of behavioral health.
• 18:53
  So specialty behavioral health is less than half of, like, people like me, a psychologist. It, a lot of it is solely treated by PCPs, and oftentimes with medication, because they don't have time, right?
• 19:09
  So now then you start to see these over-prescribing of antidepressants, mood stabilizers, and so forth, and many people don't need to be on those medications. But what's, uh, uh, I'd love to learn
• 19:24
  how, what you've learned or the most surprising things or most interesting things as being a clinician working at a Fortune 50- Mm-hmm... in this area, and now building as an innovator, entrepreneur in this area.
• 19:40
  What it... What surprised you most? What have you learned? What are your biggest lessons at this point- Mm... across those? Wow, that's a huge question.
• 19:51
  It's not, it's not often that someone's done all of those, so I think you have a really unique perspective to offer on... You're in the trenches working, have worked with patients, right? Yeah.
• 20:03
  And you've worked with other providers and... But also to- Yeah... see how a big company or organization or institution works. Yeah. And now you're building something really special to, to bring this to the world.
• 20:18
  I'm just curious what you love most at this point. Yeah. Or what maybe you're able to bring forward to Vibe Care that is really helpful from those previous experiences.
• 20:32
  You know, I, I think that one of the biggest learnings I had, and this came from originally just deciding to go to business school wanting to understand why can't we get more funding for behavioral health.
• 20:48
  I think what I've learned and appreciated over time is that everybody looks at the healthcare problems from their own lens and their own perspective.
• 20:59
  And so in a managed care, you have very much a margin, bottom line, depending on if it's public, returning sh- shareholder value, all of that perspective. From a provider perspective, it's, "I'm burnt out. I can't get...
• 21:17
  I c- I don't have enough time to see all of these people."
• 21:20
  Th- there are just so many different ways of looking at the issue, but the one thing that I think you can get all of these different players to agree on is that at the center of it all is human suffering. You know?
• 21:37
  That's why we go into this profession. Mm. That's why I became a psychologist. It's why...
• 21:45
  It's really ultimately what drives me, is to reduce human suffering, especially when we know that there's treatments that can help people if we can just screen them and get them access to care.
• 21:58
  And I find that when you talk to people, no matter whether they're more of a CFO type or CEO type or provider type or practice manager or a provider, a clinician,
• 22:10
  they all have had either themselves a, an experience with behavioral health, or they know somebody who has who matters to them. Mm.
• 22:21
  And when you can start talking about the patient experience, I think that really helps bring people on the same page, that, "Okay, how do we start to work together to make this the best possible solution for the patient, for the person who needs the help?"
• 22:42
  And I, I feel like sometimes we lose sight of that in how chaotic healthcare has become.
• 22:47
  So my hope is that a company like mine, like Vibe Care, where we can really build our products around that patient experience, but also what the providers need, because that also gets lost [laughs], can help to drive that message.
• 23:03
  And then partnering, because I've had that experience, I know how to partner with managed care. I understand health insurance people. I can talk that language. I can talk the provider language, right?
• 23:17
  And so I'm hoping that over time we could maybe contract with a payer and help their primary care network to be more effective.
• 23:27
  But I think ultimately it's just reminding everybody this is really about the patient at the center and reducing their suffering. Let's dig into that last part a second. Who do you wanna meet?
• 23:40
  Who's Vibe Care selling into? What changes the game for you as you grow? I think it's absolutely essential that we get more access to these types of behavioral health services that, that you're bringing to the world.
• 23:54
  How... What do you need? How do you do that? Who do you need to meet? Yeah, it's a great question, because one of the... So you had asked about s- what things surprise you.
• 24:05
  We can offer our service for free to a practice with pretty much no startup fees, because we're going to be billing, we're billing insurance.
• 24:18
  But it's very hard for a practice to change their-Their behavior, their workflows, how they operate, even if it would make their lives much easier. Just change is hard, right? [laughs] For everybody.
• 24:32
  So I think getting more opportunity with primary care leaders, certainly practice managers. And when I say primary care, it spans internal medicine, family medicine, pediatrics, OBGYN, and geriatric medicine.
• 24:49
  But we're starting with family and internal medicine because those are the easier, more obvious, or more obvious routes.
• 24:56
  But I think getting more traction with practices, maybe meeting with some hospital system leaders or health system leaders that are interested in allowing us to pilot with some of their primary care practices, and then ultimately payers.
• 25:15
  But I feel like that's a little bit later because first I feel like we need to gain more experience and traction with the primary care practices, and really that boots on the ground experience that we just haven't really gotten a chance to get going yet.
• 25:31
  We have the platform. We have an MVP. We're pre-revenue. We just... That's really where we need to get started. You're, you're at that exciting moment in the journey where- Yeah...
• 25:42
  you're early, but you're bringing something important to the world that's very practical.
• 25:47
  Going in and offering a solution that's affordable to the providers, it's free, and also makes their lives easier and helps them help their patients- Mm-hmm...
• 25:58
  in really significant ways, I think is, is just a meaningful place to start. Exactly. I'm really excited about what you're doing. I'm so grateful that you're part of the Startup Health- Yeah... community.
• 26:11
  Any parting words of wisdom, things that you want to make sure the world knows about what's next for Vibe Care? And also, we're living, I think, in very interesting times.
• 26:22
  I'm curious, are you optimistic about the future in terms of people's mental wellbeing and opportunity to be? What's your take? That's a great question.
• 26:35
  So I would say one of the takeaways about Vibe Care is that there are other companies that are doing some similar things, but we are clinicians, we're technologists, and we're entrepreneurs, and we built this, these solutions around the primary care providers and patients because we are pri- primary care a- providers and psychologists and other types of clinicians, so we get that level, right?
• 27:06
  In terms of optimism- Yeah... I'm really optimistic because I do see that more and more commercial and Medicaid plans are reimbursing these codes.
• 27:17
  So they know that this is needed, and we know that the prevalence rates of behavioral health conditions are only increasing.
• 27:27
  There's a national behavioral health provider shortage, and a solution like ours uses board-certified health coaches and not just clinicians.
• 27:36
  They're supervised by clinicians, but it helps address this provider shortage that we're facing. Um- Does this make it more scalable than... Yeah. Exactly. It, it makes it far more scalable and cost-effective.
• 27:49
  But I think e- even more, we are in very challenging times, and I think people feel a level of uncertainty and anxiety and even depression that is unprecedented.
• 28:03
  And a lot of the times it presents itself in primary care because it's a safe space, it's less stigma.
• 28:11
  So I think that people need this service, and they need a place to be able to get that treatment but not have to deal with transportation and childcare and all the rest because everything we do is virtual.
• 28:26
  So I think we won't be, won't be a lack of business in our current situ- circumstances, but I am very optimistic. I'm grateful for what you're doing and bringing to the world. Thank you. Thank you.
• 28:40
  And look forward to checking in with you again soon because I just sense that you're gonna be growing very quickly because of the great need for what you're doing. Mm-hmm.
• 28:50
  I just wanna thank you and look forward to reconnecting soon.
• 28:54
  I would love to, and if we do get a chance to reconnect, I'd love to learn more about you and how you started Startup Health and how I can take the most advantage of being a member of your organization.
• 29:07
  It's been a journey, and I'm glad you're gonna be connecting with the team on Thursday because- Yes...
• 29:12
  there's so many resources and other community members and health transformers that we'd love to connect you in with because I think it'll- Mm-hmm...
• 29:21
  just leap you forward, and you'll have the opportunity to save a few steps and just really network quickly with hopefully other peers, other leaders, other innovators, other potential partners who can just kinda change the game more quickly.
• 29:37
  So looking- Fantastic... forward to you digging into all of that. But- Me too... thanks again and- And I think... Yeah, thank you for your time. So this was an amazing conversation with Indira Paharia from Vibe Care.
• 29:51
  Really, we learned a little bit about their journey, her early days at Centene and the transition to being a doctor-preneur and building with some other extraordinary founders, and really just making it easier for people everywhere to get access to behavioral health services through their primary care physicians, and also making it easier for managed care and primary care physicians to, to really offer their patients access to behavioral health services.
• 30:19
  A lot of people out there suffering, a lot of people with anxiety, a lot of people with depression, a lot of people with... who just need mental health resources and coaching and therapists.
• 30:28
  Looking forward to really supporting Vibe Care in every way we can and bringing more behavioral health services to patients everywhere.
• 30:37
  Stick around for more great conversations with other Health Transformers and checking out o- other stories and founder stories on our Health Transformer blog.
• 30:48
  And also wanna invite everyone from the community to join the Startup Health Network.
• 30:53
  We are opening up membership to the buyers, to the funders, to the industry leaders, to all those in the world that want to support amazing Health Transformers like Indira and upstarts like Vibe Care and really connect in, in deep, meaningful ways.
• 31:10
  We've got a really cool community we're building. So learn more at startuphealth.com and join the Startup Health Network today. Thank you.
• 31:20
  [outro music] And finally, an invitation to all of the extraordinary Health Transformers.
• 31:27
  Whether you are a startup, someone building the future of health, or whether you are an investor, funder, or buyer of the solutions out there in the marketplace, this is an invitation to you to join the Startup Health member community.
• 31:42
  Learn more at startuphealth.com. Look forward to hopefully seeing you soon. [outro music]