Latest / Becker’s Healthcare Podcast / Reimagining and Standardizing Hospital-Based Behavioral Health

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Reimagining and Standardizing Hospital-Based Behavioral Health · Becker’s Healthcare Podcast

0:00
A disclaimer for our audience.
0:02
This podcast discusses mental health issues and suicide.
0:05
If you or someone you know has suicidal
0:07
thoughts or is experiencing a mental health crisis,
0:10
please contact emergency services or dial or text
0:13
988
0:14
to reach the suicide and crisis lifeline.
0:17
Hi, everyone. This is Lucas Voss with Becker's
0:19
Healthcare. Thanks so much for tuning in to
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the Becker's Healthcare podcast series and our episodes
0:24
on what hospitals get wrong about behavioral health
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and
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how to fix it. And I'm so excited
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to welcome doctor Fasseltai again to the podcast,
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a board certified psychiatrist and founder of Psych
0:35
Plus, a company focused on delivering scalable behavioral
0:38
health solutions for hospitals and health systems. He
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trained at the University of Iowa where he
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served as president of the graduate medical education
0:44
program, representing over 800
0:47
residents and fellows. During residency, he also began
0:50
developing a mental health focused EHR that would
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later support PsyPlus' broader model. Today, PsyPlus is
0:56
expanding nationwide with a vertically integrated approach that
0:59
prioritizes in person psychiatric coverage, handles billing and
1:03
collections, and operates with only a minimal hospital
1:06
subsidy, enabling provider organizations to grow behavioral health
1:09
services without significant
1:11
financial or operational
1:13
lift. Doctor Tai, welcome back to the podcast.
1:15
Great to have you. Hey, Lucas. Good to
1:17
have you as well, and thank you, Becker,
1:19
for having me again.
1:20
Absolutely.
1:22
I know we've touched in our in our
1:23
previous episodes a little bit on what's coming
1:25
up here in my first question, but I
1:26
wanna dive a little bit deeper into it.
1:29
We know that psychiatric boarding in ED has
1:31
become, again, that systematic pressure point for a
1:33
lot of hospitals
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with many proposed solutions centered around that virtual
1:38
care model.
1:40
At a leadership level, how should systems think
1:43
about the limitations
1:45
of predominantly virtual approaches,
1:47
and what does a truly scalable system wide
1:50
strategy look like that improves that patient flow
1:53
and certainly also integrates
1:55
with on the ground clinical operations for those
1:57
outcomes?
1:59
That's a very good question, Lucas. And so
2:02
I let's rewind back and understand how we
2:05
got here.
2:06
And so prior to COVID,
2:08
there was not that much spotlight on mental
2:11
health services.
2:12
And so during COVID,
2:14
there was obviously a very heightened
2:17
spotlight and also a slightly increased prevalence due
2:21
to the environmental factors
2:23
around mental health in general.
2:25
And so a lot of health systems
2:27
started to see an increase in mental health
2:29
admissions,
2:31
mental health visits to the emergency room, or
2:33
even medical patients showing up with primarily medical
2:37
symptoms, but a lot of comorbid
2:39
mental health symptoms with them.
2:41
And so
2:43
at that point, they needed mental health services,
2:46
and the fastest solution was a virtual solution.
2:49
And also during COVID,
2:51
there was a lot of restraint on mental
2:53
health providers in general, and so
2:56
that was what was available.
2:58
It got deployed almost
3:00
everywhere in the country.
3:01
Health systems were willing to pay anything for
3:04
those services at that time given
3:06
the amount of tension
3:08
there was in the country
3:10
around COVID in general and around mental health.
3:13
I think as we've reeled away from COVID
3:17
and started to come to a more steady
3:19
state, the good thing that has happened is
3:21
because of this light on mental health that
3:24
was there,
3:25
now at least people are talking about it.
3:27
Right? We are much more vigilant about it.
3:29
And so the mental health visits has remained
3:32
relatively
3:33
higher
3:34
compared to prior to COVID,
3:36
but the services that are being offered, I
3:38
think, are subpar in majority of the hospitals
3:41
and emergency rooms across the country,
3:43
and it's because primarily of them are virtual
3:46
services. Now no one argues that it's better
3:49
to have virtual services than to have no
3:51
services at all.
3:53
But I think there's a big need for
3:55
actually moving to an in person primary model
3:59
for mental health services just like any other
4:01
service line in a hospital, whether that's mental
4:04
health, whether that's stroke, whether that's
4:06
neurosurgery,
4:07
whether that's orthopedics, whether that's, you know, ophthalmology,
4:10
any services.
4:11
I think if we can do it in
4:13
person, that is the better route to go.
4:15
I'm a big proponent of putting humans in
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the ERs that are dealing with these issues.
4:21
Not only that, mental health is also not
4:24
just a medical issue. There's a lot of
4:26
care coordination. There's a lot of psychosocial
4:29
issues that come up, which are oftentimes difficult
4:32
to dissect
4:33
on a virtual screen where the technology may
4:36
be okay, but not good enough to capture
4:38
every word. Sometimes they're static. Sometimes it's blurry.
4:42
You know, sometimes the Internet is is flaky.
4:45
And so really having that human element where
4:47
you can sit next to the patient, connect
4:49
with them, and really figure out how to
4:52
help them makes a much bigger difference in
4:54
real life than otherwise.
4:56
And I know we're six years removed. Right?
4:59
But a lot of people are actually craving
5:00
that now. They want personal touch points. They
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want that in person care now more than
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ever really after the pandemic specifically.
5:08
And I wanna touch on that in person
5:09
piece a little bit more. Right? When you
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look at organizations that are getting that piece
5:14
right and have that in person aspect, right,
5:17
what does effective integration of psychiatric services look
5:20
like when you look at in pay inpatient
5:22
operations?
5:23
And then also, if you can touch on
5:25
how that all translates into
5:28
potential performance gains. Right? We talked about length
5:31
of stay throughput readmissions.
5:33
Yeah. So
5:35
emergency room visits make up five percent of
5:38
your
5:39
total admissions in the ER.
5:42
Let me actually step back for a second.
5:44
So when you look at a total dollar
5:46
spent on mental health services, 50% of it
5:49
is in emergency rooms. Right? So when everyone
5:52
is talking about cost cutting measures,
5:55
this is by far your biggest bucket. And
5:57
interestingly,
5:59
even though emergency room visits, only 5% of
6:03
them are mental health visits, they make up
6:04
35%
6:05
of the bed capacity of an emergency room
6:07
at any given time. So they're essentially clogging
6:10
up these ERs
6:12
from being able to take an MI case,
6:14
an orthopedic fracture, a more motor vehicle incident,
6:18
you know, a stroke case, which can be
6:21
relatively
6:22
much more
6:23
revenue generating than a mental health patient that
6:25
is sitting in your ER for twenty four
6:27
hours.
6:28
It's not outside of the fact that it's
6:30
not good from a revenue perspective, it's also
6:33
it's also bad care. I mean, why is
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this patient
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sitting in an ER for twenty four hours,
6:39
which is not the best place for him
6:41
to be at or her to be at?
6:43
And so
6:45
oftentimes,
6:48
there's multiple factors that are causing those issues.
6:51
Right?
6:52
And I think
6:53
having a virtual provider
6:56
and expecting them to not only see the
6:58
p the patient, assess the patient, but all
7:00
the all also facilitate
7:03
the post discharge plan,
7:05
I think, is asking too much.
7:07
I'll give you a good example. We service
7:09
tons of level one trauma centers,
7:12
and they're always tight on people because they
7:14
have
7:15
emergencies coming in that require five people at
7:17
a time sometimes. Right? So you have a
7:20
large hospital
7:21
on a Sunday night at 6PM.
7:24
I get a call from my provider.
7:27
Well, we can't service the hospital because the
7:29
there's no individuals available to carry the the
7:32
machine around or the camera around to see
7:35
a patient. I called the hospital CEO,
7:38
and they say, well, we're short on staff
7:39
right now.
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So if we don't have,
7:43
an in person services at that hospital, the
7:46
patient will never get seen.
7:48
Right? Because until whenever they have availability.
7:51
But because we have in person services, guess
7:53
what? Even if the patient doesn't get seen
7:55
overnight, the next morning someone will go in
7:57
and actually see this person.
7:58
Right? And what we've seen is that
8:02
that the in person services
8:04
has allowed us to reduce the clogs in
8:06
the ER so much that we've been able
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to generate
8:11
significant amount of revenue
8:14
and a much higher quality
8:16
for patients,
8:18
for payers,
8:19
and for health systems. Right? Because number one,
8:21
there's the patient who now has a human
8:24
talking to them.
8:25
Most patients are
8:27
conflicted about mental health services to begin with.
8:29
Right? They don't always are agreeable to getting
8:32
help, but now we've added a human element
8:35
who can engage with them and can get
8:37
them convinced to go see a provider on
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the outpatient side.
8:41
Now this patient shows up to an outpatient
8:43
appointment. We actually provide them a next day
8:45
appointment
8:46
in the ER so they know exactly where
8:49
they're showing up and what time they're showing
8:50
up. They get seen by a provider next
8:53
day. They get their medications. They get their
8:55
therapy. Now they are less likely to come
8:58
back to this ER for their services
9:01
if and in fact they have another
9:03
emergency situation. Right? Because now we've plugged them
9:06
in.
9:07
Hopefully, they won't have another emergency situation like
9:10
this. But if they do, they also have
9:12
access to us 247.
9:14
So now they're not coming back to the
9:15
ER for the same situation.
9:17
Right? Unless it's really nine one one situation
9:20
type type scenario. Right? And so
9:23
that reduces the cost for the payer. That
9:25
is a better outcome for the patient.
9:28
And it actually is something that the hospitals
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prefer because, yes, they don't mind the revenue
9:34
from the psych patients,
9:36
but that's not what they're living for. Right?
9:38
That is not their bread and butter. That
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is not what they're set up for. You
9:42
go walk to walk into an ER room.
9:44
Does it look like a therapy milieu room
9:46
to you, or does it look like a
9:48
surgical,
9:49
OR suite to you? Right? I mean, it
9:51
looks like a surgical OR suite because that
9:53
is what their core competencies. Right?
9:56
Now, thankfully, in the country, there is some
9:58
trend moving towards empath and crisis stabilization
10:01
units, which are helpful more helpful than what
10:04
the typical ER is. But those are maybe
10:07
one or 2% of the country today. So
10:10
very minimal,
10:12
you know, support systems for this, which is
10:14
why I think the solution lies in providing
10:16
in person care in these health systems.
10:20
I wanna touch a little bit more on
10:21
some of the financial aspects that you've just
10:23
talked about. Right? And and in my intro
10:25
here, I mentioned that you're really focused on
10:27
sort of doing all of this with minimal
10:29
hospital subsidy, right, and making sure that there
10:31
is no financial burden. When we talk about
10:33
the revenue cycle in and of itself,
10:35
how should health systems think about structuring partnerships
10:38
where the behavioral health provider takes on those
10:41
billing collections, and and what defines the alignment
10:44
there both from a financial risk perspective and
10:47
the accountability part?
10:49
So we as an organization
10:51
are contracted nationally by majority of the payers.
10:55
What that means is that when we see
10:57
a patient in the emergency room, we can
11:00
actually bill and collect for their services.
11:03
We can continue to service them
11:05
on the professional side. Right? So in a
11:07
hospital setting,
11:09
you know, the way The US is set
11:10
up, right, is you go into hospital, you
11:12
gotta have a hospital bill and you have
11:13
a physician bill. Right? So I'm talking about
11:16
the physician bill piece.
11:18
We are able to bill for the physician
11:20
piece to the payers directly
11:23
when the patient is in the ER, when
11:25
the patient is on the medical floor, and
11:26
when they go out into the community and
11:28
they're seeing us in the clinic. Right? And
11:30
so the entire loop is covered by us.
11:32
The patients aren't just not sort of thrown
11:34
out into the ocean of abyss and told
11:37
you need to figure out what you're gonna
11:38
do from here. Right?
11:41
Because we do that piece,
11:44
majority of our revenue, 90% of our revenue
11:47
gets derived and generated by by the payers
11:51
themselves. Right? For the insurances that the patients
11:54
are paying for or the government is paying
11:56
for. And our model is all inclusive care.
11:59
So we take Medicare, Medicaid,
12:01
and commercial payers
12:03
everywhere in the country and in every state.
12:06
And so our model is really how do
12:07
we make sure we see the patient without
12:09
them worrying about whether we accept their insurance
12:11
or not. Right? Now some payers
12:14
find ways to tell you, oh, we the
12:16
network is not open. But I would say
12:17
by far, 95% of the payers
12:20
are pretty open
12:21
lending mental health providers into their ecosystem.
12:24
But because we do that component,
12:26
we're not going into these hospitals and charging
12:28
them an arm and a leg to provide
12:30
psychiatric services. Right? And psychiatric services to hospitals
12:34
to most hospitals, I would say, are a
12:36
cost center. They're not a revenue center. Right?
12:39
So they're not like a,
12:42
a a cath lab or a colonoscopy
12:45
or a surgical procedure where they're generating
12:48
tens of thousands of dollars for that procedure.
12:51
Right?
12:52
Psychiatry services
12:53
are costing them. To me, the way I
12:56
describe it and some peep you know, this
12:58
may not be the best analogy, but mental
13:00
health services
13:01
is like recycling services. Right? Yes. There's one
13:04
waste management,
13:06
but there's only one waste management. It may
13:08
be a billion dollar business, but you can
13:10
make if you walk into a new city,
13:12
you don't have 10 choices to choose from
13:14
where you're gonna get your green bin from.
13:16
Right? Because you're not making a $100 from
13:18
on the green bin. You're making 50¢ on
13:20
the green bin. Right? But everyone in that
13:22
city must use that green bin because it
13:24
is so ubiquitous,
13:26
and it requires so much infrastructure to really
13:29
do it well
13:30
that you have to do it at scale
13:32
and you have to do it at population
13:34
health, especially when you start doing Medicare, Medicaid,
13:37
and the seriously mentally ill population.
13:40
That's the only way to do it,
13:42
and you have to do it in partnerships
13:44
with health systems, with cities, with communities, and
13:46
with payers.
13:48
And that's really when you can change the
13:50
way this operates. Right?
13:52
And that's why our systems are
13:55
are significantly
13:56
cheaper,
13:57
from a cost perspective than almost anything that
14:00
exists out there. Typically, when we go into
14:02
a hospital system,
14:03
we're able to reduce their physician spend on
14:06
mental health services
14:08
minimum by 50% of what their current spend
14:10
is today.
14:12
And, unfortunately, in the situation we're in in
14:14
The United States today, the financial piece of
14:16
all of this remains a big stressor from
14:18
a population health perspective for somebody that comes
14:20
to a hospital because they have to. Right?
14:23
Especially when it comes to behavioral health, they're
14:25
looking for for help.
14:27
One more thing I wanted to ask connected
14:28
to this really quickly here too was
14:31
when hospitals are in the process of evaluating
14:33
all of this and and doing some due
14:35
diligence on processes and trying to figure out
14:37
how to do this right specifically with the
14:38
patient in mind, right, what are those questions
14:41
that they need to be asking to make
14:43
sure that they're very good. Question. That's a
14:45
very good question. And and I will I
14:47
will say that
14:49
one of my biggest frustrations when I came
14:50
out of residency was looking at the lay
14:52
of the land in the psychiatric hospital world
14:55
or in general in the psychiatric,
14:57
inpatient world. Right? There's a lot of mom
15:00
and pops that are delivering this care today.
15:02
So every hospital you go to, there's a
15:04
local doc that may be doing it. There
15:06
may be some vendor. It's it's patchwork together
15:09
that you may have an employed provider.
15:11
And and my frustration was when you have
15:14
a stroke, you go into hospital, hospital a,
15:16
b, c, doesn't matter. Your standard of care
15:18
is pretty consistent. You know what you're gonna
15:20
get. If you go to an HCA or
15:22
an Ascension or a Methodist,
15:24
you're not worrying, oh, one person gonna treat
15:25
me differently for stroke versus another hospital. Right?
15:28
When it comes to depression, it's not the
15:30
same. You can go to the same hospital,
15:32
two different docs. One's gonna hold you for
15:34
three days, another for thirteen for no rhyme
15:36
or reason. Right? That lack of standardization,
15:39
in my opinion,
15:41
causes psychiatry to become a pseudoscience for the
15:43
rest of the world that doesn't spend time
15:46
in it. Right? Which is a fundamental problem
15:49
of legitimacy and validity in our space.
15:52
Most payers, most people that I talk to,
15:54
they think mental health is an art. Psychiatry
15:56
is an art. It's not. It's a science.
15:58
To the people that are living it in
16:00
it, right, to me, it's physics.
16:02
But if you don't know much about it
16:04
and we haven't done well as an industry
16:07
organizing and having a unified message around what
16:10
standard of care looks like,
16:12
then what you get is all kinds of
16:14
different shades and colors. Right? And my philosophy
16:17
was,
16:18
if we're gonna be in a 100 hospitals,
16:20
we're gonna be a shade of blue, and
16:22
we're not gonna be blue one place, red
16:24
one place, and yellow another place. Right? And
16:26
so, sure, you can have some variances,
16:29
but it shouldn't be so different
16:31
that a patient gets a completely different treatment
16:33
at hospital a than hospital b, right, or
16:36
provider a and provider b. So we spend
16:38
a lot of time
16:40
codifying,
16:41
standardizing procedures and processes so that I believe
16:46
that in the future, five, ten years from
16:48
today,
16:49
patients are gonna go to a hospital not
16:51
because the hospital belongs to a certain entity,
16:54
but they're gonna go to a hospital because
16:55
Psych Plus performs services in that hospital because
16:58
they know what they're gonna get. Right? I
17:00
think as a mental health professional
17:03
and as a mental health industry, we have
17:05
done a significant amount of disservice to our
17:07
patients.
17:08
Right? Today, when I drop my dog off
17:10
to day care,
17:12
I get a report card. I get pictures.
17:13
I get told exactly what they did. If
17:16
I drop my child off to day care,
17:17
what am I gonna oh, to to a
17:19
psych hospital, what am I gonna get? I'm
17:20
gonna get a I'm gonna get a call
17:22
two days from today
17:24
with the child calling me saying, dad, pick
17:26
me up. Someone's trying to hurt me. Right?
17:29
That's a problem. I mean, that is supposed
17:31
to be a safe space for us. Right?
17:33
But it comes
17:35
it it's not treated as such because of
17:37
lack of transparency, lack of visibility,
17:40
lack of communication to our patients. They don't
17:42
know what's going on. They don't know what
17:44
we actually do.
17:45
And we have to change the narrative
17:48
and standardize and speak up
17:51
about organizing
17:52
and delivering high quality mental health services and
17:55
what mental health looks like and why it
17:57
matters. Right? You have a you have a
17:59
patient who may need to stay at a
18:01
hospital for seven, ten days,
18:03
but then on the contrary,
18:05
you're getting accused by patients in the community,
18:07
oh, the patients are being held against their
18:09
will.
18:10
Well, the patient
18:11
just committed suicide. Well, the patient is saying
18:14
they're not suicidal anymore. Well, I tell my
18:16
providers all the time, ask a patient who
18:18
attempted suicide two hours before they did it.
18:21
Are they gonna tell you they're suicidal? No.
18:23
They're gonna tell you they're not suicidal. Ask
18:25
a patient in the ICU that overdosed. The
18:27
next day, are you suicidal? They're gonna tell
18:28
you they're not suicidal,
18:30
but a brain is an organ just like
18:32
any other organ, and it needs to heal.
18:34
If you break a bone and you put
18:36
a cast on it, you know at this
18:38
point in time in our medicine that it's
18:40
not gonna heal overnight. It needs time to
18:42
heal and it needs a place to heal.
18:44
Whether that's a psych hospital, whether that's home,
18:47
whether that's a different type of service
18:49
is a question,
18:51
but it still needs to heal. And I
18:53
think
18:54
we have to do a better job educating
18:56
people on what healing looks like in the
18:59
mental health space.
19:01
Yeah.
19:02
To close us out here, I wanted to
19:04
come back to that the piece that you've
19:06
just mentioned and come back to the actual
19:08
patient. Right? Again,
19:10
we you just touched on it. We hear
19:12
so much about problems with keeping folks engaged
19:15
right after they discharge, which is so crucial
19:18
in making sure that they are on the
19:19
right path and they find a way back
19:21
into their life, which is the the old
19:23
goal, the outcome. Right? What should health systems
19:26
be doing there,
19:27
and how do you know that it's working,
19:29
that you're doing a good job of making
19:30
sure that focal folks are staying engaged?
19:34
Well, today, I don't think there's much incentive
19:37
around health systems in general
19:40
from payers, from states
19:42
to ensure that they get to an outpatient
19:45
appointment after their discharge. Right? So we call
19:48
that it's and it's a HEDIS measure,
19:50
and HEDIS measure are measures by which, you
19:52
know,
19:53
payers or the state measures
19:56
quality of a provider, but one of the
19:58
HEDIS measures is a seven day post hospital
20:01
discharge follow-up.
20:02
That HEDIS measure across the country for a
20:04
Medicaid patient is about
20:06
twenty percent.
20:08
For psych plus here is for us, it's
20:10
about seventy five to eighty percent.
20:13
And I think the fundamental difference is that
20:15
we take a lot of ownership in ensuring
20:17
that that patient actually shows up to their
20:19
appointment, and it's little things. It's making sure
20:22
we know where they're where they live. We
20:23
know where they can actually come in for
20:25
an appointment,
20:26
actually getting their right phone number that's working,
20:29
actually getting an email that's working, making sure
20:31
their name is correct so we can verify
20:33
their insurance correctly.
20:34
It's simple things that are just not done
20:37
correctly.
20:38
And what happens is the patients get patients
20:40
get lost to to follow-up. Right? It it
20:44
the
20:45
it's it's frustrating to me how little
20:48
intensity there is around ensuring that patients actually
20:52
have a follow-up appointment when they discharge.
20:56
In fact, I I think a majority of
20:59
your reimbursement
21:00
should be tied
21:02
to that happening because of how critical
21:04
that function is in ensuring that patient doesn't
21:07
become
21:08
a repetitive patient coming back into the ER.
21:12
Yeah. Absolutely.
21:13
Doctor Tsai, so great to have you. As
21:15
we close out, anything else you wanna touch
21:17
on? Anything else that we haven't mentioned that
21:19
that might be important for for our listeners?
21:22
Yes.
21:23
I I would say that that looking at
21:25
the landscape
21:27
of mental health ecosystem across the country,
21:30
what we recently realized that a lot of
21:32
health systems
21:33
and a lot of organizations
21:35
lack leadership in mental health. Right? And so
21:38
they don't have someone that knows the space.
21:41
They may hire someone,
21:43
but they don't really know. There's no vetting
21:45
system for them to really know if this
21:47
person knows what they're talking about. And so
21:50
we we recently launched a model where we
21:53
end up providing
21:55
sort of a vice president of of behavior
21:57
health services to health systems and organizations
22:00
who's basically like a contractor for them.
22:03
They're an employee to us,
22:05
and we don't charge them anything more than
22:08
what their salary is. But now the benefit
22:11
is that this is a dedicated individual that
22:14
is hired. So the process is basically,
22:17
we put candidates in front of you. You
22:19
actually interview them in in collaboration with us,
22:22
and you decide who you wanna hire out
22:24
of the people we have already vetted for
22:26
you. Right? And so they're going through some
22:28
vetting. They get hired, but the nice thing
22:30
now is they have the ability to use
22:33
our entire infrastructure and
22:35
research
22:36
and information systems to be able to benefit
22:40
these hospitals.
22:41
And some of it may be
22:43
providing some of the services, but some of
22:45
it may be just organizing and collaborating with
22:47
other health systems and health partners that we
22:49
work with in trying to bring them from
22:51
the room. Right? Because even with that, we
22:53
don't do everything internally. There's tons of things
22:56
that we don't do, but we work with
22:58
tons of partners that we know provide high
22:59
quality services,
23:01
and we can integrate them in QB, all
23:03
of that for them. Right? And so
23:05
I think this is really
23:07
how
23:08
we go around changing
23:09
the this conversation and adding value to health
23:12
systems where they need it.
23:14
Absolutely. Doctor Tai, thank you again for taking
23:16
some time for us. It's great to have
23:18
you as always. Appreciate it, Lucas. Thank you.
23:21
We also want to thank our podcast, MonsterSite
23:23
Plus. You can tune into more podcasts from
23:24
Beckers Healthcare by visiting our podcast page at
23:27
beckershospitalreview.com.