Latest / The Mental Health Evolution / Ep 3: Strategy, Not Panic with Jeremy Zug

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Ep 3: Strategy, Not Panic with Jeremy Zug · The Mental Health Evolution

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(Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick Podcast Network.
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Learn more at ListenFrederick.com.
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Welcome to Mental Health Evolution, a podcast about what's changing in mental
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health and why it matters.
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I'm your host, Rachel Harrison, inviting you into honest conversations with
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people from all perspectives in the field, clinicians, tech founders,
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investors, insurance companies, and all the folks in between.
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Let's explore what's working, what's not, and what's next.
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All right, well, welcome back everyone to the Mental Health Evolution podcast,
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where we are talking about how the landscape is quickly evolving in
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the mental 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, we dove right into talking
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about the trends in our industry and what he's seeing from his
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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% 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, so that was already happening.
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But in this article, they are discussing merging Alma and Headway.
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Most people have heard of Alma and Headway 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 Headway.
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That brings up all kinds of questions about who's covered, what are
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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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Thank you.
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Wonderful.
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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 like, 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, you probably up until this point,
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you 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.
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You know, oftentimes providers come in to these big MSOs, they try
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it for a little bit and they think that the guarantees that
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were sold to them are sort of the golden goose of private
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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.
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And then they decide that doing the uphill work of starting a
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private practice is really what they want to 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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Those big MSOs- Can you define MSO just for people that
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are maybe not familiar?
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What MSO is?
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Yeah.
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Yeah, 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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It's a great clarification, Rachel, thanks.
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Yeah.
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There's a lot of acronyms floating around the building.
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I know.
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I know.
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I gotta be a little slower.
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It's all like everyday talkers to you, right?
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It's just everyday conversation for you, but not necessarily for listeners.
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Yeah.
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During COVID, those organizations had a lot of sway, because all of
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a sudden they had this new, they had tens of thousands of
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new therapists that 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 or are you talking both?
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Both.
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Okay.
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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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right?
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Versus like 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, right?
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Like Optum and insurance companies at large buy practices all the time,
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right?
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Like they could approach your practice and say, Rachel, we want to
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buy your practice and they could offer you some kind of deal.
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Like I have a friend who has a friend whose practice owner
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sold to Optum because of this exact kind of swirly deal that
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they 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, right?
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And no judgment, right?
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I don't own a practice and I don't know the pressures that
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that particular practice owner was facing and a huge range of reasons
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why you'd want to do that.
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But practice owners are going to get approached by insurance companies, right?
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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, they know the game board, and they're able
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to make the best decision they can, even if it feels a
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little bit like attrition, right?
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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, right?
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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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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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It takes longer to get credentialed than say an Alma or Hedway.
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Like there are all these sort of ways that they are maybe
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reducing 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 because our healthcare system
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is like broken pieces of ice floating 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 got to think, right, if you're not going to
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make a panic decision, which I don't recommend, don't make a panic
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decision, go, okay, they're going to offer me half.
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Let's say just for round numbers sake, that that's 50 bucks a
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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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And because you're not going to find the same therapist, right, somewhere
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else.
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It's not like, um, I don't know, another medical specialist, it's not
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like a pharmacist who can just do it.
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You know, it's very relational rapport matters.
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So what I would say is leave the network, right?
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Maybe charge five bucks more than what they were going to offer
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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, 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, that part
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of 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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Like what do you see on the horizon?
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Yeah.
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So I have a couple, 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 more brighter pieces of
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news or trends that I'm seeing is a commit, a renewed commitment
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from insurance companies 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's also, and this is kind of the interesting conversation that
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you and I can have about this process, but prior authorization is
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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 at a $500 million state
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budget deficit because of all these bad actors.
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And so you have to balance this system wide chain.
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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 or renewed one looks like, because
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with it as it exists today, you prevent care from people that
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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 got to get off like either or and find a new
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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.
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This is currently happening, but insurance companies are not giving the same
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rates to big therapy because they're not adding net 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 like 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
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to look like, right?
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We think 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.
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Well, yeah.
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And then in the industry, you have clinics, practices that are all
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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
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would think, as well, and maybe even self-pay.
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For sure.
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So like Centene is a really large publicly traded company that all
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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.
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And then UnitedHealthcare also has quite a few Medicaid members.
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And so, you know, the folks running those companies, again, are pretty
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smart and 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 the 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, like just starting.
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What would be your move?
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Well, I've definitely recommended to some people who are starting out in
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like solo practice not to go with any of these MSOs because
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I think it's a gamble, right?
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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
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want control over for the long haul.
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So it's sometimes a hard sell, though, because they look at me
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and they go, yeah, but they these people are going to do
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my credentialing and do my billing for me and all that.
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And I'm like, OK, I mean, do you?
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But if you're asking me my opinion, I would say steer clear
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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 venture capitalists are
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investing in these companies, right, they're at the market grab part of
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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.
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You do all these things with all this money.
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We can get all these providers, right.
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But at some point, the payback has to happen.
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And that's where I think all of these changes are going to
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come is like, OK, we can ride this wave of you're getting
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more than you would if you were paneled individually.
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And what's going to happen when they reduce that?
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And maybe there's something in there.
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Reach a contract really well to make right.
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Make sure you can actually get credentialed independently.
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And then how long is that going to take?
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And then do you have patience in the meantime?
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Right.
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There are all these risky things when you're not the one that
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sort of owns those processes.
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So that's part of what I see as well.
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For sure.
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And I would highlight a bright spot in the M&A world
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like it's not all there's only like from what I've been able
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to meet in this community, there's only one good one.
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Like Fireside Strategic.
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I don't know if you've heard of them.
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I haven't.
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But they're looking at like, how do we do this M&A
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thing so that the clinicians benefit?
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Right.
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That's like their mission.
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But they won't buy a practice that's within those big MSO companies.
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Right.
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And it's not yours.
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I like exactly what you're saying.
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And so you look at that, too.
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And you look at a Fireside Strategic, who I think is actually
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going to be a very good actor in this, like a good
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influence in this space.
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But it's not your practice if you're part of those big MSOs.
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So 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.
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Sure does.
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For sure.
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Yeah.
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Yeah.
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So I'd love to sort of talk about another piece on the
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side here, but it has to do with payers.
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I'm hearing all of this talk about value-based care and insurance
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companies requiring that of behavioral health and mental health providers.
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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
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practices and for medical providers.
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So I'm curious some of what you're seeing there, because you work
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with practices all over the country.
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So how much value-based care are you seeing being implemented?
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How much is not?
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What are you noticing?
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Yeah.
18:48
So yeah, value-based care is here.
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It has been much slower to roll out in the mental health
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space.
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But when you look at the MACRA and MIPS program within Medicare
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and even for behavioral health providers within facilities have to report
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certain data measures that influence the reimbursement rate.
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There's already a template for this.
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The debate in the insurance companies is whether it's value-based care
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or whether it's value informed care.
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And there's a big difference here.
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Value-based care is these are your outcomes and your reimbursement follows
19:23
how much value you provide.
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Right.
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So on paper, that makes sense.
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Value informed care says that the outcome measures for the treatment you
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provide are a factor of the reimbursement.
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Now that matters in real life.
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So like I live in Detroit.
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There are some pretty wealthy suburbs around Detroit.
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And then there is there are some pretty poor areas in Detroit.
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Let's say, Rachel, you were practicing in a fancy suburb and I'm
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practicing in downtown southwest Detroit, for example.
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There are some like much bigger factors than just the care that
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are provided that influence the outcome of that care.
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Right.
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Value-based care says the better grade you get, the more reimbursement
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you receive.
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But you never had an essay, leave your office and then go
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live its life somewhere and then have that impact your reimbursement.
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And that's the trouble in mental and behavioral health care is you
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can be a very talented clinician, but you're dealing with people that
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make decisions.
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Right.
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Like contrast that to like a medical provider with, let's say, a
20:28
population of folks that have diabetes.
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Right.
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You can throw those folks on a medication, almost very little lifestyle
20:35
change, and you're going to get better outcomes.
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You can't do that in the mental and behavioral health world.
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So the question has always become for like Kaiser and Optum, to
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what extent are we measuring the outcomes and how much are we
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weighting those outcomes?
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Medicare rolled out MACRA and MIPS.
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They're going to continue with that program.
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And you're going to continue to see payers play around and experiment
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with this idea.
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But it's eminently complicated in mental health care, given like geography,
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socioeconomic status, diet.
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There's like a million variables, right, that impact the outcome of treatment.
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And so insurance companies are aware of that and they're trying to
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solve for that.
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That's kind of in my hunch about why it hasn't rolled out
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yet is like, what are we actually using to measure?
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What are we measuring?
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How do we know that that's a fair measure?
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All the things that you're saying.
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Yeah, that's right.
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And if you are in a poorer geography versus a wealthier geography,
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your outcomes will be different.
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And so do you want to penalize the clinicians that are in
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a poorer demographic?
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No, you don't.
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Because you want providers there.
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And if you punish them for where they are, they won't be
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there.
21:47
So you have to figure that out.
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And the network has federal responsibility, according to the quality
21:52
associations, to provide access to care.
21:55
So that's not in their interest to do that either.
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So they're going to figure out a better system there.
22:00
That makes sense.
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That's a good one, I think.
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I appreciate that perspective.
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So I'm curious about your business in particular.
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How is all of this impacting you?
22:10
What do you see as changes for you or maybe changes in
22:13
services that you're offering?
22:15
What's the outlook?
22:16
Yeah, we're pretty optimistic in the independent private practice world.
22:21
I think therapists are pretty smart.
22:24
I think they are independent.
22:26
They represent a group of people that I greatly enjoy, because of
22:30
the qualities that they carry.
22:32
For Practice Solutions, we only exist to empower providers to focus on
22:38
their patient care by relieving the burden of billing.
22:42
And part of how we do that is we educate a lot.
22:45
And so we do this kind of thing.
22:47
We're launching our learning hub in 15 days, where if you're a
22:52
new clinician, and you have no clue what we're talking about, you
22:56
can get our playbook, right?
22:58
All of our downloadable tools and resources there within the learning hub.
23:02
We published a book, Insurance Billing Basics.
23:05
Our podcast is coming out this fall as well.
23:08
So all of those resources, we want to educate providers on how
23:12
to make the best decisions for their practice.
23:15
We also offer like done for you billing.
23:18
I don't think...
23:19
It would be shocking to me, Rachel, if private insurance in our
23:23
country went away overnight.
23:24
That would be like, that would be a wild shift.
23:27
That would be wild.
23:28
It would definitely simplify our work.
23:32
So there's always going to be an element of outsourced, like we're
23:36
a US-based company, all of our billers are here in the
23:39
US, and we serve independent practices that way.
23:42
But if you're a big group, we also help build out billing
23:46
departments nationally.
23:48
So between all three of those, we really enjoy the work that
23:52
we're doing.
23:52
And we're kind of used to these changes, right?
23:54
I feel like last year was change healthcare getting hacked.
23:58
So that was real exciting.
24:00
This year was Tricare West not paying a cent, Carillon.
24:04
So these are like normal changes that our leadership team sits down
24:08
and we plan for as well.
24:10
So we're right there with practice owners and thinking through, okay, well,
24:14
like, what's the next thing?
24:15
Like, how do we help empower more practices to enter the marketplace?
24:20
Yeah.
24:20
Because that's where I think the best care happens, ultimately.
24:23
I love that.
24:24
I love that.
24:25
We are about out of time and needing to wrap up, but
24:27
I have one more question for you.
24:29
If you could highlight just one critical piece of information for people
24:33
to know, maybe practice owners, maybe people that are seeking care, just
24:38
in general, what would that piece of information be?
24:41
Oh, that's a good question.
24:42
There's so many.
24:43
The one I would say is ask for more, like negotiate higher
24:47
rates, demand better from the insurance companies for sure, build good
24:53
relationships there.
24:55
I think there's more available than providers in private practice think there
24:59
is.
24:59
And so the care you provide is worth it.
25:02
I know sometimes that's a struggle for especially new therapists in the
25:05
market, but the care you provide is eminently valuable.
25:09
And so if you're not getting that value out of a partner,
25:12
they're the wrong partner.
25:14
So find a new one.
25:16
But yeah, ask for more.
25:18
I love that.
25:18
That's great.
25:19
Well, I want to thank you so much for your thoughts.
25:23
Definitely gave us a lot to consider and think about, Jeremy.
25:26
So thanks for being here.
25:27
And thanks for the work that you do.
25:29
Definitely.
25:29
Oh, thank you.
25:30
Yeah, it was a pleasure.
25:31
Thanks so much, Rachel.
25:32
Yeah.
25:33
Everyone else, we will see you back for a new episode to
25:36
talk more about the changes in the mental health industry.
25:39
Bye for now.
25:42
Thanks for listening to the Mental Health Evolution podcast.
25:46
Join the conversation.
25:47
Find us on socials, send us your thoughts, and tell us what
25:50
you're seeing in your corner of the mental health world.
25:53
Until next time, stay curious and keep evolving.
25:59
Live radio, local podcasts, the Frederick Podcast Network at listenfrederick
26:03
.com.