An Introduction into Behavioral Health and Primary Care Integration
October 28, 2022
While behavioral and physical health are deeply linked, our siloed and fragmented health care system does not treat them in a coordinated and holistic way. These gaps lead to avoidable delays in diagnosis and care for patients, exacerbating the current crises of suicide, overdose, and behavioral health morbidity. To that end, the continuum of “integration” holds promise as a way to promote team-based care that meets patients’ mental health, substance use, and other medical needs. This briefing highlighted how behavioral health and primary care integration can help improve the overall health and well-being of individuals, as well as explored the opportunities and challenges in policy and practice. Panelists also discussed potential federal policy levers for better enabling integration.
Speakers:
- Amy Bassano, M.A., Managing Director, Medicare, Health Management Associates (HMA)
- Parinda Khatri, Ph.D., Chief Executive Officer, Cherokee Health Systems
- Harold Pincus, M.D., Vice Chair, Department of Psychiatry, Columbia University College of Physicians and Surgeons
- Reginald D. Williams, II, Vice President, International Health Policy and Practice Innovations, Commonwealth Fund (moderator)
This event was made possible with support from the Commonwealth Fund.
Presentation: An Introduction into Behavioral Health and Primary Care Integration
Event Resources
Key Resources
(listed chronologically, beginning with the most recent)
“What Is Integrated Behavioral Health Care (IBHC)?” Agency for Healthcare Research and Quality, The Academy: Integrating Behavioral Health & Primary Care. September 29, 2022. Available here.
“What Policymakers Can Do to Address Our Behavioral Health Crisis.” Counts, N., Nuzum, R. Commonwealth Fund. September 21, 2022. Available here.
“Primary Care-Mental Health Integration (PC-MHI).” U.S. Department of Veteran’s Affairs. September 19, 2022. Available here.
“HHS Roadmap for Behavioral Health Integration.” Bagalman, E., Dey, J., Jacobus-Kantor, L., et al. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. September 16, 2022. Available here.
“Integrating Primary Care and Behavioral Health to Address the Behavioral Health Crisis.” Horstman, C., Federman, S., Williams, R. Commonwealth Fund. September 15, 2022. Available here.
“Parinda Khatri, PhD, on the Use of Technology in Behavioral Health Integration.” Khatri, P. American Medical Association. May 26, 2022. Available here.
“Testimony: Ensuring Access to Behavioral Health Care — Making Integrated Care a Reality.” Williams, R. Commonwealth Fund. March 30, 2022. Available here.
“Primary and Behavioral Health Care Integration Program: Impacts on Health Care Utilization, Cost, and Quality.” Breslau, J., Sorbero, M., Kusuke, D., et al. RAND Corporation. 2019. Available here.
Additional Resources
(listed chronologically, beginning with the most recent)
“Primary Care Behavioral Health Model.” Rural Health Information Hub. September 29, 2022. Available here.
“WHO Guide for Integration of Perinatal Mental Health in Maternal and Child Health Services.” World Health Organization. September 19, 2022. Available here.
“Encouraging Health Information Technology Adoption in Behavioral Health: Recommendations for Action.” Medicaid and CHIP Payment and Access Commission. June 2022. Available here.
“Industry Voices—How the Pharmaceutical Industry Can Turn the Tide on Mental Health.” Pisano, R. Fierce Healthcare. May 13, 2022. Available here.
“Integrated Care’s New Protagonist: The Expanding Role of Digital Health.” Steele Gray, C. International Journal of Integrated Care. October 13, 2021. Available here.
“Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program (MDRBD).” Health Resources and Services Administration, Maternal and Child Health Division. October 2021. Available here.
“America’s Mental Health and Substance Use Crisis Requires Integrated Care.” Donnellan, J. Bipartisan Policy Center. March 31, 2021. Available here.
“Examples from the Field: Regional Networks of Behavioral Health Improving Access to Care.” American Hospital Association. 2021. Available here.
“How Practices Can Advance the Implementation of Integrated Care in the COVID-19 Era.” Docherty, M., Spaeth-Rublee, B., Scharf, D., et al. Commonwealth Fund. November 17, 2020. Available here.
“Connecting the Dots: A Full Health Approach to Integrated Care.” Nelson, V. Blue Cross Blue Shield Association. July 2020. Available here.
“Rethinking Workforce Planning for Integrated Care: Using Scenario Analysis to Facilitate Policy Development.” Rees, G., Crampton, P., Gauld, R., et al. Biomed Central Health Services Research. May 15, 2020. Available here.
“Learn More about the Collaborative Care Model.” American Psychiatric Association. April 25, 2019. Available here.
“Market Insights: Behavioral Health Integration.” American Hospital Association Center for Health Innovation. 2019. Available here.
“The Role of Integrated Primary Care in Increasing Access to Effective Psychotherapies in the Veterans Health Administration.” Possemato, K., Shepardson, R., Funderburk, J. Focus: The Journal of Lifelong Learning in Psychiatry. October 19, 2018. Available here.
“Integration of Pediatric Behavioral Health Services in Primary Care: Improving Access and Outcomes with Collaborative Care.” Campo, J., Geist, R., Kolko, D. Canadian Journal of Psychiatry. July 2018. Available here.
Experts
Speakers
Amy Bassano, M.A.
Health Management Associates, Managing Director, Medicare
abassano@healthmanagement.com
Parinda Khatri, M.D.
Cherokee Health Systems, Chief Executive Officer
parinda.khatri@cherokeehealth.com
Harold Alan Pincus, M.D.
Columbia University, Professor in the Department of Psychiatry
pincush@nyspi.columbia.edu
Reginald D. Williams II (moderator)
Commonwealth Fund, Vice President, International Health Policy and Practice Innovations
rw@cmwf.org
Experts and Analysts
Alexander Blount, Ed.D.
Integrated Primary Care, Inc., President
ABlountEdD@gmail.com
Henry Chung, M.D.
Albert Einstein College of Medicine, Professor of Psychiatry
hchung@montefiore.org
Michele Gilbert, MPH
Bipartisan Policy Center, Senior Policy Analyst
mgilbert@bipartisanpolicy.org
Larry McNeely II, MPA
Primary Care Collaborative, Director of Policy
lmcneely@thepcc.org
Anna Ratzliff, MD, Ph.D.
University of Washington, Professor, Department of Psychiatry and Behavioral Sciences
annar22@uw.edu
Government
Erin Bagalman, MSW
U.S. Department of Health and Human Services, Director, Division of Behavioral Health Policy
Erin.Bagalman@hhs.gov
Stakeholders
Matt Eyles, M.S.
America’s Health Insurance Plans, President and Chief Executive Officer
meyles@ahip.org
Rebekah Falkner, MSW
National Academy for State Health Policy, Senior Policy Associate, Behavioral Health, Aging, and Disability
Rfalkner@nashp.org
Eliot Fishman, Ph.D.
Families USA, Senior Director of Health Policy
EFishman@familiesusa.org
Karen W. Linkins, Ph.D.
Integrated Behavioral Health Partners, Project Director
karen@desertvistaconsulting.com
Sandra Wilkness, Ph.D.
National Academy for State Health Policy, Senior Director, Population and Public Health
Swilkness@nashp.org
Transcript
This is an unedited transcript.
0:04
Hello, everyone. Thank you for joining today’s briefing, An Introduction and to Behavioral Health and Primary Care Integration.
0:11
I am Bailey well-being Government Affairs Associate at the Alliance for Health Policy.
0:16
For those who are not familiar with the Alliance, Wacom, we are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.
0:27
Today’s briefing is generously supported by the Commonwealth Fund.
0:32
Additionally, you can join today’s conversation on Twitter, using the hashtag all healthwise, and are in our community at all Health policy, as well as on Facebook and LinkedIn.
0:45
For today’s panel, we have a Q and A section at the end of the hour, and we want you all to be active participants.
0:52
Please get your questions ready, you should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark.
1:00
You can see, you can use that speech bubble icon to submit questions you have for the panelists at anytime.
1:06
We will collect these and address them during the broadcast.
1:09
Throughout the webinar, you can also chat about any technical issues you may be experiencing, and someone will attempt to help.
1:17
Now, I’m excited to introduce Reggie Williams, our moderator for today’s event, Ready, Join the Commonwealth Fund in 20 20 as a vice president of the International Policy and Practice Innovation Program.
1:30
In this role, he is responsible for fostering international dialog, Exchange, and Education that enabled US policymakers and healthcare leaders to learn from cross national experiences.
1:42
He is responsible for the organizations, International Benchmarking Activities, international research, and policy analysis, and the educational exchanges they conduct with key international partners.
1:53
Reggie, we’re so excited to have you here with us today and to hear some opening remarks from you. And with that, I will turn it over to you.
2:04
Thank you. Greetings and a special thank you to the Alliance for organizing this wonderful event.
2:11
As you said, I’m Roger Williams and I lead the International program at the Commonwealth Fund.
2:15
I also code the funds to work on behavioral health.
2:19
For over 10 years, I volunteer my time in the mental health community, serving on boards of several international mental health non-profits, whether it’s been for work or for fun.
2:31
Improving the systems that people want families must navigate to achieve them To achieve the lives they want to live has been an important part of my life.
2:40
I’m here today not only of someone who spent more than 20 years on health policy but also as a black man who strives to manage his own.
2:48
As you all know, there is a behavioral health crisis in the United States.
2:53
You can just look the headlines, ruby, music, also to our friends, parents, children, our co-workers, the crisis is nationwide without regard for political affiliation, class, or education.
3:08
That’s particularly acute for economically disadvantaged and historically excluded communities at the core of this crisis.
3:18
There have been incredible strides with the passage of the Affordable Care Act, but also more recently with the bipartisan, safer communities, which includes policy to support community mental health, particularly for children and adolescents.
3:33
This is an important step of the work that we’re forming the nation’s behavioral health system as far from home.
3:40
And as we all know, the stakes couldn’t be higher.
3:44
The problem is big and complex, however, I believe we have the tools to make meaningful change in people’s lives.
3:51
We, at the Commonwealth Fund, believe there are three things we can do to expand access to equitable behavioral health services.
3:59
First, is Integrate primary care and behavioral health.
4:03
Second, strengthen and diversify the behavioral health workforce, including peers.
4:10
three, leverage the power and influence of Medicaid and Medicare join us today for an Introduction to Behavioral Health and Primary Care Integration.
4:24
I’d like to introduce the audience for today’s panelists, their full bios, their materials.
4:30
But, first, we will start with Harold Pincus who is a leader in psychiatry from Columbia University.
4:40
Then we’ll hear about on the ground experiences from around the country who was the Chief Executive, Sharkey helps us, whoa!
4:51
Have a third portion of our discussion with Amy …, a former Medicare official, and now leader, and working with many organizations, trying to transform the way care is delivered.
5:06
So join me in welcoming harrell, or in the image of this discussion.
5:13
Carol, let me pass the microphone to you to start us off today.
5:17
OK, I’m delighted to be here. Thank you Reggie.
5:22
And so, what I’m going to be speaking about is sort of giving a kind of overview and definition and context to the issues around integration of behavioral health into primary care and really general medical care more broadly.
5:36
So, if I could have the next slide, please?
5:42
So, this is basically the focus of it.
5:44
And I think one of the issues that we find is that, you know, there is this kind of duality that is a kind of a theme for across all of issues around behavioral health, which is, to what extent does it get ignored?
5:58
Versus, to what extent if, does it actually get empowered and placed in the mainstream of general health care, but doesn’t drowned, but actually survives and naturally thrives when put into the mainstream of general health care? So, next slide, please.
6:18
So these are the key issues that I’m going to be talking about and Why is it important?
6:23
What exactly does integrated care mean?
6:26
What are some of the barriers that are being faced in terms of silo ISM fragmentation, duality and dualism and stigma.
6:37
And then what are some of the policies that might help to break down some of these silos? And then talk a bit about some of the key challenges.
6:46
So next, please.
6:49
So I think the importance of the interface is made clear when one looks at the data around global disease burden and cost. But it goes beyond that.
6:57
So, depression, If you look at the World Health Organization’s list of global causes of disease burden, depression turns out to be number two globally. And actually, if you look at just disability, behavioral health conditions actually turn out to be four out of the top five disability sources.
7:15
If you’re looking at just a cos on average individuals who have a general medical condition.
7:23
But also have a behavioral health comorbidity have about 50% higher costs in terms of health care costs.
7:30
But think about it from the point of view of individual cases. So for example, think of a 35 year old man with schizophrenia diabetes, and tobacco dependence.
7:39
What you’ll see is that this individual can expect up to a significantly shorter lifespan of up to 25 years, and also significantly greater medical costs.
7:49
Another example to consider is a 25 year old HIV positive, female intravenous drug user who also has PTSD.
7:58
In this situation, you’re often going to find that the woman has frequent. Emergency department visits. Typically may not be fully adherent to their medications. And again, they’re likely to have increased medical costs.
8:12
And finally, they look at the older age group, 65 year old woman with diabetes, congestive heart failure and depression.
8:20
Here, you’re going to find somebody who often will be frequently hospitalized or re hospitalized, difficulties in self management and adherence, and likely being an early candidate for long term care.
8:34
So, to think about these things from both abroad, societal point of view, but also in terms of thinking about this from the point of view of individuals.
8:42
Next, please.
8:45
So, what exactly is behavioral health integration? And I think people tend to think of behavioral integration as being sort of in one direction.
8:53
Obviously, the most obvious issue is How do we deal with pay with patients who are seen primarily in the general medical sector, including primary care and other areas of general medicine who have comorbid behavioral health conditions, typically mild to moderate depression or anxiety?
9:12
In many cases, these individuals are not typically recognized in a systematic way, and oftentimes, they are treated as acute problems, little follow up and often fall through the cracks.
9:25
But we also need to think about integration in the opposite direction.
9:29
That is, How do we make sure that people with severe behavioral health conditions, people with serious mental illnesses, like schizophrenia, bipolar disorder, various addictions who are treated primarily in behavioral health specialty settings?
9:44
How did they get their general health care, their primary care, their preventive care, their chronic disease care, by and large, that, because of stigma, the other reasons, they often have difficulty and also poverty. They also have difficult access, accessing treatment for their comorbid medical conditions.
10:01
They often don’t get good preventive and wellness care.
10:04
They don’t get immunizations, they don’t get cancer screenings. They also, their condition often puts them in a situation of having poor self care taking medications that might worsen their met, general medical conditions, and we may want to think about in some ways, people with severe mental illnesses as kind of a disparities category.
10:25
The other kind of thing that people often forget about when they talk about behavioral health is that when we say behavioral health, we mean both mental health, treatment of mental health and substance use disorders, which often have their own sort of separate institutions, clinical organizations, and policy directors.
10:47
The other thing is, you know, are we thinking about just primary care, but aren’t we talking about other forms of specialty care, both medical sub specialties, but also different types of programs, whether it be palliative care pace programs, other types of innovations that are being developed in terms of new healthcare organizations.
11:09
Next, please.
11:12
So thank you.
11:14
From a long term, actually going back centuries, there have been a number of major barriers. Number one is going back to Hippocrates and Descartes. we’ve had this mind body dualism that really thinks of mental health and general health care as being two entirely separate things.
11:32
Your mind and body are split.
11:34
In addition, there’s a great deal of stigma, both stigma directed towards individuals with behavioral health conditions but also self stigma.
11:42
And finally, there’s fragmentation. So think about these silos here.
11:47
And sort of agriculture is sort of that it’s sort of the industrialization of agriculture is kind of a good metaphor of thinking about general health care, mental health, and substance use, or being the separate silos.
12:00
But, actually, it goes beyond that next slide.
12:04
So, that there are these other silos, also, that have to do with often with either the settings where people are or the these social determinants of health that might include criminal justice, that might include for children, educational systems, for social service systems, et cetera. And so, there’s multiple silos on the horizon.
12:26
Next, please.
12:30
And what we really are looking for is sort of a kind of a family farm kind of model, where everything is together. We have a team, family working together to make sure that the work gets done properly in a co-ordinated and effective way.
12:46
Next, please.
12:49
So, there are a lot of barriers beyond the fragmentation, because one of the things that come up is like, well, who’s actually responsible for care in terms of looking at the role of the primary care provider and also the behavioral health specialists. When you think of this in terms of this, you know, rectangle, where do you slice it in terms of who’s responsible for what?
13:08
We haven’t really done that in a very clear way, either for individual patients often, but also on a societal and policy basis.
13:16
And so, these kinds of distinctions for determining who’s accountable for what needs to be clarified.
13:25
Next slide, please.
13:27
Number two, how are providers connected in terms of thinking about behavioral health specialists and general health providers?
13:35
In an ideal world, we do want this family farm is integrated team, but if you look across these different models of how providers are connected, most of the action right now is at the bottom of this slide, more or less parallel play, or sort of just complete, independent, connect without any connections, and that’s something that needs to be, uh, dealt with.
14:01
Next, please.
14:04
The other question comes up is Where where do you actually place this sort of integrated framework?
14:09
Um, do you embed a primary care provider into a behavioral health setting?
14:16
Do you put a behavioral behavioral health provider into a primary care setting?
14:20
Do you set them up as separate entities that have some formal agreement for collaboration and co-ordination, or do you really set it up as a truly unified team?
14:32
Next, please.
14:36
I’m or do you really set it up in the cloud?
14:38
And certainly with the with the kovac pandemic and the incredible growth of Telehealth services and the incredible growth of, um, tech startups in behavioral health and health care world more generally. These are options to consider.
14:57
Next, please.
14:59
Another issue is, when does care get provided?
15:03
When you think about the range of different points on the care continuum, where you might intervene, it can range from risk factor identification and prevention, too, an initial diagnosis and assessment to what’s done in short-term management.
15:17
And then most of these conditions that we’re talking about are not one shot guilds.
15:21
They actually are very similar to other chronic medical conditions, whether it be diabetes, arthritis, hypertension, and so there really is a continuing care longitudinal component to it.
15:33
Right now, most of the action is, is right around the middle because of diagnosis and assessment, and short-term management.
15:39
Very little is done at either end of those of the spectrum, and that needs to be reinforced.
15:46
Next, please.
15:50
So how do we do it?
15:51
So one of the things that’s really put been very helpful in thinking through the concepts for integrated care has been the chronic care model, which was really developed for thinking about all sorts of chronic conditions.
16:05
And to apply a systematic longitudinal measurement based approach to care, which means that we systematically apply appropriate clinical measures initially and over time.
16:17
And for example, just like hemoglobin A one C are for depression, PHQ nine, or for children the Andrew Built Assessment Scales And actually need to have a kind of a measurement toolkit that one can apply.
16:30
And then you’ll want to make sure that there’s consistent longitudinal assessment, which, in most cases means to make sure that people don’t fall through the cracks.
16:40
To have what I call ruthless follow up and also to in the context of foul up to also do care management to make sure that we properly engage the patients.
16:50
And then we’re not just measuring things for measurement sake.
16:53
We’re actually doing it because it’s good, based on the measures were going to be making decisions about how to intensify treatment to actually see if people are not getting better, how we can intensify treatment, using really a menu of evidence based care, so-called step care.
17:10
Now to do this you have to actually have some kind of infrastructure.
17:14
There’s practice space.
17:15
That’s supported with IT, and has established the kind of longitudinal registry, and it also means that there has to be clinical connectivity among all these systems.
17:24
And it’s not just mental health, substance abuse, primary care, but also thinking about linkage to social services, and for kids educational issues.
17:34
Next, please.
17:38
There’ve been a number of different frameworks that have been developed for how to think about and structure integrated care.
17:44
This is one that was developed by myself and Henry Chung from Montefiore Hospital that rather than giving organizations a kind of a number of how integrated they aren’t. They actually break it down.
17:56
two, what are the different components of integrated care?
17:59
And to think about sort of different levels for each of those components, so that it can be done in a way that offers opportunity for improving this structure, and improving quality over time.
18:11
Next, please.
18:15
So, what kind of policies do we need to actually make this work?
18:19
Probably the most important one is that is to really apply a shared accountability.
18:25
Which, you know, is, is, in some ways, a very simple context concept, I mean.
18:31
And it applies for all participants caring for, for a patient, This means both providers, their practices, but also health plans.
18:39
For example, if I I’m seeing a patient who has both schizophrenia and diabetes, I’m responsible not just for their outcomes for their schizophrenia, but also for their diabetes.
18:54
And and my colleague, who’s treating the diabetes is a primary care provider, or a diet batali just is also equally responsible for the outcomes for those schizophrenia and diabetes and diabetes.
19:08
And so, that means, in order, in order for us to actually do this, we have to work together, we have to actually talk to each other. And this applies in the same way to med surge health plan, and a BH behavioral health carve out.
19:21
And ultimately, we want to have this kind of concept instantiated in those training, practice contracts, performance incentives.
19:29
And, you know, and the biggest challenge is actually doing it so that it actually penetrates the culture.
19:36
Next, please.
19:40
So, one of the questions that comes up is, how do you actually make sure that there’s some accountability? What do you actually need to do in terms of accountability?
19:51
And, there’s a number of different ways that thinking about it. I mean, one is by regulation.
19:56
So, for example, enforcing parity of insurance benefits, there’s been greater attention paid to that more recently.
20:02
Um, the other thing is to actually apply quality metrics in some way.
20:07
one of the problems is we don’t have great quality metrics, and there needs to be a greater investment in developing them, testing them, but also we need to have incentives that are meaningful.
20:18
In many cases, we’re in a situation where it’s easier and cheaper to take the penalty rather than solve the problem, and that’s often the case with regard to addressing behavioral health conditions. Next slide, please.
20:33
So, there are a number of key challenges in doing this. one is, as I mentioned before, is changing cultures, both from the point of view of mind body dualism, but also in thinking about federal, state, and private roles.
20:45
You have to remember that for almost 200 years, treating behavioral health conditions was primarily almost exclusively a state responsibility.
20:54
And it was only with the advent, the President Kennedy and the Community Mental Health Centers Act that that was changed to put more to make more resources available at a community level.
21:05
And even then, it was very little in terms of direct supportive behavioral health care through insurance.
21:14
Number two, we have to establish some kind of shared accountability approach that takes into account the different types of resources that are needed to actually implement care accountability, shared accountability, um, but also to make sure we have, that kind of those kinds of measures.
21:31
So that means building a quality measurement infrastructure that requires both stewardship, pip, organizations, and leadership at federal level, and also the private level, to develop these measures and resources for developing these measures and test event.
21:47
We also need to develop sustainable payment models and incentives that allow for people to actually be incentivized to implement these kinds of things, because they’re not inexpensive to do.
21:58
Most of what we see is that, we are actually spending less than 5% overall on behavioral health care as a proportion of the, of the total cost of health care, and aye.
22:11
And so we need to think about how do we actually provide the resources necessary, not just to provide the resources budget to do it in a way that incentivize action.
22:20
It also means we have to do something about bridging some of the technology gaps, establishing the capacity to build registries, behavioral health providers that are not physicians.
22:33
And most behavioral health settings were left out of the high-tech Act.
22:38
They didn’t get the incentive payments for, for, for developing and using, um, no electronic health information systems. So they’ve had to develop, then, in some ways, sort of on their own, or it with not necessarily sort of mainstream types of ontologies and behavioral health informatics is way behind the rest of medicine.
23:02
Um, we also need to think about how we deal with social determinants of health, and the fact that the reality is that people with behavioral health conditions are much more likely to have these kinds of problems And these connections with social services, dealing with criminal justice issues, educational issues, and so on.
23:20
There’s also an expectation with some of the new payment models, that somehow, that the reason for putting behavioral health into the mix is that it’s going to save money.
23:30
It’s sort of interesting.
23:31
It’s if you actually look at the data, Yes, there’s some money saved, but there’s also some money spent to make sure people don’t fall through the cracks, and make sure they’re actually taking their medications are actually seeing there.
23:40
Providers.
23:42
And, and the risk is that if you make it the incentives dependent upon cost effectiveness, it may mean that people who are not necessarily going to be highly costly or not necessarily going to the hospital, make, It may get less attention.
24:00
In some ways, it’s almost a philosophical issue.
24:03
For example, we don’t really think about, well, we’re only going to provide support for lung cancer treatments in order to save money, but somehow that notion has entered into the discussion when we talk about behavioral health.
24:17
And finally, we clearly have a workforce crisis. We need to develop some new models for training and education.
24:23
We need to look at, you know, the roles of peers and community health workers and care managers in terms of how we can standardize and produce people who can do that. There’s a number of different the so-called interstitial workforce.
24:40
There’s a number of ways to do that that have been done in both in this country and also in other countries that need to be examined.
24:47
Next, please.
24:50
And so, just in closing, let me just say that we need to sort of get rid of this, the fundamental issue, which is thinking of these things as two different worlds and eliminate mind body dualism.
25:03
So, why don’t I stop there.
25:12
I would like to invite Katari to turn on our camera.
25:18
Heralding: OK.
25:29
OK, hello. Well, thank you very much, and thank you, doctor Pincus, for setting the stage. I’m delighted to speak with you all today about our journey as a comprehensive health care system and in Tennessee and our experience with integrated behavioral primary care.
25:49
Next slide, please.
25:53
So, part of what I would like to do is give an overview of our model of care and a little bit of information about what it’s like in the trenches and, you know, taking what doctor Pincus talked about. You know, We can certainly run resonate with many of those key points as as a Safety Net provider in East Tennessee.
26:18
Next slide, please.
26:22
So this is hello from the beautiful Smoky Mountains. Cherokee Health Systems is a Federally Qualified Health Center, a licensed community mental health center and a licensed alcohol and drug treatment facility.
26:38
We actually started out, as a community mental health center in rural Tennessee, in Hambling County, and what we found over the years, is that our patients were dying, and they were not dying of their behavioral health conditions, it was not suicide Or overdose, they were dying of physical health problems, and nobody, were, would see our patients.
27:07
They did not want patients with behavioral health conditions in their waiting rooms.
27:12
To be honest, in rural areas, if there were, the access to primary care, was already quite limited.
27:21
And so, we started branching out into providing primary care, medical services as just a way of helping our patients stay alive.
27:34
And what we noticed when we started opening up primary care and in embedding primary care in our community mental health sites is that the level of psychopathology that we were seeing in primary care was just as severe as what we were seeing in our traditional community mental health sites.
27:58
And what we recognized is there were a large numbers of people who had significant behavioral health concerns, who are not getting any care.
28:10
We thought we were meeting a need, but we really were not.
28:14
Then we noticed the same issues in areas when we opened up primary care, is there was no access to behavioral health for people. So since 19 84, we have been blending behavioral health and primary care.
28:30
It was an act of desperation. It was a way of providing the care that our patients needed. As a community health provider, we felt very responsible to our patients, and, to be honest, our patients showed us the way. This was not some top-down initiative. It was, This is what our patients need.
28:54
So, over the past 30, 40 years, this has become our model of care, that we do not open standalone behavioral health. We do not open standalone primary care.
29:06
We deliver comprehensive blended primary behavioral care. We also offer oral health dental health services and now we’ve added optometry.
29:17
So, what we’ve recognized is that there’s tremendous opportunity in the blending of these traditionally siloed areas.
29:26
Health equity is also a focus of ours. We are a safety net population and we say Safety Net Community Health System. So we serve people who have been historically marginalized, are at risk at risk and are vulnerable. And we have clinics in rural mountains of Tennessee bordering, Kentucky, Georgia, North, Carolina, Alabama. And then we also have sites in inner city areas. We have sites in Knoxville, Chattanooga, and Memphis.
30:03
And what we have noticed is the communities are incredibly diverse.
30:09
They have different needs, different expectations. And our job is really to be as sensitive and responsive, and our, our interventions need to be tailored.
30:19
So, when it comes to integration, what we have recognized as a safety net provider of diverse populations is that integrated care, integrating behavioral health and primary care is actually a wonderful way of addressing some of the health disparities, particularly when it comes to behavioral health access.
30:40
So there are certain populations for whom it’s just not traditionally accepted to seek behavioral health care. Doctor Pincus talked about stigma.
30:52
while in certain communities, the stigma is tremendous against obtaining behavioral health care.
31:00
And, in fact, in some of the populations we serve, particularly our refugee populations, they don’t even have words for depression.
31:09
We’ve got refugees’ New Americans from the Congo Please be … There’s no true traditional word for depression and anxiety. There.
31:20
Their distress is expressed in more physical conditions, so people would come present and to our clinics with horrific trauma, and they would just say, my elbow hurts. My neck hurts.
31:34
So we had to recognize that the behavioral health presentations and primary care were varied, and our teams had to be educated and sensitive and mindful in terms of how do we tailor our team and our intervention to meet the needs of the patients.
31:53
Outreach and engagement is absolutely critical for us.
31:57
Again, our goal as a community health provider is not just to meet the manifest demand, it is also to find the un presented need, and there is tremendous need.
32:12
So, we will send our care co-ordinators, community health workers there in the mountains there under bridges. They’re in the shelters. We have people in the schools.
32:22
But it’s very important for us to engage community members in their own healthcare, then certainly training and education, doctor Pincus talked about workforce. My goodness. That is a major priority I know for everyone coming out of the pandemic in healthcare.
32:40
Certainly for us from the very beginning, we recognized that our clinicians and and workforce they don’t just show up at our doorstep wanting to work with our safety net population. So we had to grow our own.
32:56
So we have every year about 115 trainees from medicine, nursing, psychology, clinical work, social work, and nutrition, among others, cycling through our system, and then finally, healthcare analytics.
33:15
We need better data, but we have to be good store good stewards of the resources we have, and that means getting the best data possible.
33:25
And our analytics, our healthcare analytics, have been useful, not just for helping outreach patients, identifying outcomes, managing care, you know, implementing step based care, and, you know, clinical decision making. But frankly, also, in our payer discussions and in payment, that moving to more advanced payment models has required that we step up our game in healthcare analytics.
33:53
So, in an in summary, you’ll see as we have kind strew strive to meet the need, we have grown. So we now are in 13 clinics. We at 13 counties. We have 23 clinics, we serve about 70,000 individuals in Tennessee.
34:12
Next slide, please.
34:16
So, if you can click, you’ll see the different bullets. You can click through the slides. You’ll see that our Health Care home, we call it a Behavioral Enhanced Health Care Home.
34:26
Hopefully, we don’t have to call it behavioral enhanced over time, that this will just be the natural way that care is provided, But a little bit about our model and that has really evolved in and transformed based on our population needs. And certainly, what the evidence suggests is, is more efficacious. But we have a behaviorist, typically a licensed psychologist, licensed clinical social worker, who is on the primary care team.
34:55
This is not just co located, their panel is the primary care teams panel. We have a consulting psychiatrist. The CHC is a community health co-ordinator, They will have functions of case management and care management.
35:10
And they are really just as part of the team. They are in the physical space. They are implementing this care based on the primary care model, not specialty mental health model.
35:24
So, with that, shared patient panel are care plans are shared. The health record is integrated, and, you know, this used to be, and I think, now, it’s much more accepted. But it really was very striking for people.
35:39
Historically, that our, everyone on our primary care team would be able to see our behavioral health notes, and vice versa, and I always responded, well, would you ever karbala notes having to do with the cardiovascular system? Would you ever say, well, anything with the cardiovascular system that is behind a glass wall? If you look at the literature and look at how behavioral health factors impact overall health?
36:07
The answer is no. You would never do that, because you need to note these things in order to provide good, overall primary care.
36:14
And then finally, I think what’s important to us as a community health center, is access, access, and collaboration At the point of care.
36:23
What we found is that, if we even tell someone to come back two days later, for a behavioral health appointment, 50% of the time, they will not come.
36:35
They will not come. And that is, you know, I believe the national average is a 50% no show rate.
36:42
Imagine if someone is in an incredible pain, and they need either an antibiotic or some other treatment and primary care. And we said, We’ve identified the problem, now come back in two weeks, and we’ll give you the treatment. So, our goal is to have a over 80 to 90% of our patients who present in primary care with the behavioral health concern, that at least, they have a touch point and are assessed by a behavioral health provider, at that point of care, often, in the exam room.
37:14
And because we are a licensed community mental health center, and an alcohol and drug treatment center, we do provide the continuum of specialty services. We’re very fortunate. So, in addition to having our behavior S and psychiatrists in embedded in primary care, we also offer a specialty mental health services.
37:37
So, we have traditional psychotherapy, clinical therapists, psychiatrists, case management, psychiatric nursing, day treatment, so all those trappings of a traditional community mental health center. So we are able to provide a continuum of care. And what it’s been very impactful for us is to recognize that not everybody needs the same thing all the time.
38:03
So we may have someone who gets access in primary care and once they meet with the behavioral health consultant and consulting psychiatrist, they recognize they need a more intensive level of care.
38:15
We can actually provide that they can transition to seeing a psychiatrist clinical therapist in our specialty mental health sector. And then once they’re stabilized, often not always, but often we actually can re absorb them in primary care. And that’s critical because we need to open up access for more specialty mental health patients. The the specialty mental health sector is overwhelmed. We could triple, I believe, the number of specialty mental health providers in this country, and we won’t have enough, so you can’t just keep sending people one way. There has to be some collaboration and support.
38:56
So when people are stabilized, if they are able to be managed in primary care, we can do that. And we can free up access. Next slide, please.
39:06
So in thinking through our points of influence and, and, you know, it’s easy to talk about barriers, because that’s what we’re, you know, what we have to live and breathe in and deal with every day. It’s also important to talk about facilitators and what what has been helping, what if it’s kind of been the wind in our back. And number one has been patient engagement and patient acceptance.
39:32
Patients will come to primary care.
39:35
They will present a number of issues, it makes absolute sense to them that those issues will be addressed, where they feel most comfortable, whether they’re going to mental health, asking for medical, medical needs, or coming to primary care.
39:49
So, what’s, what’s fascinating is, a lot of the resistance has come outside of the actual person who needs the support.
39:59
So, for us, we just had seen almost no resistance for our patients. This makes sense.
40:06
It’s very natural for them to get the care that they need, and that the fact, the fact that all the people involved in their care are talking with one another, they’re co-ordinating.
40:18
And, sometimes, like, in that moment, well, huddle.
40:21
And sometimes we’ll huddle both with the patient so the patient knows, OK, here’s what we need to do, and I don’t have to be the bird the person who’s responsible for bringing my bags of my pills or stacks of paper to try to connect those dots.
40:38
There has also been, I’m very happy and proud to say tremendous leadership.
40:43
We have strong support from leaders in the health care sector in terms of building integrated care and it’s that’s been very important because it’s so hard and when it’s this hard, you need people who will push through. So we are seeing just some stellar examples of leadership. We just need to scale it.
41:08
And certainly, at the federal and state level, we have had tremendous support from HRSA, HHS, and sansa, two build and kind of engage these models. So we, we don’t forget, as completely alone in this. Now, in the past 10 years, we’ve seen a surge in support, whereas, in the 19 eighties, when we were doing this, there was no support. There was no support at the state level. There was no support at the federal level. And it was just this crazy thing that our Center was doing.
41:43
And people didn’t know quite know what to do with us. So it’s actually been very nice the last 10, 15 years that what, what was a crazy idea?
41:54
I believe it was called our crazy hare brained scheme by somebody at the state.
42:00
And now, that is just considered, you know, this this is an aspirational model for most, for most sites.
42:07
And then, certainly, the evidence base is growing.
42:10
We know that if we can do this and adhere to certain critical elements, common elements that we can impact change, both at the individual level and at the population level.
42:22
And so, with that, we have this base of people who have formed a learning community.
42:28
You know, there are a number of organizations, and people are coming together, and because we’re relatively in the adolescent stage of blending behavioral health and primary care, people are teaching each other. We are learning as we go. But people are. People are reaching out and so what we’re seeing is networks of people at the grass roots level saying, Well, I’m struggling with this. How do you handle this? What are you doing? What this might, state doesn’t allow this?
42:58
And so when you have a learning community, I think over time, you are seeing this almost wave, and this wave of energy and power in terms of taking what’s happening in pockets across the country as exemplars and slowly seeing movement. So, it’s not just highlighting exemplars in pockets, but we’re seeing slow. It’s very slow but we’re seeing much more uptake every year. You know there’s a little bit more interest and we see more progress.
43:35
And then the barriers boy, there are a lot of barriers and I have to tell you we have many battle scars that there are countless stories that we can tell about struggles with workforce.
43:51
We have made progress, but we do not have a workforce who is prepared to collaborate with one another.
44:01
We are training people in silos, then they come out into the real world, and they find, whoa.
44:09
I’ve got, know, someone with a multitude of behavioral, physical, social, environmental factors that are driving their health and impacting their health, and I feel like I’m doing this all on my own.
44:26
Now, there are many more training programs that are building this, but, again, we need to take it to scale.
44:33
I think one of the most challenging parts of integrated care is the paradigm shift.
44:40
It’s not just geography, it’s not just saying, oh, I’m gonna check these boxes.
44:46
But, fundamentally, people providing care, have to shift their mindset on the kind of care they’re providing, their goal.
44:59
There are goals of providing the care, and even their belief systems about communication.
45:05
It’s really fascinating when we will even interview potential clinicians, that they will know, they will struggle with, well, why do I have to take that extra step and call somebody?
45:19
No, can I just send a referral and let it be? No, you can’t do that.
45:23
And then, certainly, we could talk ad nauseum about the reimbursement, financial challenges in primary care, behavioral health. Everybody’s time is squeezed, everybody’s money is tight. The fee for service payment model, frankly, has been very difficult to navigate.
45:44
And we’ve just had to, you know, be very creative and worked very hard in building relationships with payers to try different models to support our work financially. And then finally, regulatory restrictions are tremendous.
46:01
I have to tell you, I cannot believe there are still states where health centers cannot get paid or practices cannot get paid Or two different services, medical and behavioral on the same day.
46:16
if they cannot get paid to provide access at the point of primary care.
46:22
And you know certainly the way the billing is structured, we’ve made progress.
46:27
But you know until the pandemic when we beam a psychiatrist or a behavioral health consultant to a far away rural site that may be 2 to 3 hours away from our hub.
46:40
We couldn’t get paid as a federally qualified health center if they had Medicare. It was just it was not allowed and that’s the flexibility that was allowed during the pandemic. But that’s the opposite of what we want. So I’m hoping that there will continue to be disruption in the in the field. So, those of us who are on the ground, it will be just that much easier for us to do the right thing and provide the care care that our communities need.
47:07
Thank you.
47:13
Great, And I’d like to invite you to give your presentation.
47:20
Great. Thank you.
47:22
And the previous speakers really teed up a lot of the issues in terms of the challenges, whether it be workforce or pay means or technology, cultural issues that confront the, this topic. And so, I’m going to spend the next few minutes talking about some of the federal opportunities places where the federal government is taking on some of these challenges where they have not gone or where it could be doing more legislative issues. And then, I think was doctor Pincus, I mentioned the State issue. A lot of these do fall in the state, either was licensure or scope of practice other issues. And so, it really, ultimately, solutions need to be asked for federal and state.
48:09
But I’m going to focus on federal, for the most part. And so, next slide, please.
48:18
Let me next slide.
48:22
So, this is actually a very timely conversation we’re having here. Because at the end of last month, HHS, put out this roadmap for behavioral health integration. And I encourage everyone to take a look at it. I have some highlights here that I’ll walk through.
48:36
But there’s a lot more in there that outlines how HHS, all across all events, agencies are attempting to address this behavioral health integration issue. And so, they look at it from these, well, first, equity.
48:55
They have equity as a crosscutting issue, which is consistent with the administration’s priorities on trying to address health equity across the board.
49:04
And so that, that is important to remember. That’s the lens they are looking at through, through many of these things. And equity was mentioned earlier, as well, because there are no access issues and differences in racial, geographic variety of different metrics, and that we’re need to improve that. But these three categories of strengthening the system capacity. Connecting to care, and then creating healthy environments, and so the, there’s a variety of different policies that HHS has been leading on this and the first and there’s this Strengthens isn’t capacity. Is the 98 Suiciding crisis Lifeline that was implemented earlier this year. That’s something that SAMHSA has stood up and is going through. It’s, you know, early, relatively early, in its utilization. I think we’ve seen lots of reports about the utilization of wait times, but they’re working very hard to get that going, to have access to that services and help then.
50:07
point individuals to services in their community. Workforce issues are important, as we’re talking about, and so HRSA funds graduate medical education, and they have a number of primary care residency programs that include psychiatrist. So, that better integration of the care.
50:23
And, I think the point of it going both ways is something that these GMV slots are trying to address, because we hear so much about the clinicians. The physicians were never trained in these areas. And, you know, they get into their particular silos, They look into, you know, that in their culture of how they practice. And so, to sort of break that down at the training level is trying to address that as well.
50:49
Also, then, the their oversight and implementation of the certified community behavioral health clinic model.
50:57
Again, another way to think about this integration and to fund and incentivize that type of care.
51:05
Medicare Payment and I have a whole separate slide on Medicare payment but Medicare’s payment for behavioral health integration into primary care practices.
51:14
Medicare, as a leader, as a major payer across the country, you know, that they can really take the leadership in a number of those those payment issues. As I said, I’ll talk more about those. And, then the Office of National Health co-ordinator support on health information technologies to support the integration of behavioral health care into other settings That was mentioned earlier as well. This really is not a, there may be some technological issues, but it’s not really a technology problem.
51:44
It’s a policy problem of not supporting that integration, not having the policies in alignment to allow that to happen. So, ONC is working to try and clarify that and to make it easier for that integration to happen. Again, sort of taking the leadership there.
52:04
The Connecting to Care, or another way of thinking about increasing access to care. Medicare, recently put out a number of changes in the Physician Fee schedule, which is my next slide on to increase access to behavioral health practitioners. And so Medicare, having a whole behavioral health strategy that addresses integration, is really showing you some of this leadership.
52:25
And that how important this topic is, and really on the in the front of everyone’s mind, to think, as we’ve learned a lot of lessons from coven. You know, these issues have been around a long time. But there are things we can be doing, and should be doing to, to improve them.
52:42
Medicaid also has a big role here.
52:46
one of the things they point out is a recent Medicaid bulletin, her mind, sees that Medicaid state, Medicaid agencies about the EPSDT benefit Early and Periodic Screening Diagnostic and Treatment Benefit.
52:59
Meaning that behavioral health is part of that and should be integrated and that they have Medicaid programs, and there are practitioners working at have responsibilities to be fulfilling that statutory benefit. And you should be looking at behavioral health, as well as part of it.
53:17
Um, HRSA has pediatric mental health grants, which they knew to help increase access to the pediatric mental health care services. And then the Administration for Community Living, established the National Resource and Technical Assistance Center for People with Co-occurring Intellectual and Developmental Disabilities and Mental Health Disabilities.
53:39
So, again, another place to go that the federal government can help educate and support community providers who are trying to address these issues in there, communities and on the ground. And then, finally, the idea of creating healthy environments.
53:57
This is a little bit more research focused and guidelines focused.
54:04
So the National Institutes of Health has A A number of grants they have, or are set to study in research, mental emotional behavioral health, CDC has guidelines and research, also that What Works in school for, again, for children and adolescents. And then, HRSA has a Bright Futures program for guidelines to improve infants, Children, and adolescent health. And so, as I said at the beginning, there’s, there’s a pretty comprehensive document that outlines all the things that HHS is doing as this is a priority for them. And it really is multi-faceted from the payer, research, support workforce. All the things we’ve talked about so far. And so, next slide, please.
54:53
I do want to go a little bit further into Medicare payment issues because they are very illustrative many of the topics you can see been talking about here and how Medicare can really be a driving force on these payments and to ’em and for other payers to follow Medicare.
55:13
Medicare’s lead and so, this past year, the proposed rule that’s coming up for next year’s implementation. And we’re expecting a final rule early next week, November one. Is there a statutory deadline to get that?
55:25
But they had a whole suite of policies, many of which have been around for a long time and discussing. I.
55:32
Number of these, I, I’ve been working Medicare policy for more than 20 years, and I remember very early on, hearing about access to marriage and family therapists, trying to understand that issue, you know, two decades ago.
55:44
And so, these are having their moment today. And there’s always a new discussion of how the policy process. And when things become ripe and get there are moments in time.
55:52
But a number of policies that CMS as proposed is that allow payment to the clinical psychologists and clinical social workers for behavioral health integration on their own, Or as part of a primary care team that’s different, usually would have to be done underneath a physician. So, giving them some flexibility there.
56:14
This next one is technical sense, but it really is increasing this, these, these incident to rules, the technical Medicare payment Provision, but this flexibility, allowing, marriage, and family therapists, licensed professional counselors, Addiction counselors, and others provide these behavioral health services without the doctor or nurse practitioner. on-site means that they can, you know, providing telehealth running in other locations, you know, providing additional access.
56:43
And so, a really big change that I know has been considered for a long time in Medicare. Many people thought Medicare would never get to this now.
56:52
As I said, these are proposed, but I think they’ve been relatively well received, and, you know, we’ll see what CMS actually does do next week, But, um, there’s some big changes here: the Medicare Shared Savings Program, which is an Accountable Care organization.
57:08
They made a number of changes to sort of make investments to increase smaller ACOs, and you can use funds for these some of these investment funds for, to hire behavioral health practitioners, address social needs of people with Medicare, including food and housing. So, all the things, that sort of whole person care, we’ve been talking about. And just didn’t know here. Value based arrangements, in general, are supportive of many of these initiatives for integration. When you’re, you’re taking away those silos and those barriers.
57:41
And if an ACO, or a physician primary care practices accountable for the patient’s total cost of care, and a variety of quality measures across these domains, they will have be now incentivized to really think about how to incorporate the behavioral health incorporating due to think about the patients, the person’s behavioral health needs. Because if they can improve their care, they would be rewarded from those environments as opposed to a more traditional fee for service where there are silos And no real, no incentives to think across the spectrum of the individual’s needs.
58:16
And then, on the telehealth is this is something Congress has sort of taken on, but, you know, implementing the allow telehealth services in any geographic area, any originating site kootenay beneficiary’s home, and, especially, on an audio only basis. For behavioral health, we understand, you know, again, from Learning from coven, that the audio. one, being anywhere and not having to be in a rural area, not having to be a physician office, but be able to be in your home, and take, on some of the audio only, is really important.
58:46
for individuals to be engaged in their behavioral health, services counseling, and want to do it, and continue it.
58:54
Because it takes away some of the, you know, those barriers.
58:58
Then, finally, Congress is in this X to the Oh, sorry. Next slide, please.
59:07
And so, just a snapshot of what’s going on in Congress last month. The Ways and Means Committee approved a package of bills that look at this topic.
59:19
A number of changes to Medicare, the inpatient psychiatric payment system, additional outpatient services, and, again, here’s the marriage and family therapist and mental health counselor. This would allow them to be direct practitioners in the Medicare program. So, they wouldn’t even need any of those supervision requirements.
59:37
And so, for them to be able to practice independently, you’re always subject to state scope of practice. Is it is a major. Taking away a major barrier to many of these services And, as someone mentioned earlier, you know, we can, you know, we don’t have enough workforce.
59:53
We can double triple and still not have enough, but adding more trained practitioners here to logs Bill Medicare and then, so that was that passed the house, the ways and means.
1:00:04
Sorry, we have ways and means committee, and then the Senate Finance Committee also is working on a number of proposals. These publicly talk more about the use of telehealth in behavioral health.
1:00:16
But, as we expect, a relatively large Medicare package come the end of the year, too, mostly to address physician payment cuts that are scheduled to go into effect into the new year.
1:00:28
There is an expectation that a number of other provisions will get added in, and I believe, you know, behavioral health isn’t top of mind.
1:00:37
And Telehealth is top of mind as they look to make those changes, given the evidence to support the, had the success of those flexibility.
1:00:45
So, this is a very much a area of high interest and moving fast in terms of particular changes.
1:00:54
You know, we could be here, 2 or 3 months from now, and, you know, the environment may look a little bit different, but that is a snapshot of some of the efforts, and some of the barriers to getting the care, that Affect enlists exist on me Federal level.
1:01:08
And so, with that, I think I’m turning it back to our Reggie. So, thank you.
1:01:18
I would invite everyone panelists here to turn on your, your cameras and your microphones.
1:01:27
Thank you all, for such a robust discussion, of what it would mean to have better integration Harold from the history and literature.
1:01:41
Brenda, from the on the ground experience, Amy, from the policy landscape.
1:01:47
And so, just to come up, kick us off in the Q and A I want to ask each of you the same question.
1:01:54
Each of you mentioned workforce and technology.
1:01:58
As a part of your remarks, and I would like to ask you: What do you believe are the top 1 or two policy actions that can be taken to implement integration most effective?
1:02:14
Let’s start with.
1:02:18
So I think, a couple of things. So number one is actually recently, I gave a talk to CMS is for CMS Grand Rounds on the Top 10 Reasons Why value based Payment Doesn’t Work for Behavioral Health.
1:02:32
And there’s actually going to be a viewpoint coming out next week in JAMA psychiatry.
1:02:37
That’s a brief summary of that.
1:02:40
And I think that that part of it is to make value based payment actually work for behavioral health.
1:02:44
one thing that’s wonderful about value based payment is that it allows for flexibility.
1:02:49
That it’s not on a fee for service basis and people driven by price volume kind of incentives. On the other hand, we don’t really, at the present have great capacity to assure accountability.
1:03:02
We don’t have great behavioral health measures, quality measures.
1:03:06
Some of the reasons for that is that there’s nobody responsible for developing them really effectively.
1:03:11
There’s nobody really investing in that in a significant way.
1:03:14
But part of that is also has to do with some of the issues around technology and informatics and that, you know, there are no lab tests that you can track.
1:03:22
You know, there are tests and various measures, but that’s not captured in a similar way, and that has to be further developed in some way. There’s a number of programs that Amy mentioned, that you all have potential, but don’t they need to be, in some ways, fine tool to be able to make behavioral health Effective. For example, they certify community behavioral health centers.
1:03:45
I’ve been part of the evaluation for that, and they’re a great idea. But their level of accountability for integration is not that strong.
1:03:54
In terms of what’s expected of them, they’re primarily expected to screen and refer, but not necessarily assure certain outcomes.
1:04:01
And I think that those are the kinds of things that we need to sort of work on developing, so that, as some of these initiatives are put in place, that they actually have the capacity to show accountability.
1:04:12
And with regard to workforce, I think, you know, the, the value based payment programs with width, the flexibility, they allow for different forms of workforce application.
1:04:24
But we also need to think about, how do we develop the infrastructure for training people to do this stuff?
1:04:29
And there are programs in other countries. For example, in the UK, there’s the Improving Access to Psychological Therapies Program.
1:04:36
That has been remarkably successful, Integrated with the GP’s where they’ve developed a technology platform to both train, supervise, and monitor, and evaluate workers that are trained, you know, with really limited degrees, bachelor’s degrees in psychology.
1:04:55
And provide, you know, various forms of Cognitive Behavioral Therapy and other other evidence based therapies. So that there are models that we can develop and apply here.
1:05:07
Great. Thank you for that.
1:05:09
Doctor Carter.
1:05:14
Yes, so you know, this is why I like to use the term advanced payment versus value based payment, because exactly, we just don’t know.
1:05:25
Let’s just call it. We don’t know what the best way is.
1:05:28
We can say fee for service is not the best way, but I’ve moved more and more to talk about advanced payment. You know, let’s let’s be creative and think beyond it.
1:05:40
You know, if we’re not set up for value based for a number of reasons.
1:05:46
And the least Of which is, we don’t have even the data capabilities in terms of interoperability to be able to track the data the way we need to be successful in that. And I know we’ve tried that and we still have value based contracts. And it’s a lot of work just to reconcile the data.
1:06:06
So, the two things I would say, Number one is the lowest hanging fruit. Let’s just pick the lowest hanging fruit.
1:06:15
Lowest hanging fruit is allowing primary, you know, primary care, behavioral health service is to be billed on the same day.
1:06:24
It’s just, know, you’re it’s a huge disincentive. Just tell someone, come back tomorrow because then I can, I can get paid if I do tomorrow. So that’s the lowest. And that should be the standard right now. I know that it’s, it varies by state, but certainly, that should be the baseline across. So, that’s number one.
1:06:45
Number two, and this is a little bit self-serving, but, you know, and I believe, you know, Amy talked about this, that if you are a federally qualified health center, just let us do Telehealth to rural areas and get paid.
1:07:02
And, you know, we’re because we have sites in urban areas, We have sites and rural areas. It doesn’t make sense for us to pay for a psychiatrist, or a psychologist, or someone to travel there over mountains two hours there and back when we can have a telehealth unit in a small clinic in the mountains.
1:07:23
But, we’ve been doing that for many years, to consultant, to our small primary care, rural practices. We just haven’t gotten paid. We just absorb that cost. So, that those to me are the two lowest hanging fruits. It just makes sense, and let’s just let’s get those out of the way and then we can tackle the tougher challenges.
1:07:46
Yeah, I would say, say, when I hear that like the interoperability is not there, that, you know, in almost 20 23, we need, there’s no need to get to the place. And then, like I said, I don’t think it’s a, it’s not a technological issue. It’s a policy issue and a funding issue.
1:08:03
And so, solving that, I think, can go a long way.
1:08:07
And then from the workforce, there’s so many different issues there, but as a peanut person, I think, you know, looking at it from the payment, whether it be appropriate payments for telehealth, appropriate payments, for the variety of different practitioners who can deliver this. You don’t always need an MD or PHD to be doing this, and so, and also been thinking about what doctor … was saying in the community. People may, not saying that, that may not resonate with individuals seeking out this care, they want someone you know other communities. So, there’s a lot of different ways to expand the workforce into, recognizing, into, pay them for their services, and, you know, training and access to it. But then also thinking about, you know, such thought even at the psychiatrist level or psychologist level.
1:08:51
There’s such low participation in the Medicare and Medicaid programs for them, and sort of how to attract the, the workforce to these programs to, to provide care for, you know, the Medicare and Medicaid patients as well.
1:09:07
Yeah.
1:09:08
Part of the problem is exactly that, Amy, that, you know, that, you know, several years ago we showed that, you know, 65% of psychiatrists don’t take Medicaid.
1:09:17
And, you know, a lot, a huge portion of the clinically licensed behavioral health workforce is basically a cottage industry.
1:09:26
People working in, you know, out of solo offices.
1:09:30
No offices or homes or garages that they’ve converted.
1:09:34
Not taking insurance with very limited infrastructure to participate in some of these more complex programs. And I think and it’s not just, you know, psychiatrists. I mean, it’s a multiple behavioral health providers, you know, are, you know, have this sort of cottage industry type of operation?
1:09:51
And it may be that we’re also not, you know, part of the problem is that Medicare, Medicaid, and actually, actually, private insurance is not really paying market rates.
1:10:02
And that, I think, is part of the problem.
1:10:04
That, you know, that, that’s why, so, such a large proportion are simply not participating in insurance at all, and know that parity rules are not being fully enforced in terms of somebody’s sort of so-called phantom network, kind of things.
1:10:24
I mean, I will, I will.
1:10:27
I’ll just say, um, We have a team of 28 people who were tracking up payment, working denials, all the forms. And I have to tell you, I don’t, I can understand what people in private practice don’t want to spend their nights and weekends filling out forms for insurance companies. So it’s not an easy gig. We don’t make it easy.
1:10:54
For the uptake, there is a lot of bureaucracy. There are a lot of hoops.
1:10:58
And so, you know, whether this is a policy or legislative, and there’s gotta be some movement, if we want more people to take these payment payers to improve access. We have to make it easier, but I hate that as an org as a Safety Net organization. We have to do both so many resources that there are people. All they do is work denials.
1:11:25
All they do is do prior authorizations and, you know, sometimes we have prior authorizations. I’m not kidding. They are approved 100% of the time.
1:11:36
No, we do provide good, you know, stepped care 100% of the time and we still have to do all the paperwork.
1:11:44
So, no, those are some of the barriers that we just have to see addressed, because I, again, if we want to see uptake, we’re going to have to make it easier for people to do the work and get paid for it.
1:12:01
You know, Lisa, if we triple the workforce. We might not have enough.
1:12:06
Amy, you said that they can nearly 20 years to add some providers to being reimbursed as, uh, as part of some government programs.
1:12:18
So, when we think about this workforce, can you just talk a little bit more about the breadth of the workforce that we, we could have.
1:12:28
How technology and digital solutions could help support that?
1:12:32
You mentioned a program out of the UK, which really does provide a step wise approach to meeting people’s needs with the wide variety of different services.
1:12:42
Can we talk a little bit about how we can meet meet people’s needs with a broader workforce?
1:12:51
But I’d like to start.
1:12:53
Sure, Well, I think one thing is that we ought to think about actually having a formal program to actually develop different and test different models of workforce development to that, so that it’s really something that brings the data out, be open, to see what works and what doesn’t work. And I think that’s a formal kind of process to think about that.
1:13:14
And then build on some of these models that already exist. I mean, there are a number of, you know, so-called test shifting or test sharing kind of models that have been developed.
1:13:22
Some of which actually, yeah, investigators in the US have been doing in other, less developed countries, you know, in Africa, South America and so forth, that have been shown to be pretty effective.
1:13:38
You know, in terms of behavioral health, we have seen as a real surge in peer workers, peer support specialists, and that really came from the substance use treatment. You know, where we had patient recovery, peer recovery navigators, but in terms of tasks, task shifting, and high touch points. We have grown our peer program, and we have peer wellness coaches, you know, peer navigators, and they are supervised by a licensed behavioral health providers. And they get trained, so motivational interviewing, problem solving therapy, cognitive behavioral therapy. And when you have a team based approach, you’re not relying on one person. And they can, everyone becomes an extender of one another.
1:14:29
And so when we send our community health workers, they’re the ones who are, who will go into the apartments of people saying, I’ll tell you what’s in that.
1:14:38
And there refrigerator.
1:14:39
And this is why there, hemoglobin A one C is not under control, But they, then, because of the collaborations, when people, who then can work with them in terms of, what are the specific functions that they can provide? Whether it’s reinforcing behavioral activation, or reviewing certain cognitive structuring techniques, they can absolutely do that.
1:15:06
And I think it it, from a clinical quality perspective, we need to make sure that we have fidelity to the high quality interventions. But you can do that if you have layers of supervision, layers of support. And that way, we can actually have multiple touch points. Sometimes our peers are, I mean, they go to the emergency rooms, They’re touching base with our patients. Every day became a licensed person do that. You know, when we start a new medication, to have a behavioral health assistant calling every day, or calling every few days, saying, how are things going to questions?
1:15:41
And then if the need arises, then we can have that taken to. Or know, someone who is higher trained. And so part of it is our model of care has been one size fits all. We get the a team for everything and we really don’t and I don’t even know if our definition of the team is correct.
1:16:01
But we don’t need our highest trained specialty providers highest trained folks doing everything and that frankly that has saved us during the pandemic, our Behavioral Health assistance and peers say just during the pandemic.
1:16:16
Because we just did not have the bandwidth to only rely on our licensed clinical staff for the demand of behavioral health. That’s out there particularly now after the pandemic.
1:16:29
I think Brenda said it exactly right. Then it’s gotta be a team.
1:16:33
It works much better as a team.
1:16:35
By having a lot more independent, other providers scattered around, it’s going. in some ways, there’s a risk of even further fragmentation.
1:16:47
And I think setting these things up as a team, having some kind of organized way to think about the different roles and responsibilities. And ultimately accountabilities, really classifying the kind of tasks that are expected and how you can make sure that those things are being done at an appropriate level and getting the right outcomes. I think there has to be kind of an infrastructure to support that.
1:17:08
So that, and, and, and one part of the infrastructure is really establishing them as effective worker working teams.
1:17:18
I would just quickly, out of the fee for service system, was, did not set that up, it’s, you know, it’s one more person to bill. There’s no one knew everyone gets their full amount.
1:17:27
And so as we move away from whether it’s diabetes care, advanced care, whatever you wanna call it, like an environment that incentivizes more team based care and recognizing, you know, you don’t need to have a psychiatrist checking in every day for you 60 minute as your, there’s different ways to approach this and that you get paid for either outcomes or for the broader services that hopefully, will, you address some of these issues. Definitely, it’s gonna take awhile, and it’s going to lag behind.
1:17:55
But you can make making sure you have the capacity to keep people accountable, because I think that’s the issue is that, you know, it’s a great attraction, and it’s terrific to have the flexibility, but also to make sure that you’re getting the results.
1:18:14
Well, how do we start to translate the experience and evidence base that we have into those quality metrics?
1:18:23
I mean, it should be talked about payment, having more Matrixx, taking evidence based approaches.
1:18:33
Well, how can we really get to a place where are we have more effective quality measurement in this world?
1:18:43
What can be done to improve the development and the use of the quality?
1:18:52
Well, I can tell you I actually co-chair the National Quality Forum’s standing committee on mental health and substance use. And we don’t get a lot of quality measures that have new quality measures put forward.
1:19:06
It’s been really very limited in terms of, you know, we we reviewed them for endorsement and yeah, the bulk of them are coming from, either, on the one hand, you know, the whole, the whole quality measurement, industrial, complex.
1:19:22
It’s out there for developing, and, you know, and endorsing and using measures. And it’s complicated. It’s not a simple process to go through.
1:19:32
You know, there’s some places that take a big role in this.
1:19:34
Like, you know, NCQA and they have a number of different projects that they’re working on. In fact, actually, there’s, I think, next week, there’s a, they have this innovation summit, and they have a number of different project where they’re experimenting with different types of quality measures.
1:19:49
But there’s not any kind of program in outside of government, inside of government, that really is responsible for developing and funding and providing support for these kinds of quality measures, is I think that’s one of the problems that is note it, like, that’s not SAMHSA’s responsibility.
1:20:10
You know, NIMH has had very little involvement in this, you know, you know, CMS has done some work on this, but, know, that, no, but there, you know, it really needs to be some, some basic development here.
1:20:26
And also, if I try to leave the field of, behavioral health informatics, is pretty far behind the rest of of healthcare.
1:20:36
Amy, what what role do you think that CMS can play?
1:20:40
In supporting this development of evidence, experimentation with different ways of collecting that data, and ultimately helping us get to a place where we have better quality measurement.
1:20:54
Yeah, I think they can play a really robust role because they played it in, you know, quality measurement across all the other programs. I think the issue is, you know, how do you encourage the stakeholders that come to the table, to others to, to want to develop these, these measures here. And so there’s, you need to have, or the associated, or accountable part of it so that people are not just developing measures and nothing’s going to happen to it. So they need to have a sense of, like, this is meaningful, because we’re going to be held accountable, Our payment will be tied to this.
1:21:27
I think, as they look at other sort of, outcomes based or approaches, or, you know, thinking about the way they changed their payment, There’s an expectation of quality measures to go along with this. You know, the tension on the quality measurement side is the burden issues and the specificity. And so, you know, the pendulum has swung back and forth on that over the past decade.
1:21:51
Or so about how many measures you should have, how much specificities you have, how many burdens is going to place on, any practitioner to have to, um.
1:22:00
To report them. And, and the process for development and validation is so long. There’s such a long lead time on that.
1:22:07
So, I think they can really add this two part of their sort of priorities and say, you know, the, in the value side, you know, in any of the value programs. The payment has gotten so much. Focus on the quality sort of lags behind.
1:22:21
I think there’s, you know, there’s ways to, you know, make this a priority, as well, that the better quality measurement in this evolve and behavioral health space, but then, you know, in the integration holding entity is accountable. And they should be thinking about it, especially if they’re going to be adding. You know, Congress is going to change the law, adding new practitioners to it, Encouraging new ways of payment that there needs to be sort of the, the accountability and then the measurement of the outcomes. To go along with it.
1:22:45
And it certainly fits in along with it, in the Equity approaches, because you want to make sure that all these initiatives that you’re targeting are achieving the outcomes you say they’re going to.
1:22:57
Yeah, well, it’s just one thing is it’s important to develop quality measures, but it’s also important to apply them in a way that gets results.
1:23:04
So, if you actually look at, you know, every year, there’s a National Center report, the quality measures that exist, that, that’s put out.
1:23:12
And it’s, it’s important to note that in the behavioral health set of measures has not improved.
1:23:21
Other areas have improved. In fact, in a number, for a number of the measures, it actually has gone down.
1:23:28
And yeah, when you think about what the expectations are, for example, if you look at a simple measure of follow-up after hospitalization for a behavioral health condition, your mental health condition, you know, it’s really hard to get into a psychiatric hospital.
1:23:44
You have to be really sick.
1:23:46
Yeah. And the average length of stay is only about a week.
1:23:50
So it’s not like these long stay kind of things. You think about less than 40%.
1:23:56
Less than half of the people who come out of a psychiatric hospitalization have a visit within a week, coming out.
1:24:07
So, they’re going, you know, very sick people, under 24 hour care, for about a week, you know, came in in a crisis.
1:24:15
They come out and they have no connection to seeing anybody, any provider afterwards, and that’s for a majority.
1:24:21
And what’s important is it’s been no impact no improvement in that in 15 years.
1:24:26
Um, so, there’s something. It’s not just measurement.
1:24:29
It’s measurement in a way that gets action.
1:24:33
Right, right? And I’d like to invite you into the conversation here.
1:24:37
Means, you’re on the ground, you’re working with, with people and providers. How do you think about this issue of evidence generation, quality measurement, and equity?
1:24:56
Oh, You? Think you’re on mute.
1:25:14
It seems that we have lost audio.
1:25:16
So I am going to, as we work on getting that, Kara, I want to transition to a little bit of closing and give everybody an opportunity to make a closing remark.
1:25:29
Amy, do you want to kick us off with a closing statement or remark? on your takeaways are on an average.
1:25:37
Well, thank you for having me. This was a great conversation. I think it’s sort of, it’s a, As I said, it’s very timely. There’s a lot going on in the space I’m excited about.
1:25:47
The opportunities are a lot more work to be done, but hopefully it’s, it’s tough, because we’re having its moment, and we’ll be able to really improve some policies in this space, in the coming months and years.
1:26:03
So I just wanted to say that, you know, on the one hand, you know, what I’ve been saying? It’s been it’s fairly pessimistic.
1:26:09
And the other hand, you know, you look at what per India has been doing, and Cherokee has been doing for a long time. That’s something that’s really somewhat unique.
1:26:19
They’ve been able to figure out how to actually apply it in a practical way, in a very difficult sort of, broad setting in rural areas, develop the, the technology capacity for doing that, develop the training capacity to do that.
1:26:32
And I think that that’s really something that’s kind of a national model to think about in terms of how to integrate care.
1:26:38
I think that, you know, there are obviously all kinds of obstacles in, in generalizing that to other settings, but I think it provides some hope that it’s possible to actually do it.
1:26:54
Parental care.
1:26:57
Yes, Good. So, well, yeah, thank you for that, Harold. I think my point previously that I wanted to make, so I’m going to tag that on, is, we have a serious problem with data.
1:27:11
And I will tell you that the data are very poor quality in many cases, so we will, we will get into the quality measures will get in the weeds of the data. The data is sometimes that the payers share with us are incorrect. Claims are incorrect. It’s messy.
1:27:31
So, before we even get into this space or maybe as we’re, as we’re making progress in trying to address kind of what measures, we have a serious issue in terms of our data quality. Everybody has different electronic health records. They’re putting things in different places. There are all diagnosis codes. So I will just say that the data quality has to be addressed because we’ll never be able to really, truly move forward without that.
1:28:03
And in terms of the final thoughts, I have I think that the the momentum that we can provide from both the academic policy, payment, clinician, you know, in the trenches.
1:28:20
That’s incredibly powerful and we we are, this is the time we’re coming out of a pandemic where mental health need and people talk about the Twin ….
1:28:31
No, the, the, the mental health need has never been greater.
1:28:35
The call to action has never been louder.
1:28:39
And so, this is probably where we’re seeing alignment, more than we’ve ever seen it, in terms of policy, payment, frankly, legislative, and, um, legislative, federal, state, where there’s more opening. And so I think that we are at the cusp. And I think the important thing is to identify what are going to be the key elements and habits, all, working on those key elements. Moving forward together, I think there has to be a common elements approach. Otherwise, it’s, everyone’s going to be working in different ways. There’s got to be some synthesis of how we’re moving in, identifying where to move forward.
1:29:23
I wish I wish we had more time because I feel like we’re just going to getting warmed by that.
1:29:29
I really want to thank each of you for bringing your perspectives.
1:29:33
I’ll say that the academic, the practice on the ground and policy perspectives are all needed to really address this. This important topic and your insights were invaluable.
1:29:45
Ah, so, so energized, but unfortunately, that’s all the time that we have for today, so thank you for, for spending some time.
1:29:57
Everyone that says joined us, I’ll say please take time to complete a brief evaluation of our time together today.
1:30:05
We will have that immediately to you as this broadcast ends, so check your e-mail inboxes.
1:30:13
A recording of this webinar, and additional materials will also be made available on the Alliance website.
1:30:20
This concludes today’s webinar, our introduction into behavioral health and primary Care integration.
1:30:27
Thank you, Harold. Brenda. Amy, thank you all for joining us today.
1:30:32
Wonderful afternoon. Good.