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Canton Pulse E3 | Caroline Carney, President of Behavioral Health, CMO of Magellan Health
102 Plays2 years ago
In this special recording of a live Canton Pulse webinar, host Don McDaniel sits down with Dr. Caroline Carney, President of Behavioral Health and CMO of Magellan Health, to discuss how health centers have embraced integrated care as a driver for improved outcomes. Dr. Carney is an active clinician practicing internal medicine and psychiatry, and works with a FQHC in building collaborative care models.
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Transcript
Introduction to Canton Pulse Podcast
00:00:00
Speaker
Hi, I'm Don McDaniel, CEO of Canton & Company. Welcome to this episode of Canton Pulse. In keeping with our view that execution is as or more important than strategy over the next several months, we're going to be collaborating with you and hopefully this will be the first of many to discuss topics that we think are imperatives from both an access and a quality perspective as well as a business model
00:00:28
Speaker
perspective, right? So how you might think about innovating or changing models to be able to broaden access to care, improve quality of care, focus on consumers at the center of care, all of those things. So we are working to firm up additional topics that we'll cover. You can bet that these will be very practical applied topics. We like this term pragmatic innovation. These are things that we think you should be
00:00:57
Speaker
aggressively thinking about or focused on or doing right now with a strong focus on executing well, which I think is always a good thing, right?
Guest Introduction: Dr. Caroline Carney
00:01:06
Speaker
And we'd love to have all of your feedback about ideas for other topics. So we'll shed some light on that toward the end and let you know how you can provide information to us about things that you might want to see in the future. So more forthcoming on that.
00:01:23
Speaker
Our approach to this webinar and all of the webinars that we do, and we're going to do more and more of these, we hope is different and refreshing. No one wants to hear somebody drone on like I am right now, so there will be a short porch on this, but we want to have conversations with you, and we love to have really brilliant experts that help us focus and have, I say, been there, done that, people that have done the work and have actually helped to drive success, and we've got a great
00:01:52
Speaker
guest and partner today.
What is Integrated Care?
00:01:54
Speaker
But so our topic today, the first in this series focused on supporting community health organizations is on integrated care. And when we think about integrated care, we think about models that take a core broad based primary care model and integrate as much whole person care as you can. And also don't just focus on
00:02:18
Speaker
uh you know therapies and addressing disease states but focus on prevention and screening and try to get things early and so this is very much a discussion about integrating behavioral health into a primary care setting and we're going to walk through this today in essence in segments this is not rigid at all but we're going to talk a little bit about the problem
00:02:41
Speaker
We're going to ask our friend Dr. Carney to talk about what is integrated care and there's some different definitions, but broadly speaking we can get to a definition. We'll talk about barriers and challenges, benefits, a lot of discussion about how to really implement the practical issues, and then what's next. And then we will follow up hopefully with you all and afford opportunities for you to learn more, have access to some more resources.
00:03:07
Speaker
you know, etc, etc. So our takeaway. My takeaway is I'd love for you to come out of the same. Jeez, we really need to investigate. Can we become an integrated care organization or can we develop an integrated care strategy? I also want you to walk away. Many of you, all of you likely in the FQ space have behavioral health and I want you to walk away saying, well, maybe we have. We might have behavioral health and primary care, but do we really have an integrated model? And I know that's something Dr.
00:03:38
Speaker
At Canton, one of the things that we're very focused on is there is no asterisk next to FQHC. Our job in life is to enable FQHCs to compete with everybody and anybody in their market, and that is the go forward, and that's what's going to happen. FQHCs comprise in the markets that they're in about 15% of all primary care capacity. There is no reason why
00:04:01
Speaker
FQHCs can't dominate markets in a good way, broaden access, improve quality, reach more people, reinvest in communities.
Dr. Carney's Experience with Integrated Care
00:04:09
Speaker
These are all great things, so no excuses there. And then our killer guest is Dr. Caroline Carney.
00:04:17
Speaker
from Magellan and high-level introduction for Dr. Carney. Dr. Carney is the president of Magellan Behavioral Health and the chief medical officer for Magellan Health. But interestingly, Caroline, you've been in a number of incredibly advantaged seats in your career
00:04:43
Speaker
to help this discussion. So just to start, maybe you would give folks a little bit of that background, but talk about those different views that you've had. Sure, I feel some days like I am the luckiest physician out here because of the opportunities I've had in my career. First of all, I grew up in a really small town to the point that
00:05:06
Speaker
When I went to medical school, I recognized that all of the people in my town still wouldn't fill all of the beds in the hospital that I was training at. And so by background, rural community, small town. And I trained in internal medicine and psychiatry. I'm board certified in both specialties. And for those of you who are with FQHCs, I work for Heart City Health Center.
00:05:32
Speaker
In Indiana, I work with them twice a week doing rounds in our integrated behavioral health clinic there. And the FQHC world is near and dear to my heart. I was in academic medicine, trained in health services research and psychiatric epidemiology, saw patients on a med psych unit, and had an academic career until I recognized that I wasn't patient enough to be a researcher.
00:06:01
Speaker
And I had started my research doing the kind of large claims-based analyses to see what was happening to people who had both medical and behavioral health claims. Were they getting the right kinds of services? And over and over, we saw signals in the data, you know, lack of cancer screening, lack of immunization, you name it. And that really, I think, supercharged my desire to do more.
00:06:29
Speaker
When I got into managed
Addressing Mental Health Access Issues
00:06:31
Speaker
healthcare, I worked for Blue Cross Blue Shield of Iowa and South Dakota, known as Wellmark, and really understood the power that managed care could have to change things quickly for the better and to find where things weren't working and change that as well. And so it was perfectly aligned with how I wanted to approach med psych care, if you will.
00:06:57
Speaker
And we started one of the first collaborative care kinds of programs at that point in time, but nothing like the real model. I had the good fortune to become the chief medical officer for Indiana's Medicaid program. And during that period of time, worked with FQHCs, community behavioral health centers, a whole lot of constituents across the state to really push forward what we were doing in integrated care and behavioral health care.
00:07:26
Speaker
and really learned my chops around policy and how we had to work with that. I then became chief medical officer for a managed care organization, primarily working with Medicaid and exchange lives and learned very deeply policies around Medicaid and what we could do to really improve care and quality of care for persons insured through the Medicaid space and the exchange space.
00:07:54
Speaker
I then went to Magellan and from this perspective have had an incredible opportunity to see nationally what we do as a country of all sorts of different beliefs and opinions about healthcare. And as I landed in the behavioral health space after serving in different parts of the company,
00:08:18
Speaker
I really found it important to address some of the key initiatives and the key things that keep people up at night or the headlines that we see.
Impact of COVID on Mental Health Services
00:08:28
Speaker
And the biggest of those, like if it's a list of five, it's one through four is access and availability for all types of services, for all population demographics. And it was something that I set out to solve. And in looking for what could be scaled, what had an evidence base behind it,
00:08:48
Speaker
what we could support as a behavioral health company to get the word out, every path led to collaborative care and needing to figure out a way to scale it. And I'm happy to say we figured out that way and we're out there implementing collaborative care programs now. And you know, we're going to jump into this. That's just absolutely wonderful. Exactly what I was hoping for. I think for folks out in the audience,
00:09:17
Speaker
We want you to be thinking about this concept of integration as, hey, we are trying to drive upstream or forward, forward integrate, screening prevention, and also candidly, the workflow, workforce benefits, advantages of driving this into the primary care setting, as opposed to thinking about this in sort of a bifurcated way there.
00:09:41
Speaker
BH strikes me as one of these areas where there is a specialty component, if you will, there's the role of a specialist, but there is now an active need to think about behavioral health in a primary care sense. And a lot of this is thinking about, okay, how might we change a business model? If you think about behavioral health, high prevalence, really, really poor access, and not just in the communities where you would imagine poor access more broadly than that,
00:10:10
Speaker
Tremendous cost impact. So through the lens of value based care in the business lens. This is a disease state that could be better controlled and and you know cost resources and puts people in in very bad spots. And there's also I think.
00:10:29
Speaker
But I know a high degree of variation in terms of how we deal with these populations. So this is a problem that is immense. It's growing. I also think of this as hidden and a little bit, right? Because these aren't always the things that we see or are manifested necessarily in front of us.
00:10:51
Speaker
One of the things that struck me a long time ago, and I really believe this, is we've had this history in the country of bifurcating behavioral health and somatic care in terms of policy, in terms of approach at the state level, and so on and so forth. And I really believe that's put us behind and come back to bite us a little bit. But when we think about these three components, the significant access issues, the prevalence of
00:11:20
Speaker
these disease states, either primary or comorbid, and the cost impact, it's incredibly powerful. Caroline, if you wouldn't mind, there's some more data, and I think our audience really understands this, but I want to make sure
00:11:37
Speaker
because this is such a top end problem to focus on. I wanna make sure people understand it. So maybe you would just talk a little bit about some of the challenges that you and your colleagues at Magellan have found as you've been digging into this. Sure. I want to start with that big number on the side and I'll round it down a little bit just to say only one in four of us who need mental health treatment has that need being met today.
00:12:05
Speaker
that is outrageous. If we thought of only one in four people with diabetes having their need met or one in four with cancer having their needs be met, we would never stand for it. And so we are not standing for that and are trying to move forward and getting those needs met. However, the issue is that there is a nadir in the number of providers in the country right now. We will go down until at least 2025
00:12:33
Speaker
But what wasn't anticipated in those models was COVID. And COVID changed the course in a good way for stigma to be reduced with more people coming into services. So we have a huge mismatch of something that's great, more people coming into services, but still heading toward this nadir and that mismatch is going to happen for a while. That mismatch leads into long waits for getting your first appointment.
00:13:02
Speaker
It leads into inaccessible services. It has led in a good way to getting more telehealth services and having disruptors out there. But the issue with more telehealth services and more disruptors and more finding your way to a provider through an app doesn't mean there are more providers. It just means that more providers have shifted seeing individual patients in an office.
00:13:29
Speaker
to these other modalities. It hasn't actually increased access to care in ways that we need it to increase access to care. The other thing that happened with COVID and during that period of time was happening a little before that, but I think there was truly for the first time a real recognition of that med psych coming together that we can't think of
00:13:54
Speaker
down below the head and above, that that's how we're treating people in this two separate fronts. Unfortunately, the healthcare system as a whole hasn't really caught up with that. So we still have a functional structure in the healthcare system that's continuing to keep those two separate. But with people like you all and the folks that I work with, we can really push that idea of integrated care together.
00:14:24
Speaker
So we're working toward solving for that 27% number by trying to get people the right services. So I'm
Benefits of Integrated Care Models
00:14:34
Speaker
going to pause and put that all to the side for a second. As we look at what's happening, we know that conditions are being underdiagnosed and undertreated.
00:14:47
Speaker
And the reason for that is because most people don't present in the behavioral health system first. It takes them a while to get there. They come through primary care, whether that's family doctor, an FQHC, a community health center, whatever it might be. They're coming through that door first and most likely coming through that door several times before they actually are ever treated in the behavioral health system.
00:15:15
Speaker
By the time they get to the behavioral health system, they are on medications that may not be warranted with side effects that are causing other downstream medical problems and may have missed some of the most important interventions early on that could have changed the course of their disease. We know that in terms of integrated care, that members who are medically ill and have a behavioral health diagnosis are up to over 300%
00:15:44
Speaker
more costly than those individuals who don't have a behavioral health diagnosis. And so we know that this problem is really huge. And it tells me over and over, we have to address it where it starts, either preclinical care or at the first stop in the primary care setting or in the medical care setting. So many people have seen that primary care doctor first.
00:16:10
Speaker
But many, unfortunately, arrive too late. And they arrive too late, and we know this because of the percentage of those who died by suicide. If we had been able to identify and diagnose many of those people or change the trajectory for them, I think we could save a lot of lives, which is an initiative that's built into what we're doing here in collaborative care.
00:16:36
Speaker
We know from research that 64% over well over half of people who die by suicide have seen a doctor in the weeks before, but not a behavioral health specialist. So it doesn't matter where in the country I look, it doesn't matter if it's commercial data, Medicaid data, Medicare data, exchange data.
00:17:00
Speaker
This all looks the same to a lesser or greater degree in the cost that we're seeing that leads to that downstream dollar by dollar difference in the cost of care for individuals with a behavioral health condition, a substance use condition, or SMI. And you all who are clinicians know and understand this. You understand that it's challenging to take care of those individuals. It's challenging to be in a primary care setting
00:17:30
Speaker
where you don't know where to refer to, or you try to refer to, and that member may never get there, or the wait is six weeks if you're lucky, three months in most cases across the country these days, and you lose that patient, or else they just start getting stacks of medication. There are recent statistics that show that during COVID, the number of prescriptions
00:17:57
Speaker
like per each American has markedly increased over the time since COVID up to now. So we need solutions to address all of this. And that's another thing that led me down the path of we really need to bring collaborative care into the mix. So that's a great segue. Let's talk about this concept of, and we're using these terms somewhat interchangeably, integrated care, collaborative care.
00:18:26
Speaker
the definition there, optimally, top of license. All of these are words that you all see in webinars, and you say, oh, that sounds great, but what does it really mean? I think Dr. Carney said a lot of really good things. One is, and it might be a little crass, but who really cares about those data points? Well, ultimately payers. If you understand the data and the impact,
00:18:50
Speaker
that your patient's disposition has on the medical loss ratio as an example, that's incredibly powerful. So some of the practical takeaways of this are, hey, let's make sure that we are armed and we understand this. We talk about integrated care as a medical model and a business model because it seems to make a lot of sense as a clinical model.
Collaborative vs. Co-located Care
00:19:15
Speaker
It also, I think, and particularly for FQHCs, makes a lot of sense
00:19:19
Speaker
business model and part of what's happening in our world is because so many of these value based constructions are relatively new and early. That we're not necessarily aligned like the design the org design is not necessarily aligned with the payment design or in particular with Medicaid payment reform as an example, maybe we're not caught up.
00:19:41
Speaker
The good news is that is changing, that's catching up, and all of us have to proselytize to the people that care to make them understand the impact of really improving these systems. So, Dr. Carney, one of the things that we talked about and I mentioned earlier is some people do confuse, and particularly FQHC world, this notion of, oh, we have a great behavioral health practice, we have a great primary care practice, but co-location doesn't necessarily mean
00:20:10
Speaker
integration and maybe just speak to that a little bit and what you're even seeing in your world at your FQHC. Sure, so colocation is one of the terms that comes to mind when I say, do you do collaborative care? Collaborative care means something different to so many people and I often hear, yeah, we collaborate. It's not the same, of course, as the collaborative care model, which is the
00:20:38
Speaker
truly evidence-based practice of addressing the conditions at the same time. In my FQHC, we started the clinic because the primary care providers had such a burden of behavioral health conditions in the clinic. And we had done some analysis on prescribing and downstream care that there was just the need to do this right. And we actually started with collaborative care before there were the right tools to try to do this.
00:21:05
Speaker
and it failed miserably. You cannot use an Excel spreadsheet to track patients over time and have a clinic running the way that it should. We grew the clinic over time to have both prescribers and therapists in the clinic and offer a full range of services, but our medical record keeps both sides separate. So there's a patient safety issue there. Even if you have an integrated group like mine,
00:21:33
Speaker
It's not fully integrated in the clinic for that life. The primary care providers may be in the middle of the day, say, have an emergency, and we run up and help those primary care providers with that. But then there's a whole clinic sitting there behind that's not the same thing, right? It's not doing effectively what it could be doing.
00:21:57
Speaker
And we need other supports that often the primary care providers are getting and using like social supports in the community, access to other community resources that often in the behavioral health clinic in an FQHC are not there or because they're just part of so much that is needed in terms of social determinants of health, we don't get enough of it. Another really telling figure is even now when
00:22:25
Speaker
HRSA requires PHQ reporting. And even now, my clinic, I'm happy to say those primary care providers, we are at like 99% month over month on those metrics. Our primary care providers on a good month get to 30. And so even with us there, it's not the same thing. We're not doing systematic
00:22:52
Speaker
diagnosing, finding cases, diagnosing cases, knowing who and when to refer or when I should or shouldn't start a medication. And so this idea of even a fully integrated clinic doesn't mean that true collaborative care is getting done.
Setting Benchmarks for Integrated Care
00:23:10
Speaker
Based on your experience, and I'd love to have a hand raise, how many people have seen what they think to be a pretty fully integrated business model in this way?
00:23:20
Speaker
Because, you know, you raised the question about even you think about fundamental benchmarking like screening, like what should our goal be for screening primary care patients for behavioral health issues versus where we are? Daniel, why don't you chime in? Yeah, we do fully integrated care. So we've got three behavioral health providers that are in our clinic.
00:23:42
Speaker
Um, all the time, and we always have at least 1 that's available to meet with patients on the spot. So, if if we get a high PHQ 9 result, or somebody that that has.
00:23:57
Speaker
a slew of other indicators, then we get a behavioral health. We offer them to be able to see a behavioral health therapist at that time. But it's also just fantastic if we have somebody who comes in and they're suicidal, then we've got that specialist right there to come in. And it's not just a provider handling that. We've got a full team that can step in and work as a team in a collaborative way for the best case for that patient.
00:24:27
Speaker
So just so that we're aligned here, and that was great feedback, it would be great to really, obviously, be on the scope of this call, but to really start to talk about how do we start to measure the things that are important to measure, Dr. Carney, in terms of how we know we're making progress toward there. I think that we have a lot of discussion about things, but the reality is when the pedal hits the pavement, where do we go? And
00:24:53
Speaker
What I like in this part of the discussion is this should really be the ideation part where we're thinking about, okay, how do we remedy these things? How do we deal with these things? I think that some of these challenges are probably the reason why a Magellan behavioral is in business, right? Mission wise.
00:25:10
Speaker
But I think part of this also is getting very creative about how we build those models. As the person that just shared, we don't know the behind the scenes, but they've done a very good job, probably with some bubble gum and baling wire to get there because that's the way things happen. The most significant barriers and challenges that we hear from in terms of prevention of deployment of this model at scale,
00:25:40
Speaker
obviously workforce.
Advantages of Collaborative Care
00:25:42
Speaker
And one of the things I want to emphasize to Dr. Carney said is there is an underlying supply demand dislocation in and around behavioralists, behavioral clinical specialists, and that will continue right now in the face of dramatically growing need, aging, all of these other factors that are driving the need dynamic
00:26:05
Speaker
But a big part of this discussion is also how do you change your business model and workflow to get the most out of what you have or what you could have? You know, we have health centers all the time that say, hey, we've got a bunch of social workers that are, we're not sure if they're optimized or we're doing this or we're doing that. So what we would encourage you to say is, hey, let's brainstorm this a little bit. I think change management is a big deal. You guys are on the front lines. Caroline, you're on the front lines.
00:26:32
Speaker
Can you get folks bought in, particularly as the clinical dynamic? You mentioned technology. It seems like the EHR vendors are allergic to BH compliance issues in that they are so nervous about it that they overcompensate. We know that a lot of community health centers dramatically overcompensate also because of that concern
00:27:00
Speaker
But again, let me just say to you, there's not much value if you're running a program that has, you know, you know, one, 100th of 1% of your eligible patients in it. You have to figure out how to scale to drive that.
00:27:14
Speaker
We are going to talk a little bit more about payments, but there's a reimbursement issue in a bunch of places. All of these things are factored together. I think that they segue into our benefits and opportunities of this a little bit. I'd love for you, Caroline, to talk a little bit about your view of the opportunities and how we can drive forward here, and maybe a little bit of the experience at Magellan and what you guys have tried to build just to give people context for
00:27:44
Speaker
I like this concept of capacity building, right? We have to be thinking longitudinally about how we're going to revamp the business model and build the capacity, the skills, the competencies, the upskilling to get the top of license. Yeah, so we have looked at many models over time to get to that point of what could be scaled, but also you brought this up a little bit ago, which is can it be integrated into the clinics workflow and every
00:28:13
Speaker
functions in its own workflow. So it was really important to have a model that wasn't a cookie cutter that every single time we just said, here it is because that's doomed to fail. And so we started working with a technology partner called Neuroflow to address some of the issues here. So if you think about the collaborative care model as a whole, the intention of collaborative care is to deliver measurement informed care to improve the quality and outcome of treatment
00:28:44
Speaker
for behavioral health conditions, initially depression and anxiety, and now well beyond that. The model is really aligned if say you're an ACO or you're an FQ taking risk in some population, because at the end of the day, the evidence all shows that the collaborative care model ultimately reduces overall cost of care. It leads to enhanced engagement, especially if you're using a tool like we are where there's a take-home app
00:29:13
Speaker
and we can gamify the content so that individuals get drawn into the care and can use the tools to help support them between visits. As a young physician, I, in training, I remember watching anesthesia and I would see an anesthesiologist watching six rooms of nurse anesthetists. And I was like, wow, I can do six times the surgery at once. That'd be so cool if it was in other parts of, you know,
00:29:42
Speaker
the healthcare system. And in fact, it is in collaborative care because in collaborative care, you need one psychiatrist who can serve a multiple, you know, multiple number of primary care providers and doing the right thing because the model is aligned to bringing top of license expertise when it's needed, where it's needed, and how it's needed with continual support from a top of license social worker
00:30:10
Speaker
doing the kind of day-to-day management that supports this model. So it's an evolving landscape of what we need to do, but the benefits of doing collaborative care are really huge. We know that there are other models and other ways to put revenue in a center through fee-for-service payments for care management, for instance. Many of the changes into CCBHCs
00:30:39
Speaker
that are coming with federal funding being moved forward to try to address some of the integrated care through the Community Mental Health Center lens. And so there are other models out there, but where we are today and trying to scale in primary care, we think this is the best one. We also think that FQHCs are the best way to do this.
00:31:04
Speaker
At Magellan, we stay agnostic to the insurance. We want to serve everybody so everyone can have the tool and the primary care doctor agreeing to that can take care of that. However, many primary care doctors bring that up as, I can't do this, the insurance won't let me, or I have four different providers of Medicaid insurance, so how am I going to figure this out?
00:31:33
Speaker
You figure it out by doing it for the clinic as a whole. So in a population health, doing population health as it's meant to be, we screen, we find cases, we address them early and get them in the right care.
Technology in Collaborative Care
00:31:47
Speaker
And the psychiatrist in the background supports that primary care provider for cases that are challenging and need higher levels of care, but still need that treatment to get started off on the right foot.
00:32:00
Speaker
We are, and I would say that you said a lot of really, really good things. And again, as we're getting close, please, folks, if you want to chime in, do so with a hand raise. We are not suggesting a separate business model. You need to think about this through an integrated lens. So, you know, one of the things that we've learned as an example is, and you may already be doing this to the extent that your patients have access
00:32:24
Speaker
to mobile tools with patient reported outcomes or check-in or tracking. Those tools are very powerful in populations that have behavioral health co-morbidities. And it's also a great engagement tool. So you think about this entire continuum, it's almost like we're saying, okay, we're gonna change the definition of primary care at its core and add all of the behavioral health pathology and complications into that model. Dr. Carney talked about
00:32:54
Speaker
We see there are a number of and some of this again is, as I said, being you know sleuthing or you know I might use the MacGyver analogy right is being creative because we're early and there's a lot of of you know this it's it's very dynamic right now, but there are.
00:33:12
Speaker
tremendous payment and revenue opportunities we believe long-term. There are new fee-for-service care management payment opportunities. Many of you are familiar with that. You may or may not feel like you can do that, have the workforce, whatever those things are, but there are, I think, creative ways to address that. Anybody that has a native behavioral health clinical cohort model
00:33:36
Speaker
can benefit from integrated care because you're going to identify there are significant numbers of patients that go undiagnosed. And, you know, now some of you, I can hear you already saying this is the proverbial dog catching the car, like, yeah, just what we need, more, you know, more behavioral health demand. But it helps you to plan and think more holistically broad term. One of the things that we've learned really significantly from this is
00:34:04
Speaker
Behavioral health is at the core of closing gaps in care, and there's a very practical crosswalk between driving integrated care and improving your incentive payouts and those kinds of things, which again, I would characterize in this bucket of these are short term and sometimes some cases these might be efforts by CMMI to create enabling financing. I would call it. You know these are not permanent solutions, but this is all in a path toward
00:34:33
Speaker
Could you be someone who actually impacts quality cost value and can talk to the people that care about that the purchaser in a way where you get some of that benefit i'm not suggesting that's going to happen overnight but that is sort of the.
00:34:52
Speaker
the evolution of the thought process in the model. And so you have to think about this holistically. We are, and I would love for you to comment, Dr. Carney, the more that we dig into this, and we know very little, certainly not nearly as much as you, but
00:35:12
Speaker
You find out that this behavioral health world ecosystem is almost like the saying in the land of the blind, the one eyed man is king. I mean, there's very nascent understanding broadly about the impact, the power, what has to happen, and even relatively straightforward things that impact deployment and implementation. So what advice would you give to our audience about that? I would give the advice that it's
00:35:40
Speaker
Nothing is impossible, even if it feels like it is going to be pushing that boulder up the mountain. It's really not once you start digging into it and breaking apart the component parts and seeing how it fits in your workflow. You're already seeing all those patients with behavioral health conditions today. So the difference is you're now getting support from care management and from psychiatrists in the background.
00:36:07
Speaker
to take care of them the right way, to get them to the right level of care if they can't be treated in the clinic. You're already doing measurement-based care today in cardiology and diabetes and cholesterol management. It just doesn't sound like it because it never came out that way. We think of that as a biomarker, but it's really your changing therapy to drive to that right LDL number, for instance. So here, we're changing therapy to get to the right
00:36:37
Speaker
number on a PHQ or a GAD, but you're doing it with support. So I think of it as in an FQ, you're already seeing all of this anyway. Now there is a way to better address it, to better find it and catch it before it kind of boils out of control. There's also that component of behavioral management in terms of taking care of medical disease.
00:37:04
Speaker
So like those HEDIS measures that are on the screen right now, the collaborative care model helps find that because now you have another ally who is helping to address those issues with that member to get more holistic care done. The results speak for themselves. Those numbers get shown over and over in research in this model. There's also another benefit in RAF scores because so much of behavioral health is not coded because it's not officially found.
00:37:34
Speaker
Now, with coding that, that can also help graph scores, which ultimately show the level of severity that you have in the patients that you're taking care of. That's a really great point. Some of these are in a sense like future considerations where maybe we're not caught up time-wise, but that's a great example of
00:37:56
Speaker
in a time and place where states have historically on the Medicaid side had a very disjointed approach to risk adjustment, right? Every state's had a different approach. I think it's fair to say we're seeing the Medicare advantage-ization of risk adjustment. So it feels like we're moving to an HCC world that will impact ultimately you all and your payments at some point in time, probably in the not too distant future,
00:38:24
Speaker
There's also a lot of discussion about because it's an acuity marker that you start to think about benchmarking that to staffing and other things right people are going to start to use.
00:38:36
Speaker
HCC and RAF scoring as a basis for those kinds of activities.
Future of Integrated Care
00:38:42
Speaker
So there is, we think of this very much in alignment with when you think about really getting ready for value-based care, really becoming the kind of organization that can withstand and be competitive, these are very important activities. So in this approach, just to make it really concrete for you, on the front end in the PCP or any other kind of provider office,
00:39:06
Speaker
We use technology to screen in a kiosk, an iPad, or your app on a phone if an individual has that to do the assessments. And we have depression, anxiety, and 26 or seven other assessments in the app that can screen for substance use disorder, PTSD, postpartum depression, et cetera, et cetera. All those data in real time go into a patient registry. So on the PHQ, for instance, if someone endorses suicidal ideation,
00:39:34
Speaker
you can see that in real time and address it in real time. The data that's coming in can also be integrated into the EMR, which is a huge plus so that you're not going to different systems to look at it. And then it leads downstream to the right clinical pathways that a member would see in their journey or the patient would see in their journey. And that app
00:40:00
Speaker
lets you do remote monitoring so you can push out things to individuals, put them on the right kind of journey. And it's not really you doing that, it's that care manager who's up at the top who helps coordinate and do that kind of work for the practice. So you can focus on doing what you do best while the care manager focuses on what she or he does best. Every
00:40:26
Speaker
score that comes in is reviewed by the care manager and those that are moderate or severe get reviewed by a psychiatrist with recommendations evidence-based recommendations made back for treatment. Like if it's mild maybe you don't need to treat yet or you could do digital cognitive behavioral therapy in the app without having to go to a therapist or a psychiatrist or into the mental health system which opens that system up then for
00:40:57
Speaker
individuals who need to be in the system. So it really helps align right patient, right care, right time. And if things change, we pick it up because we're continually screening through that interface with individuals and following their data over time. The ability to show positive change in measurement-based care
00:41:19
Speaker
will be critically important going forward in payment models, 100% that is going to come into play as we progress in cracking the nut on the best kind of behavioral health care as a country. We can use those data to help them close HEDIS gaps, the relationships we've developed with the patients as we've talked, and most importantly, monitor that patient's progress. So that patient's always in the center
00:41:47
Speaker
being touched most directly by the care manager and the PCP. You said something really powerful. When we've talked to payers, and this has really been eye-opening for us the last couple of years, payers generally don't believe there's anyone that can come with a quantifiable sort of projection of care path, treatment protocols, how people should evolve. This notion of measurement-based outcomes
00:42:15
Speaker
many people aren't doing it and it is very much the wave of the future. And the other thing you said, which I like is that there is very much a sense that mild and moderate is essentially crowding out. We have a misalignment of input output in terms of how we're treating these things. So we're not really getting the right alignment between people that have severe persistent and the types of skills and competencies they need.
00:42:42
Speaker
because they're getting crowded out by mild and moderate. And we see that in our data. You see individuals who are in therapy for, if you do cognitive behavioral therapy, you think eight to 12 sessions. We see people in therapy for years with generalized anxiety or codes that don't suggest they would need that level of care. I think the measurement informed care is so important.
00:43:12
Speaker
Literally this morning I was reading a study about partial hospitalization that was done in implementing measurement informed care in the partial hospital setting with much better results and outcomes and length of time in treatment than without.
00:43:32
Speaker
So as more of that research gets done, the policy world will move in that direction. So to be able to be ahead of it, have it implemented in your setting, and have it automated is a plus. There's one more plus here, which takes out one of the really big barriers for collaborative care. The data that we accumulate all goes into a registry. That registry every month then populates
00:44:02
Speaker
those codes. So for every individual who's touched, collaborative care codes are time based. The registry rolls all of that up and creates the effectively a billing sheet for you to submit to the payer so that you don't have to do that yourself. You don't have to track and count minutes and all of that. It's all built into the software. That's that's great. And you know that there should be an expectation that that
00:44:30
Speaker
The technology component of that strategy should be integrated. It might not be day one, but there should be a path to doing that, right? Because you're not going to create different source system sources, right? You're going to have one source of truth and workflow, but all of this fits together. And in terms of privacy, there's an important thing to remember in the tool that we're using this software. There aren't clinical notes.
00:44:56
Speaker
and there are not diagnoses and there certainly is no psychotherapy being documented. It's scores, that's it. And so in the background between the two providers, there is a discussion, but that's not something that everyone can see. So the privacy around this is really important and I think we've solved for that as well.
Conclusion and Resources
00:45:21
Speaker
Great.
00:45:23
Speaker
Thank you, and I want to thank everybody for hanging around a little bit longer. Can't thank Dr. Carney enough for illumination. Thank you everyone for letting me be part of your meeting today. And to our listeners, thank you for joining us for this episode of Canton Pulse. Canton Pulse is brought to you by Canton & Company, the leading strategy performance and growth optimization firm focused exclusively on the healthcare industry.
00:45:51
Speaker
We'd love to continue the conversation with you. For more episodes and resources, visit us online at cantoncompany.com. Thank you. And I look forward to sharing our next episode of Canton Pulse.