Inside Behavioral Health Systems with Cathy Gilbert

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies, and all the folks in between. Let's explore what's working, what's not, and what's next.

Welcome back everyone, to the Mental Health Evolution podcast where we are talking today about mental health care systems. We want to dig in to look at things like what are themes in payer relations, contract negotiation and network provider relations. Our guest today, Kathy Gilbert, currently works as a consultant to providers, but she has a history of working with big insurance groups, working with provider network development and operations. Kathy has supported behavioral health provider organizations in areas like payer relations, contract negotiation, compliance review, and program consultation. She has also been on this podcast before. She had so much to say that we invited her back for a new topic. So welcome back. Kathy.

Hi. Nice to be back.

Yeah. So I want to get us started with looking at a couple of things that seem to be happening with insurance payers in particular. So we're going to give our listeners a little picture of some of what's happening in the news and then we'll dive into some conversation. The first is the concept of value based care. And while this has been slower to roll out in behavioral health, it is here and it is rolling out. And there are both pros and cons to this noted in the Evernorth study, which was a look at the progress toward value based care in mental health. And this article talks about how technology and systems see seem to be a heavy lift for a lot of mental health practitioners, but it also talks about better outcomes for patients. So that's one idea that I want to kind of dig into a little bit more. The other is the idea of insurance companies creating their own care clinics, such as creating a mental health treatment center or a medical facility. There was an article about medical facilities that are run by insurance companies from Times Union titled Congressman Pat Ryan Releases Optum Health Survey results and it really reveals the declining care, increase in prices and poor quality offered based on survey ratings of the Optum clinics that have opened to provide direct medical care. And then there are these other models too. There's CVS clinics, there's Humana clinics opening in Walmart, and various models for treatment in places that are not typically medical health practices. So I want to make sure that we can dig into that. But with a little bit of background. Let me get some of your perspective. Kathy, how would you describe the state of value based care implementation specifically in behavioral health?

It's really slow. Been talking about it, let's see, probably close to 20 years and how to implement it. Okay, so it's very slow and there are some challenges in value based care. First is how do you measure mental health care improvement in mental health. Now I would say now there are two measures, the PHQ9 and the GAD7, which means your depression and anxiety that have almost become table stakes at health plans that, you know, they want, they want clinicians to be doing those measures. They want to see improvement. But the only data they have, and I think we used to be able to do, had a little more data. It changed and I. And I think it was a good change where they discontinued authorization requirements for outpatient behavioral health services. It's something that you can access under parity very easily. I think that's very important. But the change that made from the plan side and being able to measure outcomes is when the only data then plans really have is what comes in on a claim on somebody's outpatient care.

Yeah.

So they get data when somebody goes inpatient because they're doing a clinical review or a higher level of care. So the data that health plans really have ends up becoming flat on what's happening in an outpatient practice. So that I think that in some ways slowed down a move towards value based programs because you just had less data to be able to build that and how a practice was performing.

Right.

So that being said, I have seen several plans implement kind of a report that they give to providers based on the data they have available. Some of it that outpatient providers wouldn't have like hospital admits and our higher levels of care, history of care. You know, plans still have that information. An individual provider may not.

Yeah.

So that's, that's one piece. And then the other thing is a lot of from claims data. But knowing that kind of they've started to implement some programs. They're more, they're very early stage value based. They're kind of like they set a report card and have metrics and if you meet certain metrics, there's an opportunity to participate in a bonus pool from those providers. The other thing they've done is some incentives for things like access to appointments, early appointment availability, and they incentivize some of those things. There have been more value based things at the higher levels of care and behavioral health because they have More information, it's a little easier to measure. They can do those things.

Right.

So I think that's part of it. The other piece in behavioral health that makes value based a little bit challenging because part of value based care is having enough data from any one plan and enough members to really be able to have any concrete outcomes and figure out what's going on. So as you know, in behavioral health, unlike the medical world, the behavioral health side, there are still many, many more single shingle small group practices in behavioral health than there are in the medical world. And they move around more because you don't need a lot of equipment to provide a behavioral health service. So it's easier to set your practice up or move it. So just in general. And then if you have a small group practice, you only have capacity for maybe say 40, you can see 40 patients a week in behavioral health if you're a therapist. And even that's pushing it because it's very intense for a therapist as well. That's tough. So when you think about all of that, even having the volume of data in behavioral health for outpatient especially is very challenging. So what needs to happen and this is, and I think technology is going to get us there is all behavioral healthcare being measurement based care, which is focused on the outcomes, you know, where the member is, you're getting that feedback loop. And there are, you know, there are platforms and EHRs that are designed for those individual and small group practices actually specifically designed for behavioral health. And it's so. And they can help with those outcomes and help a practice kind of know where they stand. Yeah, so that's, that's all part of the picture to get there. So I think it's starting and there's more measurement, especially with the tools that are now available. And those can be available electronically and with electronic health records. I think it's coming, but it can also. There's a cost factor to implementing that in a small practice. So yeah, so kind of figuring out all of those pieces, but it's coming slowly. But it's. I mean I would call it, it's young, it's very young. And we're finally getting the tools to be able to do it. I've seen a couple not implemented on a national basis with a national plan, but in certain markets for national payers, but more market specific smaller programs. And so I've seen some of those slowly be implemented. One has, like I said, they have us, a couple of them have programs where they incentivize different things that are outcomes based Access, appointment availability, even things that are measured are, you know, if you're seeing somebody outpatient, how many of your patients were admitted to a higher level of care, you know, end up paying Intella, provider that, you know, provider may not be so. Or ER visits. Those kinds of things that, you know, if a mental health provider knows about, it can help help somebody troubleshoot things and maybe prevent some of those admissions. And. Yeah, so, but it's, it's challenging.

It is. I think this, this piece, too, you've mentioned, like, increasing, like, access to care is one of the things that practices would be rated on. And I think that's particularly difficult in mental health, though it's needed. You mentioned the limitation, right. Of seeing maybe 40 clients a week, but that's high for a lot of what people are doing. And so it's not like a doctor's office where you see someone once every six months. If you're seeing somebody weekly, you. You're full when you're full, you know, so I'm, I'm curious how or if you've had any chance to dive into how outpatient can make accessibility better.

You know, there's a variety of ways. One is having a way for plans to. Or the online scheduling so people can see your appointment availability. Because honestly, most providers, I mean, they actually have midday availability where they're. They're booked early morning and evening appointments, or if they happen to offer weekends, those are, those are always full.

Yep.

So it's, you know, figuring out how to, you know, have people realize, you know, take those midday appointments. The other piece is. And that online scheduling also addresses another piece. In a small practice, you may not have a receptionist to answer the phone. So when you're in session, you can't pick up the phone if somebody's calling.

Right.

So I think some of those technology pieces can really help a small practice. One, save those phone calls, because that's when you may not get a patient or, you know, or somebody who. One of your current patients who really needs to reach you in an emergency can't get through because you're in session. And you should be focused on your session.

Right.

With that individual. And, you know, reimbursement rates don't always allow for providers to have somebody to answer their phone all the time.

Yeah, yeah.

In a small practice, just realistically. So it's thinking about some of those things that technology can help and cost effectively help. Some of those integrated practice management systems have the online scheduling built in.

Yeah, yeah.

So that they'll help you with that so looking for those kinds of things that makes it available and then health plans are starting to connect to people's online availability in their provider directory. So if you have it and they can connect it into your profile in their directory, that all of those little pieces and then if you know. So I'm thinking as you think about the technology and then when we talk about outcomes, some of those systems can even push out a PHQ9 or a GAD7 pre session so that you can get that feedback. I will say that most of the digital providers that I work with in rel virtual care that is part of their app or their program is that they push out those. The appropriate assessment tools to the member and then do post session surveys and they push that those out to the member and it's kind of part of their program and that's how they're able to demonstrate their outcomes. Which is leading some of those digital programs to get to value based care because they have it built in to their reporting.

Yeah, yeah, that makes a lot of sense. That's great. Food for thought. Yeah. So if we dive into some of these other trends that we're seeing to insurers opening their own behavioral health clinics and I understand there's kind of been a shift in this over the last few years that that's kind of shifted. Some people are shifting away from it. But do you still have Humana with Walmart and some things like that? I would love to hear some of your thoughts about that trend and about what you're seeing happening and how that's impacting care for people in general, the public and how that's impacting providers.

One of the things I mentioned is access and the idea behind those programs like Humana at Walmart and others, Caroline's done some of those things as well is it gets the services to where people are.

Yeah.

So it helps people get to care, find care easier. I'm thinking even for an example nowadays, I mean you get all of your vaccines, you get them at cds. I mean you don't get them from your doctor's office. That's a convenience. I mean I'd even ask my doctor about something. It doesn't happen in pediatrics typically, but for adults, for adults that it takes away the challenge that practices may have. Especially if it's in a practice where they do a limited number of vaccines other than maybe the flu vaccine in their practice, in a primary care practice of storage of those vaccines and monitoring all of that. And it also makes it easy access when I need you Know, I go to CDS to pick up a prescription. I go stop to pick up something else. You can get your vaccine, like if it's something that's. And I think that also came as a part of COVID too, when they were trying to get everything out. But then they realized, oh, this kind of makes sense in that way. I think it's a positive because it brings the. It brings access to medical care and if you think about it, into rural areas because there's a Walmart in almost every small town.

Yeah, that's true.

There's a CVS or a pharmacy. So it brings care to areas where maybe care was hard to access. So for some pieces, I think I see that. I see the point and I see why plans do it. But what I say it doesn't do, it doesn't give you net new providers. It doesn't help. We know that there are not enough behavioral health providers in the country for the demand. We know there are. You know, in large metropolitan areas you can access care. For the most part, you could find someone available, but as you get into rural areas, it's not there. There's not enough people providing the care. So in that sense, I think it's good to bring it to the people, but it doesn't really bring net new providers. So I think that's something we need to focus on in this country is, you know, how do we attract people to healthcare professions, to behavioral health? I mean, you know, I know even when I went into social work eons ago, people are like, are you sure you want to do that? You're not going to make any money. And I'm like, well, that wasn't the point.

That's actually the point.

Right, so. Right. So as for quality, I think that goes back a lot of like I read through the article for with Congressman Pat Ryan. A lot of it is a provide or is impacted by provider shortage and then a shortage also of people to simply answer phones. There are not enough. Probably when in his article with the one Optum took over, it probably increased the volume to that clinic because then anybody who had Optum United coverage, they would want to send to their clinic. It increased volume. And then do you have enough people to answer the phones? Because it's not just the healthcare professionals, it's all the support staff.

Right.

So when you look at that whole picture and not that that was a good thing, I mean, we've got to address it. But those programs don't create more providers and get. They may attract somebody who was in private practice and was looking for something to just be more steady and have set schedule and hours. But that still doesn't get. But you lose that private practice. So it's not in that new providers.

Yeah.

So I think that, I think it's a vicious circle. There's. There's pros and cons to it and it. They're not addressing all the issues.

Yeah, that's an interesting thought when you talk about that circle because I think there are so many more people coming into the field. There are tech companies, there are MSOs, there are all these people, the insurance based clinics. And it is the same providers maybe cycling through those at the end of the day. Right. So we're not really. We're not building a network of providers.

Right. Well, you have to think about it as the baby boomers and I'm that last tail of that baby boom generation. As bat providers retire, we have the next generations more willing to access behavioral healthcare. Fewer of them going into behavioral healthcare. You have boomers. We're still around. We probably still need behavioral healthcare. And there's more behavioral health providers retiring every year than are coming out of schools. And that's especially true with psychiatry, which is another huge problem.

Oh, wow.

It's not even just therapy, it's psychiatry. And people coming out of medical school aren't choosing psychiatry. It's not as sexy as stay cardiology or cancer treatment. Those are very challenging. Our surgery, neurology, all those are very fascinating, much needed fields as well. But we still need. Maybe if there were a few more psychiatrists and mental health professionals treating people, we would catch things sooner. People would be more aware and we'd have less of these other issues because they'd be more compliant with other areas of their lives like diabetes and diabetes management. And it helps people work through those types of things. So there's all of those pieces. It's all one system and you need all of those.

Yeah, you do.

So, you know, yes, it's terrible what Congressman Ryan found, but you have to look at multiple underlying issues within our society and our structure.

I love that perspective and seeing the bigger picture because yeah, I think everywhere I see that even a change. And when I'm accessing any kind of medical care, there are clearly shortages and longer waits and all of that.

Mm, right. Well, and that was one of the reasons when I did my thesis. National healthcare 30 years ago is the biggest challenge to national health care in the US Is our culture. We want the best care, we want it now, and we want it cheap. I mean, bottom line, yeah, yeah.

I mean that is

if you look at other countries that have national health care, for the most part people are okay to wait. They understand the weight and the prioritization and you know, elective versus must have now. And so there is that. But it to me it does a lot of times come back to our culture. Yeah, you know, it's the Walmart, Amazon.

Yeah, we want the lowest cost but the best.

The lowest, but the best. And we want it right now. You know, if I can get it delivered in an hour, I'm great.

Yeah, we are pretty spoiled in that way in a lot of areas.

We are quickly.

All of that.

Yeah, yeah. So when you think about that whole concept it's like, okay, so how can, what, what do we have to change? It's not just the healthcare system, which I totally agree means change, but we have to think about it in concept of what people will accept.

Right, right. And so what do you advise to people that are looking for care to overcome some of these barriers?

One is look for the virtual care options because that does stretch capacity and so you can do that. And they also have things that I think there are a lot of things that are going to become more self serve and then as more complex things will be escalated to individuals. So I think that's, you know, all. So you know, kind of playing a little bit with the virtual care where you can to check that out because it's. But always, you know, you look for, do your research on the providers so you find one that kind of matches. Because it's also hard when you do, you know, doctor shopping and you take an appointment and decide you don't like that and want to go to somebody else. So kind of do your due diligence ahead of time. It's easier to do that nowadays to find a match for what you need and that can be, you know, your primary care doc can help you with that. You know, anybody, you know, in the community use for kids, talk to the school's counselors. Then they'll know who in the community might be a good fit.

Right.

But you know, look at what you have available and health plans are trying to make things available. They really are. And so, you know, kind of see what they have. If you have a health plan, not everybody does and not everybody will in the near future. Yeah, but yeah, they'll have, you know, preferred providers or providers that really are meeting some of those outcomes and quality measures that you're looking for. You can find those in your health plan. They have preferred networks, they have Digital providers that they've contracted with and they are a good value and are giving meeting patients needs. And you know, I think sometimes it's knowing that you don't always need that specialist because a lot of times the wait is for that specialist. So somebody will think in behavioral health it may be you'll probably be able to get an appointment with a therapist, but you may not be able to get a psychiatrist. Well, starting with a therapist may be okay because and for the most part people can get into their primary care document. So start with primary care. You don't necessarily always need the specialist because that's where the long waits are. And if you're working with your primary care or with a therapist and you do need that specialist, they may have the connection to get you in quicker with somebody.

Yeah.

Because they have a preferred providers that they work with and they can make that referral and help you get into that care.

Yeah.

So it's, you know, really looking at the system and looking. Using the tools that are out there.

Yeah.

So yeah, it's still. There will still be challenges. Yeah, that's not going to change. There will still be challenges but you know, try to use the tools that are available for someone who's trying to access care.

Yeah, that's awesome. Well, Kathy, thank you again for giving us some very concrete things to think about and to do with this whole all the systems changes and things that we see happening in the mental health industry. I appreciate you being here.

No, no, thank you. I enjoyed it. And you know, if there's ever any questions, feel free to reach out.

I appreciate that. Thanks everybody for being here. Join us next time to take a look at all the changing landscape and different perspectives in the mental health industry. Bye for now.