Leaders from collaborative care model platform company Concert Health and Pennsylvania-based health system WellSpan Health recently spoke with Healthcare Innovation about their new partnership to expand access to behavioral health services alongside primary care.
Collaborative care is an evidence-based approach to identifying and treating patients with behavioral health conditions such as anxiety and depression in primary care settings. Through this partnership, Concert Health will connect with referred WellSpan patients within 24 to 48 hours to monitor symptoms and medications and provide evidence-based counseling interventions. Concert already works with health systems such as AdventHealth, Mass General Brigham, Trinity Health, and CommonSpirit.
Healthcare Innovation spoke with Spencer Hutchins, M.B.A., co-founder and CEO of Concert Health, and David Vega, M.D., M.B.A., senior vice president and chief medical officer at WellSpan.
Healthcare Innovation: Spencer, before we get into talking about the partnership with WellSpan, could tell tell the origin story of Concert Health and its deployment of the collaborative care model?
Hutchins: I happened to read the original randomized control study for the care model called the Impact trial in the summer of 2016 and I thought that the idea that you're going to have a behavioral health clinician and a psychiatrist support primary care makes sense in this measurement-based approach. Not only did it make sense, it had pretty bulletproof research, far better than most health services interventions.
And I was just kind of mystified why it hadn't scaled. I realized that there were two reasons. One was that the money didn't work. There wasn't a coherent reimbursement mechanism. The studies had all been grant-funded, and people were trying to do versions of it. The doctors could get paid to work separately, but they couldn't get paid to work together. The second reason was that it's kind of complicated to put this together, put the culture, protocol, and technology enablement together. That fall, I got word that Medicare was going to provisionally create a reimbursement scheme for it.
Although I thought that technology is an important part of it, I felt like, frankly, someone needed to build the whole stack — including the medical group itself to employ amazing behavioral health clinicians and psychiatrists who could offer it as an easy button to the primary care teams out there. I thought if someone made this possible, the primary care doctors and their medical groups would be really excited about that kind of model. And so that started us. We had to wait for about a year for the regulations to clarify, and then we launched care starting in suburban Phoenix in 2018.
HCI: Dr. Vega, could you talk about some of the benefits of integrating behavioral health into primary care, as well as some of the challenges in making it happen from your perspective?
Vega: Partnering with Concert Health in this way really builds on our mission at WellSpan of making sure that we're meeting our patients where they are, with the kind of quick access to behavioral health at the time that they need it.
I'm an emergency physician, not a primary care doctor, but what I've seen in over 20 years of practice in emergency medicine is people coming to the emergency department when they have no other solution that they can find related to behavioral health. They've tried to access behavioral health in many different ways and just can't get it, and they end up in a bad state in our emergency department, which is not an ideal environment for a person who has a behavioral health need. Now at WellSpan, we've done a lot of work to help create better access outside of the emergency departments, and actually, our emergency department utilization for behavioral health has dropped by about 50 percent and we also embed resources in the ED to help patients. But again, it's just not the right place for somebody with behavioral health needs. The partnership with Concert Health helps us connect patients more quickly, right up front when they need it to the behavioral health counselors and psychiatrists that they need, and it's integrated with the primary care team's work.
HCI: In addition to your experience in the emergency department, as chief medical officer would you hear from primary care providers that they had patients that they wanted to refer for behavioral health, but there aren't enough providers in your area, or the next appointment is six weeks out, and they were frustrated with that, too?
Vega: Absolutely. Access to adequate behavioral healthcare is actually a national issue, and this really provides a better solution for our primary care teams to be able to connect patients to the behavioral healthcare they need. It's not having to wait two or three weeks to get into an appointment. Within a day or two, you can be connected directly to the provider.
HCI: Spencer, since there's this shortage of behavioral health providers and psychiatrists, how have you been able to scale up your company to meet the needs of all the health systems that you're working with?
Hutchins: We see that primary care providers are comfortable with the fact that they are the de facto mental healthcare system in this country. They're already writing far more antidepressants, far more anti-anxiety medications than psychiatrists are. It's a core part of their practice. They recognize that's appropriate in the same way that they do front-line care for diabetes and COPD, but they're saying that they need some help. The system hasn't set up the primary care provider to succeed, because it's also asking her to see 25 patients a day, and then asking the patient to be their own care manager.
There is a shortage in psychiatry. It is true that there are just not enough of them. More of them are retiring than are graduating. But in the collaborative care model, that psychiatrist meets weekly with a behavioral health clinician reviewing a registry of patients with this real focus on who's not getting better, or who did a primary care provider have a question about. They often don't need 45 minutes per patient. They need 90 seconds to say, hey, try to up the dose, or try this other medication that may be less likely to create that side effect. That kind of momentum creates huge leverage on the part of that psychiatrist, and in an hour, they can help the behavioral health clinician and primary care provider care for a registry of maybe 70 or 80 patients, as opposed to being able to see one, two or three in a more traditional setting.
For organizations like WellSpan, which is treating all comers in communities with real shortages on the behavioral health side, collaborative care also creates some leverage for them. It breaks apart this idea that everyone needs one hour weekly therapy. Some can be shorter interventions. Often, you’re able to carry a larger caseload than a traditional psychotherapy provider would, and you're engaging more patients, but you're graduating them more quickly.
For the psychiatrists, I think many of them find working on this sort of multidisciplinary team appealing. They see it as the future of their profession and an opportunity to support patients, not just those that are raising their hands and are willing to pay for therapy, but a broader spectrum of people really in need, but who are more likely to trust them, and they're more likely to have a bigger impact when they can be embedded in the primary care team
HCI: Dr. Vega, although you have only been working with Concert for a few weeks so far, could you talk about the process of introducing this into the primary caring physician office workflow?
Vega: One benefit of this program is that it's actually evidence-based, as Spencer referred to, so it's not a hard sell at all, because it is the right thing to do for patients. It's creating a stronger connection directly between the primary care team, the behavioral health team, and the patient. That almost sells itself. The reality is that in the first five days of doing this, we already had almost 200 referrals into the system, which is a lot, considering the number of practices we have. One of the big benefits of this is that they're integrated right into our same electronic medical record. So all of our teams are connected between primary care, behavioral health and the patient. And then it's also connected to all of our other behavioral health services. We have inpatient, we have intensive outpatient, virtual hospitalization.
HCI: What about substance use disorder treatment? Is that part of this? Or is that handled by a different, separate provider network?
Hutchins: Sometimes we create these divisions when we talk about healthcare, as if you wake up and decide you're severely and persistently mentally ill, so you go to the community clinic or the specialist, or you decide you have moderate depression, so you go to primary care. That's not how it works, particularly in communities, some of which WellSpan serves in rural areas, in which there just aren't any specialists.
We work with the primary care providers to understand where the top of their licenses are, and support them in what they're comfortable managing. Often you have co-occurring depression or anxiety with substance use disorder. If you think about opioid use disorder specifically, you’ve got a spectrum of primary care interest in prescribing Suboxone or doing medication-assisted treatment.
We're there to support them in getting the right thing for the patient and helping decide when that can be done in a primary care setting and when we should serve as a navigation engine to make sure something else gets connected. Once a primary care provider asks us to be on the team, we never say no. The question is: are we going to try to treat them to remission in collaborative care, or are we going to use collaborative care as the bridging activity to get them into a program?
HCI: Dr. Vega, do you have something you want to add to that?
Vega: I would just add that we have a spectrum of services available to patients with substance use disorder. I think it's unfortunate that it’s an area that is severely underfunded across the United States, if you look at the expenditures vs. the needs, but we've been fortunate to be recipients of a couple of grants and have some innovative programs in that area that fit well in this collaborative care model that Concert Health helps us with.
HCI: Is there complexity around the billing for this with payers?
Hutchins: Collaborative care is a covered benefit across just about every health plan in the country, and every health plan in Pennsylvania, so it's a primary care benefit billed by the primary care team.
The primary provider could be a pediatrician or an OB/GYN. We're also beginning the process of partnering with cancer centers and oncologists — anybody who is already identifying and treating depression, bringing to that team the behavioral health clinician and the psychiatric consultant, proving that you have a registry, and then it's billed on a monthly case rate.
Concert has six years of experience on how to track and administer the revenue cycle for those codes which a major advantage for patients because of their primary care benefits, they often have lower copay, and often, if they have a copay at all, it's once a month, as opposed to once per visit. So it's improving an element of the economic question when it comes to access.
HCI: What about Medicaid coverage for this?
Hutchinson: There is Medicaid coverage in 30 markets, including in Pennsylvania. Sometimes the codes were turned on, but they represented a traditional discount to Medicare. Often Medicaid pays lower in a world of collaborative care. But states like North Carolina and Montana, their fee schedule on Medicaid is actually a 20 percent premium to Medicare moving ahead. Pennsylvania has not done that. But we think that could be at a state level something very powerful, because an organization like WellSpan has the wherewithal, the ability to think at the population level, and so we're proud to be caring for Medicaid beneficiaries. But I think if you look at the fee schedule in Pennsylvania, it's not sustainable as a stand-alone service, and I think that does a disservice to the taxpayers, frankly, because we know this is valuable service for all of us and the community, that it pays for itself by avoiding higher acuity conditions on both the behavioral and the medical sides.
