Chris Weathingon, MHA - Behavioral Health Integration Into Primary Care

Move to Value

In this episode we hear more from NCAHEC’s Chris Weathington about the inevitable integration of behavioral health and primary care and the need to realign incentives and alleviate some regulatory burdens so practices can find service enhancement opportunities to remain viable and more accessible to the patients they serve.

I promised you we would get back to the behavioral health. And so I want to dig in a little bit there. As you know, the North Carolina was chosen as one of the states to participate in Making Care Primary. I know your team has done a lot of work in helping practices get information and making that determination whether that is right for them. Medical health integration is a critical part of that program. And you mentioned the collaborative care model that you all do and to support. Can you talk a little bit more not only about your collaborative care model, but also if you are seeing or envisioning that there'll be more integration behavioral health either because of making care primary or do you feel maybe it's that that may confuse it and maybe it slows down? What are you seeing?

Well, great question. Just one more thing. You asked an earlier question, what practice managers potentially could be proud of. I, I think this day and age is everything to be successful is not an individual that is accountable for success. It's true. It's truly a Team. So practice managers who are able to not only recruit but retain a family of high performing team members. I always appreciate practices that have kept their staff for many, many years. And I know that's very difficult this day and age, but those that are able to do it seem to be the ones that are most successful in keeping the doors open and delivering high quality care. But as you talk about behavioral health, that that is something I'm very passionate about. I do myself, do not have a behavioral health background, but I am drinking the Kool-aid if you will. And it's because a few years ago, the North Carolina Department of Health and Human Services Medicaid came to AHEC and said, hey, we would like to see what we can do to encourage or foster primary care to adopt behavioral health. Because as we all know, when a primary care provider sees someone with a behavioral health need or condition, they often have to refer out. And referring out is very, very hard these days with the limited workforce to take care of folks with depression or anxiety or some other behavioral health need. So what we did is we developed a training curriculum of courses and also offer learning collaboratives for practices that are interested in implementing the collaborative care model and also implementing best practices. So we have a course catered towards individual components of the work and the collaborative care model is pretty simple. It is basically a PCP, your primary care provider working in conjunction with a behavioral healthcare manager and a psychiatric consultant to screen and intervene for patients with mild to moderate depression, anxiety, and also pediatric ADHD. And there's some other behavioral health conditions that you can add to that mix, but that that's pretty much the foundation of the model are those diagnosis. But one cannot truly close the quality-of-care gaps that are present with transitions of care or diabetes or hypertension or some other chronic disease when you're not, when you're not really treating the patient holistically, both mind and body. And we tend to do to detach what is going on in the mind with what's going on below the neck. And, and so the collaborative care model really helps address that. So we've seen a lot of pediatric practices to raise this model and COVID really pushed it where this need has been more recognized. Maybe it's partly because of the social isolation we've had during COVID. Part of it is probably, I think it's just people are more accepting to get help where needed. And so North Carolina Medicaid and all of the commercial payers and Medicare have come to the table to pay for this. And these are they pay using a fee for service model, but where they pay based on time-based codes that are submitted once a month. And Medicaid pays 120% of the 2022 Medicare for service rates. And even if all your patients are completely Medicaid or Medicare, you actually can cover your cost where a behavioral health care manager who takes on around 70-75 patients in a panel can fully cover your cost. Soon we're getting ready to announce capacity building funds that are going to come from North Carolina Medicaid in partnership with Community care of North Carolina, offering capacity building funds for more practices to ramp up this this new model. The psychiatric consulting is, has been a pretty interesting situation where we have folks, psychiatrists and private practice or who work for health systems that are part of the North Carolina Psychiatry Association and also NC PAL, which is a pediatric psychiatric service that are willing to contract with practices to provide that psychiatric consulting. The care can be delivered on site or virtual. And so there's a lot of flexibility with the model, but AHEC is here to support practices that are interested in doing this. And we anticipate that that interest and adoption is only going to increase with time. When I was a practice manager, we had, we really didn't do anything like this. The only time you would really see behavioral health integrated is if you went to a federally qualified Health Center. But now you're seeing private practices adopted, you're seeing some behavioral health providers now working with primary care more. A lot of licensed clinical social workers are coming to the foray into the space. And so we're pretty excited about it. And I think it has a lot of potential not only for holistic care, but one stop shopping. So when you do go see a primary care provider, you can have all your needs met instead of being referred out.

Yeah, great. In my, I recall my practice management days, just as you said, there was very little of anything that was done in terms of integration here. A lot of times because of the sensitive nature of the notes and, and what is discussed in those visits and it made it extremely challenging. It almost felt intentionally separate and sort of isolated. So what would you say to a practice manager or a physician practice who is concerned about one of the things we talked about earlier, which is just adding more administrative burden or challenges, but may be interested in the collaborative care model? And what would their next step be if they were interested?

It's a fair question. Anytime you're starting a new service that does take a lot of effort. All I can say is that AHEC is here to provide free resources, both in terms of training and technical assistance to help practices figure out how to do this work. We've seen a number do it that are small, small offices and some very large offices. But what I could say is think about, to me, it's a good investment because it will save time on the back end when your referral coordinator cannot find a psychiatrist to see that child or that adult for things that should be easily managed. That's a problem for the practice. When you see patients constantly readmitted to the hospital or coming into the emergency room because their depression has or anxiety has gotten so significant that it's impacted not only their behavioral health, but also their physical health. And that's a problem. And then so you have all these burdens that materialize on the back end where if you just implemented the service on the front end, it, it would do wonders. And I think also just for a competitive advantage, you see a lot of health systems now embracing the collaborative care model or some form of behavioral health integration. And if the independent practices are going to keep up with that, that that need in the community, they're going to have to offer something like this. So that would be the only thing I would suggest. I talked to a practice manager a few months ago who said, you know, I'm, I'm a little concerned about this. I'm not sure whether it's worth the effort in time. But then she was talking about her son in high school and how he was super stressed and a little bit depressed about all the exams he was having to take and all the, the, the college applications that he was having to fill out. And she was really concerned for his mental health. And I said, you know, if you have the collaborative care in your office, you could probably do something about that. And so she's like, oh, OK, so I think I understand some of the burden, but we're at a heck, we're here to help you with the burden. One of the things we've, we've offered also to practice is if they just want to have a discussion and figure out if, if this is a sustainable model for them, we'll sit down with them and help them with the pro forma and figure that out. And then as they, as they go through the journey of hiring someone to be a behavioral healthcare manager or contracting with the psychiatry consultant, we're here to help them figure out how to solve those needs. And also once they get those people on board, how to make sure they're all focused in a way that makes them most successful with the model because we don't want to have, we don't really have to reinvent the wheel every time with each individual practice. We know what works and we recognize some practices have differences, but if you largely follow the template, you should be able to be successful. So, and I would say finally, one of the admin burdens also often is provider recruitment and retention. And there are a lot of providers coming out of residency these days. It used to be well, everybody had to have a highly a high performing EHR, which is still true. A lot of residents coming out and say, well, when I was a resident, there were behavioral health providers at my fingertips. Well, if you offer that into practice, I think the residents or the new docs that are coming out say, well, great, then I can focus more on A, B, and C and so that I can refer down the hall to someone who can help them with their depression and anxiety. If you ask primary care providers these days, they will tell you it's significant portion of their time. It's just filled in a 10 by 10 room dealing only with behavioral health problems. And when they have that resource under their roof, it makes a big difference, and it makes them happier. And I think it helps reduce provider burnout. And I think it makes for a happier staff knowing that they can take better care of their patients.

So absolutely I can hear the passion there, Chris, and the importance.

And I told you, I'm drinking the Kool-aid

and, and, and you've got me drinking it too. I think I also am a firm believer in this. And, and it's certainly can hear it in, in the way you talk about it and the importance of it. And I love the example that you gave of sort of making a real-life connection there for that, that practice manager. That's great. Well, always, always a good way to convince them to do something is show them the real impact in their life. So sorry, go ahead,

Josh. One, one thing is it doesn't have to be hard if someone doesn't want to take the time to recruit someone into these roles. And we do have resources for that. There's also turnkey virtual models out there, some very good companies that have been doing this for a little while and are very good. And so, a turnkey model may be what is best for a practice. If they're not quite comfortable that they can be successful recruiting and retaining someone, they can certainly go with that model and we're happy to help facilitate that as a potential solution as well. So there's different ways to do this work for those that maybe no, I'm going to go the traditional way and hire somebody or I just want to work with a vendor who will help me do this. And, and certainly we learned from COVID that a lot of behavioral health can be delivered virtually. In fact, they're often patients will prefer it for various reasons. And that is also something that's available on the table as well.

Absolutely. And that's, I'll plug in that it's one of the things that CHESS can also help with as well services we can help practices that are interested as well. So Chris, looking forward, what do you see as the biggest challenges or changes for private practices in, let's say, the next five years in North Carolina?

Well, it's a good question. I'm sure I'm not telling you anything you don't know or that your audience doesn't know, but I'll just reaffirm or preach to the choir. I would say the declining reimbursement across all payers makes it very hard to stay open and provide services while your costs continue to increase, especially in the labor market. Part of that is inflation, but that seems to be a little bit higher these days than it used to be. But it's always been the case. And I would say in addition to that, operating in both the fee for service in a value-based environment can be very challenging. I think three is recruiting and retaining your workforce. So what I would just encourage folks in leadership roles and practices, not to say that I'm perfect either, but I would say think very hard about being creative and being responsive to the needs of your staff. It's not always the money, it's, it's having there are other things you can do to make sure your staff are happy and high performing. And I would say the a lot of the regulation and red tape, there's still a lot of that out there. I think at times either government or even the even private health plans make things unnecessarily complicated. So I would just encourage anyone who's in a, in a regulatory or in a who works for a vendor or whatever, whatever you're doing, if, if the physician practice is your customer, spend a day or a week working in a physician practice. Just watch how they do their work, and you really can appreciate what folks have to go through to get the work done and to take good care of their patients. So I would say the admin burden only feels like it only continues to increase and maybe there's a way to leverage technology to improve that or reduce that burden. But it sure is hard with reimbursement declining and I don't know what the magic answer is for that. There has been discussion from providers about should we go away from a fee for service model to a capitated model. There's some beauty in that with simplicity, but the reality is you're on a budget and your capitated amount needs to keep pace with the rate of inflation. So, I don't know if there's any perfect model out there, but you certainly need enough revenue to cover your expenses and also look at your expenses and see other things you're spending money on that maybe you shouldn't be. I know that gets harder and harder every year because practice managers, if they're doing their due diligence, have really found ways to be creative. But at some point, you hit a plateau and what you can reasonably do so, and I would look for service enhancement opportunities where it makes sense. Staying on top of things, making sure you're offering at least what you're a peer practice is offering it for your specialty down the road. Make sure you're doing that and giving your patients what they want and what they deserve. So Josh, you may have other ideas of what folks should be doing or what they're going to encounter over the next five years.

Yeah, Yeah, I was as you were thinking, as you're going through those, I was thinking, man, these could almost all be things from my practice management days, I would say

still true today

and well, yeah, still true today that that still continue to be issues. And as much as we've made progress in in moving towards value-based care, those incentives to really make a full change in transformation to that is not only scary, but we're not quite there yet to fully have both feet in the in the water with it. So I think you hit on all the things that probably practices are feeling and I'll throw a plug out there for you all that as we've been talking about the work that you guys do, they don't have to do this alone. They have support from you and your team and you guys are amazing at it. So I would certainly encourage anyone listening that if they're having any issues with any of these challenges to reach out to Chris and his team.

appreciate that.

Of course. Yeah, you guys do appreciate you guys and all you do. So, Chris one last question that we'd like to ask all of our guests on the move to Value podcast is what's an important question that maybe I didn't ask today? So this is your opportunity to, to plug anything or talk about anything else you're passionate about more behavioral health or anything else. What else would you like the audience to know?

What I think you've, you've asked all the questions that I can think of. I, I guess what I would ask of you and I together is what, what can we do to help practices? Are there things that we haven't thought of that can make their lives easier? And I don't know what the answer is to that other than what we talked about today. But if, if, if folks could rewrite how practice or how primary care is delivered in a practice setting, how would they build it from the ground up if they had to do it all again from scratch? And maybe there's some things that we just, we've been so much into the box all the all this time that we haven't had the luxury of looking from outside in versus inside out. Maybe there's some things that we haven't thought of that we could be doing. And I would encourage practice managers, physician owners and leaders to speak up for what they think could work if, if they just had some cooperation and help from the ACO/CIN/AHEC/Medicaid/CMS. You know, you never, you're never going to get something unless you ask. So that would be the only thing. And I know that's sort of a generic question, but to me, it's sometimes when you have these conversations, you, we spend a lot of time talking about things we know, but maybe there's something we just haven't thought of that could strike a chord and help someone. So that's, that would be the only thing I would say.

Chris, I think that's a great response. And something that I would also echo that as much as experience that I may have had with in practice management with physicians and the work that I've done over the years and, and you have done and your team have done. The reality is it's the, it's the physicians, it's the staff, it's the nurses that are working in these practices that are really going to have the best ideas and the best, they're going to know better than us how and what will work for their communities. And what works in Charlotte may not work in the eastern part of the state. They're up in the beautiful mountains of North Carolina. So we also encourage folks to communicate what is it that you're seeing? What is it that we can help you do to make things better? And sometimes that's just incremental step by step. It's not a change overnight as we talked about, but I think that's a great, great way to end the segment. So Chris Wethington, thank you for joining us on the Move to Value podcast.

Well, thank you, Josh. Appreciate all the work you all are doing.