Health systems are embracing telehealth and
digital apps to improve workflow and reduce costs around behavioral health.
June 21, 2018
Behavioral
healthcare has long lived adjacent to the the traditional delivery system of
U.S. hospitals, but that's changing as providers and payers
begin to view patients more holistically.
In
turn, a number of companies are betting on behavioral health, with
a new twist using telehealth principles. Vendors Teladoc and American Well for
example are stepping into a vacuum created by a psychiatrist shortage, providing complementary
services to primary care settings.
Providers
are exploring these offerings, and some are seeing a return on
investment. But there's still work to be done to integrate mental
health into the larger healthcare delivery system. It's helping that
payers are getting on board, with a push to to combine behavioral health
and primary care.
“Anytime
Medicare and Medicaid or private insurers see they have a group that costs
230-250% more, they are going to want to bring that down,” said Bill Bithoney,
senior clinical fellow in BDO Advisory’s Center for Healthcare Excellence &
Innovation, told Healthcare Dive. “That’s the motivation for states to allow
the billing for telebehavioral health given the shortage of providers.”
New
York's Medicaid redesign, for
example, has pushed for co-location to allow immediate access to behavioral
health programs in the primary care office.
Healthcare
costs are a big driver and New
York isn't alone.
Spending
on behavioral health has grown steadily at 5-7% since 1986,
and is projected to reach $281 billion in 2020. In April, Teladoc announced the
U.S. launch of its Behavioral Health Navigator, a suite of services to combine
individualized support and care coordination with virtual access to mental
health providers. Others betting on the space include Quartet
Health, Avizia, Lyra Health, Vida and Doctor On Demand.
New
pressures, new opportunities
Another
driver is the pressure on providers to cut costs and take on more financial
risk. Lewis Levy, chief medical officer at Teladoc, told Healthcare
Dive: “Many individuals who have medical problems have co-morbid
psychiatric illnesses, and to maximize the clinical outcome for these various
medical conditions one cannot afford to ignore the mental health aspects of
that individual’s care.”
The navigator
was introduced last year in Canada, and the Dallas-based company says patients
have seen symptoms of depression, anxiety and stress decline by 32%, 31% and
20%, respectively.
Growing
acceptance of telehealth is helping to bring behavioral health more into the
mainstream, too.
“Providers
are finding that there’s a wider population of patients accessing health this
way for a variety of reasons,” says Lindsay Henderson, director of behavioral
health at American Well. The company employs hundreds of psychiatrists and
therapists across all 50 states, monitoring volume and recruiting and
onboarding providers in real time to meet demand.
John
Kastan, chief program officer at Jewish Board of Family and Children’s
Services, a mental health nonprofit in New York City, sees the growth in
behavioral health apps as part of a wider consumer trend.
“We
shop online, we get our healthcare online, we can make appointments online.
It’s all ... consistent with the way things have moved as a society,” he told
Healthcare Dive.
Identifying
use cases
So
who’s using these new tools? For telebehavioral health, it tends to be larger
health systems that can afford the technology and systems that are capitated or
have risk-based structures, according to Steven Chan, a member of the American
Psychiatric Association’s Committee on Mental Health Information Technology.
The general trend, though, is that more and more physicians are integrating
them into their workflows.
One
of the main use cases for telepsychiatry is the emergency room, where an
agitated or disturbed patient can upend normal routines.
“As
somebody who’s been a chief medical officer, I can tell you that disruptive
patients and patients with behavioral health issues can really destroy patient
flow,” said Bithoney. “They can destroy the satisfaction of other patients in
the emergency room as they become more and more disruptive and loud and
aggressive and lead to the harm of other patients because they are delaying
their care.”
Northwell
Health is using telepsychiatry in all of its ERs on Long Island, either
exclusively or in the later hours of the day, to assess patients with potential
mental health issues and adjudicate next steps in care. If a patient appears to
be suicidal, for instance, or has substance misuse issues that could impair
their mental capacity, a telepsychiatrist is engaged in under an hour to make
an initial assessment. They also help with referrals and can do direct
hand-offs to an admitting facility.
The
program has had a huge impact on patient flow in the ER. “From a safety
standpoint and a manpower standpoint, most of these patients, until you can
adjudicate, are requiring one-to-one care,” noted Iris Berman, VP of telehealth
services at Northwell Health. “If they can be seen and evaluated, we decrease
that demand as well by seeing them and getting them transferred to the
appropriate level of care.”
As
of last year, Northwell’s ER wait times were down 88%, compared with before
they leveraged the program, Berman said.
Patient
satisfaction has also improved due to the speed with which patients are seen.
And most people are comfortable with the technology, Berman told Healthcare
Dive in an interview. The health system also has a support mechanism for
inpatients in its behavioral health ward that links patients and on-site
therapists with family and other folks like social workers via telehealth.
The
Jewish Board is also exploring the use of telebehavioral health and has applied
to the New York State Office of Mental Health to leverage a program. The
initial use case is aimed at reducing workforce challenges by allowing
psychiatrists to treat patients remotely.
“It
allows us to utilize our workforce more effectively, more efficiently and cuts
down on issues of travel and transportation,” Kastan said. “Going forward,
there may be opportunities to actually provide telehealth services into
individuals’ homes and into other non-behavioral health centers” such as senior
centers.
The
group is also looking at how certain apps might be useful, such as reminders or
tools to support treatment and recovery. Apps self-managed by clients can
increase autonomy, which supports recovery for those seeking to live as
independently as possible, Kastan added.
Use
in long-term care
Newport
News, Virginia-based Riverside Health System deployed telebehavioral health in
its ERs and long-term care facilities through a partnership with Bay Rivers
Telehealth Alliance called the Bridges to Behavioral Health Project. The
four-year grant from the U.S Health Resources and Services Administration
supported virtual behavioral health services at 21 sites across the rural
health network, including counseling centers and mobile emergency service.
Currently,
telebehavioral health is available in all but one of Riverside’s ERs. When a
psychiatric patient presents in the ER, there’s a protocol triggering a consult
with a clinical social worker via video, says Kristi Helsel, telehealth program
director at Riverside Health System. Last year, the system had just under 1,100
consults in its ERs.
On
the nursing home side, services include an individual behavioral health
assessment, individual counseling, pharmacologic management, psychiatric
diagnostic interview exam and neurobehavioral status exam.
After
five years, return on investment on the nursing home intervention is strong,
said Donna Dittman Hale, executive director of Bay Rivers Telehealth Alliance.
A recent study in the Journal of Healthcare
Financial Management shows the program breaking even its first year, with
significant gains in year two and increases each subsequent year.
The
push for parity & awareness
Reimbursement
of mental services is improving, too. In January 2017, Medicare began paying clinicians for
behavioral health integration they provide to beneficiaries.
Starting this year, physicians have four new codes to bill for services
provided using the Psychiatric Collaborative Care Model, or CoCM.
The
codes allow for remote provision of some services by a mental health provider
and the patient’s care team. But challenges in reimbursement and mental health
parity remain.
Many
states recognize telehealth as another version of a service that was already
being paid for, but actual payment parity is not yet there. “If I collect $150
for a visit in the face-to-face world, a lot of insurance companies are saying
we’re going to give less to the same professional for same level of expertise”
because its virtual, Berman said.
“While
use of telebehavioral health services is on the rise, and growing
exponentially, we are just scratching the surface,” Glen Xiong, medical
director of mental health at Doctor On Demand, told Healthcare Dive via email.
“There’s so much demand, yet still a great lack of awareness from patients and
payers alike. Payers are just starting to develop models to pay for mental
health services, and telehealth services represent a small fraction of total
healthcare expenditures.”
Quartet,
which uses data-driven insights to match patients with a provider,
has built a network of behavioral providers incentivized to communicate and
coordinate with primary care providers.
“That’s
the trick, to get all of those elements lined up — the ROI, the patient
activation, the providers who are willing to work on this because a lot of
primary care providers, frankly, they tend to avoid these issues,” Arun Gupta,
CEO of Quartet, told Healthcare Dive in an interview.
He
added that the company’s basic intervention produces 55% to 65% engagement
rates. “That simple interaction of better enabling that authority relationship
is, I think, the biggest thing in behavior economics,” Gupta said.
Jeff
Byers contributed to this post.
https://www.healthcaredive.com/news/telebehavioral-health-finding-its-niche/525740/
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