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.