When asked (almost every day) how behavioral health will ever be able to make the switch from volume based reimbursement to a more value based model, I often times find my head spinning with all sorts of unanswered questions; 1) How will we ever be able to properly risk adjust for this inherently unpredictable patient population who often present with what may look like one primary yet in reality have complex co-occurring diseases, and if we can’t properly risk adjust we can’t shift any of the risk to providers? 2) How will we be able to define an episode of care when many times these illnesses are life-long chronic diseases (meaning the “episode” is their entire lives)? 3) How can we as providers agree to share in the risk with these patients who, unlike many patient populations, do have more power to “cause” a relapse despite the best efforts of even a coordinated and highly integrated care team?…. I begin to try and answer some of this, and then I am reminded of just how complicated this journey is. Some days the path seems clear. Other days, however, I am tempted to pick up the phone and call Professor Porter and Dr. Lee and ask them how in the world we are going to make this happen….
Yet the next thought in my head, and it happens each and every time, is my own personal experience; I believe in many ways I was the victim of a fragmented care team and subsequently I often contemplate what could have happened differently had the system been set up differently. In thinking through this the path becomes clearer and I am reminded of why we need to make this change and why it makes sense for all of us. Getting there, of course, is much more difficult.
Without going in to too much detail I have struggled with depression and generalized anxiety disorder for much of my life. I had a major eating disorder when I was a teen, and these days my Achilles heel is arguably my (over) dependence on running. That said I am incredibly fortunate that not since I was a teen has any of this really gotten in the way of my life, at least not on the surface….
Six years ago and only by pure luck, I was diagnosed with stage one esophageal cancer. In an application for life insurance I was asked whether or not I had not followed up with a Dr. on any recommended follow ups in the past year… In fact, about one year earlier I had a scope as a result of some bleeding and was told there was inflammation in my esophagus and that I should come back in six months for a follow up. I did not follow that recommendation so when the application asked the question, I had to answer and deal with it honestly. This lead to going in for the follow up. It turns out the tumor was extremely small and I had cancer. Further and as I was told, had I gone back six months earlier like I had been told to do, they would likely have been able to take it out without gutting me like a fish and removing my entire esophagus and half my stomach. I say probably because nobody really knows for sure, but probably…
During this time in my life I was under the care of my psychiatrist, my primary care doc who referred me to the GI doc and of course the GI doc who did the initial scope, recommended I come back in six months and then took me back in one year later and made the diagnosis of cancer. During this time in my life I was under a tremendous amount of stress as I was finalizing a divorce, fighting for my kids, watching my business change and struggling to stay in a relationship with my now amazing and wonderful wife. I was depressed and very anxious and my eating habits were anything but normal. I was running a lot and I was taking prescribed medication to include a lot of Zantac. The Zantac was taken to help me with heartburn and reflux that I had since I was a teen.
Hindsight is always 20-20 but bear with me…. First of all, as a man with a history of ED, reflux and heartburn under the weekly care of a Psychiatrist and annual care of a primary care doc, and knowing that there is some connection between ED and esophageal cancer (or at least Barrett’s esophagus, which can lead to cancer), why in the world was I not put on some annual protocol to preventatively check for abnormalities of my esophagus in the first place? Second, as a man with a history of ED, reflux and heartburn under the weekly care of a Psychiatrist for depression and generalized anxiety disorder, under the annual care of a primary care doc and now diagnosed with a suspicious and inflamed area in my esophagus, why in the world did these three doctors leave it up to ME to follow up in “six months” without any (and I mean any) phone calls, text message, emails, pushing or prodding? No doubt it was my responsibility to either go or not go (nobody could have forced me) but I don’t even know if my primary care doc or even my psychiatrist knew that I was supposed to go back in after six months. We know people who suffer from depression are less likely to practice self-care. Of course we are. Therein lies the essence of depression. This is not an excuse but rather a statement of medical fact. I can’t help but think that if my Psychiatrist, my primary care Doc and this GI doc all spent five minutes on the phone together maybe 2 weeks after I did not show for my six month follow up, somehow someway this very likely would have resulted in me going in there shortly thereafter. And had I gone in, the chances that I could have walked away from this far less affected than I am today increase dramatically. They could have caught it before it turned in to cancer, I would not have needed the surgery and today I would be able to eat and live far more normally than I am currently able.
Yet this didn’t happen and it brings up a few relevant hypotheticals. First of all, if the GI doc was measured and reimbursed by the value (results) he delivered to his patients and not per procedure per hour, I have got to believe he would have maybe had his secretary pick up the phone a few times when I missed the six month follow up (or maybe I never made it in the first place) to urge and implore me to come in… After all, he finds an area of concern and he knows it needs to be looked at again in 6 months and he knows my medical history (more likely to get this cancer and more likely to not show up for the follow up) yet because his mind is on the next procedure because he makes his money per patient per procedure, he is probably not spending too much time thinking about me in between visits or really once I leave his office that first time. If he is being measured based on results and outcomes, however, the best possible outcome in this case would have been identifying this cancer of mine before it turned in to cancer. Imagine if he actually shared in some of the savings that could likely have been realized if this cancer was caught earlier (before it turned in to cancer) and didn’t require the surgery I had? Risk sharing goes both ways…
In as much as Doctors are generally good people in the field of medicine because they want to help people and save lives, they too are humans. They don’t know everything about every one of their patients and frankly they are busier today than ever before trying to make back the money they seem to be losing in the race to the bottom fueled by a fee for service reimbursement model. The case for coordination and integration is made with my experience. Take, for example, a value based model where the “team” is organized around my condition and where the “team” is working together to ensure optimal efficiency, reduced redundancy and the best possible outcomes for me, their patient. In a hypothetical model where my psychiatrist was the leader of my care team, for instance, first of all for certain he would have known that I had the six month follow up and second of all, he would have done everything possible to support me in going to that appointment (and it would not have taken much). He would have done so because he cares and also because if his performance on some level is being measured by my total health and not just whether or not I am feeling depressed or anxious, he is financially incentivized to do everything in his power to ensure I am doing something as simple as a follow up with an appointment that I should have never missed. If he did his job here, he would have likely saved me from a horrendous and incredibly costly surgery and he would have helped stop my cancer from living inside me for an additional six months. And in a model where he is the leader of the team and he knows about this and he does nothing about it, he is held accountable financially because the value provided to me as measured by outcome/$ spent goes way down as a result of what ultimately happened to me. In a world where these three doctors were probably not even talking to one another, nobody can blame anyone but me.
The blame game…. So many people then begin to say to me that it was my responsibility and my responsibility alone to go to that six month appointment. Ultimately, I do not disagree. Value is not designed to shift the risk from the patient doing stupid things to a Doctor who can’t control their patient’s sometimes insane and unexplainable decisions. Nobody could have forced me to that appointment. I know that. In my case and in this hypothetical I see the my providers responsibility going as far as this care team (with my Psychiatrist as the lead) urging me to go back to this follow up, and working together to do so. This would have been something discussed in my therapy sessions. My psychiatrist, because he knows me the best of all three and was seeing me weekly throughout this time, could have communicated with my GI doc to let him know I was struggling to come back in. They could have used scare tactics, they could have gotten on the phone together and called me or maybe they could have asked for the support of my family. I don’t know what they could have done but I know they could have done more than they did, which was nothing. And as long as they could show they were working as a team, that they all understood the importance of me, their patient, following up with this appointment and that they had communicated all of this to me, they did their job and from a risk sharing standpoint they are off the hook. They did as much as they could have been expected to do and if I still choose not to go, they don’t get penalized. I do.
Another way to look at this that provides value of an alternative model. Say, for example, I am choosing not to go in for this follow up because I am super anxious about it (I don’t really want to find out at this point in my life that I have something else wrong with me), I am depressed and just overwhelmed getting through life at the time (all true). Say my Psychiatrist suggests at this time that I see him twice weekly instead of once weekly in order to discuss and address some of this because if I can’t manage to get myself in for a follow up visit with a GI doc (given my medical history), then something is obviously not right. Say this costs an extra 600.00/month for a few months in additional therapy visits. Or say months or even years earlier my Psychiatrist believes I should be coming in more than once weekly because of what I am struggling with, yet I choose not to because its expensive and insurance covers none of it (true again). Say had I done this it would have cost maybe an extra 10k annually for a few years yet because of the extra work and time I had put in to therapy I am not struggling as much and I have no trouble making it in to this six month appointment… Do we think an extra 20 or 30k invested in my mental health would have had a positive ROI if it helped avoid a surgery that cost hundreds of thousands of direct dollars, many more than that in indirect costs as a result of the lost revenue because I could no longer optimally run my business and almost my life??? Of course it would have!
The following conclusions are clear when I use my own example.
- When talking about shared risk particularly with mental health, the conversation is far more complicated than when we are talking about someone with a broken hip or even cancer. Though mental illness is not a choice by any means, there is more a patient can sometimes do or not do to effect outcomes than with some of these other diseases which makes the risk sharing conversation more tricky.
- The current state of fragmented care delivery, which is particularly evident between mental health providers and medical providers, can and does have devastating consequences on patients, their families and their payers.
- Doctors are good people and they would not be hurt by being financially incentivized to work outside their individual silos in aligned teams designed around their patient’s needs and conditions.
- Bundling one’s service and sharing in some of the risk does not necessarily mean that a provider is on the hook for a patient’s bad decision. There can and should be parameters and stop gaps put around how far a provider can be held accountable because it is true particularly in mental health that we are dealing with patients who have extraordinary powers to derail their own recovery, even if not by choice.
- The links between mental illness and medical illnesses are documented and supported by data. This means mental health providers and medical providers must work together to serve their patients best interests and overall health.
- The data shows investing in one’s mental health is a wise investment, both financially and otherwise. My experience validates this data.
- Risk sharing probably should extend beyond just payer and provider and on to the patient, and risk sharing goes both ways. When a team works together to save cost or avoid a co-morbidity because of their alignment and skill, they should be rewarded. Yet when they aren’t working together as they should and something bad happens as a result, they should be held accountable.
So while I don’t quite know how exactly to move the needle away from the current model, I do know we will all benefit once the transition happens. At SCH we are thrilled to be a part of this conversation and this movement. We believe it is absolutely the right direction for our patients and their families, which ultimately means it will be best for us as well.