Abby Burns (00:20):
From Advisory Board, we are bringing you A Radio Advisory, your weekly download on how to untangle health care's most pressing challenges. I'm Abby Burns. Back in April at Advisory Board Summit in Washington DC, I sat down with three behavioral health leaders from provider organizations across the country to have a discussion about the state of behavioral healthcare. All too often when it comes to behavioral health, the conversation starts and ends with talking about how challenging it is, but if we want to improve the state of behavioral health, we can't afford to stop the conversation at identifying the barriers. We need to talk about what progress actually looks like. We need to celebrate the wins and the steps in the right direction, and we need to understand what makes them possible. Because yes, the headwinds are very real, but there are organizations moving the needle.

(01:12):
The leaders I spoke with are doing just that. So in April we sat down for a solutions-oriented conversation about delivering behavioral healthcare at scale. You'll hear from Dr. Tristan Gorrindo, former Chief Medical Officer at Optum Behavioral Care, Dr. Mustafa Mufti, Chair of Psychiatry at ChristianaCare, and Dr. Ken Rogers, Chief Medical Officer for behavioral health at WellSpan. In our conversation, they share how their organizations are approaching digital and virtual care, how they're building and retaining the behavioral health workforce, experimenting with ways to provide crisis care, and of course tackling the evergreen challenge of making behavioral health care financially sustainable. Here's our conversation.

(01:55):
Well, welcome. Thanks for being here this morning. I have to say one of the things that I found really powerful as the four of us have been talking in preparation for this conversation is you're all psychiatrists by training. Two of the three of you are pediatric psychiatrists. You have similar titles, probably similar job descriptions, and yet the way that you have cultivated your leadership and your perspective on leadership in behavioral healthcare is so different. So I will try and be strict on the clock, but I would love for each of you to take about 60 seconds and talk about the professional experiences that have most shaped your perspective on how you can drive impact as a behavioral healthcare leader. Tristan, let's start with you.

Dr. Tristan Gorrindo (02:41):
All right, well thanks for having me. I moved to Washington DC just about 10 years ago, and I've had two major careers since moving to the DC area. The first was as the deputy medical director for the American Psychiatric Association, where I really helped influence a lot of policy and regulatory issues related to behavioral health at the national level. About five years ago, I left the APA and came to Optum and was the chief medical officer for Optum Behavioral Care. Oversaw 300 clinics in 35 states, about 5,000 clinicians providing traditional brick and mortar care, embedded integrated behavioral health and primary care settings as well as virtual care, and really oversaw the real nuts and bolts of delivering care in communities to patients

Abby Burns (03:29):
Mustafa.

Dr. Mustafa Mufti (03:30):
So I had a very convoluted journey from med school, went to med school, left, started off as a researcher at Emory working in clinical research, then residency and fellowship. As a leader, I think the way that I've seen is just developing those relationships to understand the folks that are working with me, what their capabilities are, trying to help them attain those capabilities. I've been at ChristianaCare... When I was a resident, Christiana did not have a residency program. I rotated there. I was fortunate enough to be one of the founding directors of the residency program and have transitioned up since then. Also serve on a few advisory boards with the governor for mental health and correctional health care, et cetera.

Abby Burns (04:16):
Thanks, Mustafa. Ken.

Dr. Ken Rogers (04:18):
I come from a very different background. I pretty much trained in a state hospital system and chose very early in my career that I wanted to be a public sector psychiatrist. And so that's where I've spent the vast majority of my career, mainly in juvenile justice systems and school systems and really thinking about all places that folks that are marginalized tend to live, whether it's corrections, whether it's schools, whether it's social service agencies, throughout most of my career. Then went into academia for a few years, always in state systems that were usually very much aligned to public missions as well. And then most recently served as the mental health commissioner for the state of South Carolina before taking my current role at WellSpan.

Abby Burns (05:03):
I am glad that I asked the question because I think it's helpful and instructive to understand the perspectives that you're bringing when we talk about some of the topics we're going to talk about today, like digital health and AI in behavioral health, like crisis care, like can we make behavioral health care financially viable? So I want to now shift our attention and start talking about some of these topics that we see and hear really bubbling to the top of provider organizations priority lists when it comes to behavioral healthcare. And I want to start with the question that I probably get most frequently, which simply put is, what's going on with digital and AI in behavioral healthcare?

(05:42):
Because when we think about the past few years, it's been a little bit of a roller coaster. Literally thousands of behavioral health digital tools flooded the market in the two, three years or so during the pandemic and afterwards. That's very exciting from a consumer engagement standpoint, from a patient access standpoint, it's also pretty frustrating when the quality, the ROI, is unclear, we've had some patient safety concerns. We also know when we think about the past two years or so in particular, the technology has come a long way. ChatGPT passed the US medical licensing exam in January of 2023. March 2025, an AI-powered chatbot yielded positive results in a randomized control trial for delivering therapy. How are you thinking about deploying digital health and AI tools at your organizations?

Dr. Mustafa Mufti (06:40):
We've recently taken that upon ourselves at Christiana over the past two or three years. We got a bunch of experts within our organization together to look at different digital tools that are out there for patients for therapy, ADHD, et cetera. So looking at that, we had gone through, I want to say almost 40 or 50 different applications that existed out there as an organization and vetted them. I can still visualize that Excel spreadsheet, it was huge. So after they shortlisted it, they presented to us about 20 of them. So then what we did as a service line is that I started disseminating them out clinically to our different providers, residents, therapists, frontline staff, and we had gotten some sort of licensing from them and they used the products and gave us a feedback, a rubric of what they thought that it was

Abby Burns (07:29):
Mustafa, can I ask what kinds of problems are you trying to solve with some of these tools, if you think about the 20?

Dr. Mustafa Mufti (07:37):
Right. So what we're trying to see, is it's helping with therapy, depression, anxiety. There's an insomnia app that we looked at. There's one for ADHD for children. So bridging those gaps. We're understanding that you can't get everyone in front of a therapist that quickly, at least in our health system. I mean for our med managements, we can get someone in front of a prescriber in less than two weeks, but therapy is still very long out there. So this was bridging that gap was one intent. And then also understanding there's a subset of patients out there, I think, who just prefer that digital interface. They prefer maybe sitting at their home, going out in a park, sitting at a bench and just having a conversation.

Abby Burns (08:17):
Ken, what about at WellSpan?

Dr. Ken Rogers (08:19):
I really like your question around what problem we're trying to solve. So I see two areas that we've used. One is can you use the apps as a tool for actually providing therapy? And I think one of the positive things about some of the more modern apps is a lot of them will link to your iPhone, to your iWatch. And so we're able to actually not just get what the person is saying, but also understanding in the background, how are they sleeping, what are their respirations, what's their heart rate like, what's their oxygen stats like? And so you can tell whether somebody's sleeping through the night or not, which of course is going to be a really great marker for depression. And so I think there's that set of tools. But the other set, which I like even more and I think we're further advanced on, is the initial diagnostic interview.

(09:08):
So we deployed this AI generated Anna. Anna now does our initial screenings for the health system. And what's neat about Anna, and we just did our patient satisfaction results. Anna actually beat out all of our clinicians, which I'm not sure how to feel about that. But the thing that's really cool about Anna is she picks up when somebody's stressed. If somebody mentions a death in a family or something happened to a child, Anna responds to it. "I'm really sorry to hear that that happened to you. How are you managing your way through that now?" And so Anna's able to pick up and identify issues that is then able to go to a clinician to follow up on. And so I think that looking at what she's able to do thus far really says a lot about next iterations around what we'll be able to do as clinicians and really using people to the top of their licenses.

Abby Burns (10:07):
Did anybody else notice that as Ken's talking about Anna, he's using she? But I think it speaks to, you're talking about the positive patient experience. It doesn't feel like I'm stepping out of a care team. It feels like I'm still being supported by a care team from WellSpan.

Dr. Ken Rogers (10:21):
Yeah. And the other thing about Anna, which I was struck by too, she's not just iterative about what you're feeling, but one of the things that really struck me is our non-English speaking patient populations. If Anna's doing an interview, the person doesn't seem to understand Anna, Anna can switch languages. And so she now goes into Spanish on her own. And so what we've found is that we're getting a lot more data from our Spanish-speaking populations than we did in the past.

Abby Burns (10:56):
Tristian, what do you think?

Dr. Tristan Gorrindo (10:58):
Yeah, I'm really excited about the promise that a lot of these tools have. In my role at Optum over the last few years, we were approached by hundreds of vendors who had the next greatest solution for solving fill in the blank problem. And many of them had a really wonderful clinical story and could really help solve a pain point for an individual patient or individual clinician. The challenge is really, how does it fit in a health system at scale? When you have 300 clinics working in many different regulatory environments, how does it work in terms of privacy considerations, regulatory considerations, but then also who's paying for this? And that has become a really big challenge in the vendor space. We're at this really interesting transition point in my mind, and the health system has to figure out, has to have a point of view on how do we pay for these?

(11:53):
What's the value of them? Are they replacing clinicians? Are we saving costs in one place and allowing us to spend it in another place? And then if all the tools are as well received as Anna is, then I think our entire patient population will receive them well. But oftentimes telling a geriatric patient like, you can't see this therapist. Instead, I want you to go do these online modules or do this deep breath training for your panic disorder, they're just not going to connect with it in the same way that maybe they would with a live clinician. So we're at an interesting point right now.

Abby Burns (12:26):
Yeah, you're highlighting the difference between the technological capability and the patient palatability. I'm curious, Mustafa, to come back to you, you had this list of 20 that your clinicians were vetting. Where are you in that process?

Dr. Mustafa Mufti (12:38):
So now we've narrowed it down to four actually, which are now in our EMR. And that the clinicians, once they see the patients, they're able to recommend these out. So this is the first year that we're doing this. It's only been a couple of months. We're still getting the data back and then we'll see how they do this year.

Abby Burns (12:55):
What I'm hearing is also those tools are a bit of an access play. How can we improve access for patients recognizing that we might have long wait times to next appointment depending on the type of treatment that we're trying to provide. I think anytime we are talking about patient access, we have to talk about workforce, about behavioral health clinicians themselves. So I want to talk about where we are seeing progress in overcoming the workforce shortage because the question I get all the time is, I want to implement all of these things. I can't find the people, I don't have them. I can't recruit them to my area. Tristan, you mentioned opt-in behavioral care. You have a national footprint and part of that is bricks and mortar, but part of that is virtual, enabled by AbleTo. How do you leverage telehealth, leverage virtual care, to bridge the geographic access gaps that we see across the country?

Dr. Tristan Gorrindo (13:52):
So it's worth thinking about. There's been a bit of an arms race within behavioral health clinician hiring since COVID. Behavioral health clinicians during COVID suddenly realized their value in the market. So what we saw, particularly in clinicians going onto virtual platforms, is that they bounced between platforms. So they would start a couple of days a week on platform A, and then a couple of days a week on platform B, and then they would start to play each other for higher salaries. And what we've seen actually over the last few years is the salaries for behavioral health clinicians have just shot up 15, 20, 25% across all behavioral health clinicians. We're seeing some of that calm down a little bit, mostly because a lot of these virtual platforms, they're running out of capital. And so we're seeing consolidation of the virtual platforms into a few key players, which has helped in slowing down the churn. So it's not uncommon in these startups to see 50% churn in your clinical workforce in one year.

Abby Burns (14:55):
Which is very important when we think about patient access also because behavioral health is a very one-to-one patient-clinician relationship.

Dr. Tristan Gorrindo (15:03):
That's right. And so what have these online platforms done in order to make their clinicians more sticky? So one of the things is paying competitive salaries, fine. The other is really help supporting them and connecting them with the kinds of patients that they want to treat. And a lot of that is being done through things like cross licensure. So creating a broader pool of patients for these clinicians. The psychologists did an amazing job of this starting pre-COVID with something called PsychPack. And so a psychologist can now get cross-licensed in many, many states very easily. The social workers are quick on the heels. They have their own compact that they've developed,.

Abby Burns (15:48):
And these compacts mean that you can provide care in multiple states.

Dr. Tristan Gorrindo (15:51):
It basically allows you to get a license in that state with very little work. Physicians, we still have a ways to go. We have an interstate compact, but honestly it's almost the same amount of work as just applying directly to the state. But so one of the ways in behavioral we have tried to increase access is really thinking about how do we use our clinicians to the top of their license? And oftentimes that means deploying them, if they're virtual, outside of their geographic area where they're initially licensed into other states. And that actually has helped with things like allowing us to provide broader service hours. You can provide more care to people in California before they go to work because you've got a clinician workforce on the East Coast that's already up into their day, and vice versa for after work care for people on the East Coast with clinicians on the West Coast.

Abby Burns (16:42):
That also feels super important when we think about areas of the country that have a higher rate of shortage. Right? Rural areas come to mind. We see the heartland has very different patient-physician ratios compared to New York City and Boston.

Dr. Tristan Gorrindo (16:56):
To that point, if any of you want to just have an oh my goodness moment, the American Academy of Child and Adolescent Psychiatry has on their website these workforce maps that show the number of counties in the United States that have zero child psychiatrists. And you can draw almost an infinite number of lines from the Canadian border to the Mexican border passing only through counties that have zero child psychiatrists. And so we have to think differently about how we get care into those counties.

Abby Burns (17:27):
So that is talking about trying to make the most of the workforce that we have. Mustafa, you started us off talking about relationships, talking about your own training at ChristianaCare, and helping to cultivate the residency program that now exists. Can you talk a little bit about how your work to grow the behavioral healthcare workforce at ChristianaCare has gotten you to a place where you're able to start expanding patient access to behavioral healthcare?

Dr. Mustafa Mufti (17:51):
Sure. Yeah so Christiana is just like many health systems. It's a very mission-driven health system and they have a strong interest in behavioral health. So in 2018, we were allowed to open our own residency program. This year we're going to graduate our fourth class. So we have retained 11 to 12 out of those residents within our health system.

Abby Burns (18:12):
How many total residents have you graduated?

Dr. Mustafa Mufti (18:14):
Four classes, so about 16 of them.

Abby Burns (18:15):
So you retained 12 of 16.

Dr. Mustafa Mufti (18:18):
Almost. Yeah, because some that are signing on and now I'm in this problem that is a good problem to have. Whereas I have some residents who are graduating, they want to stay at Christiana, but I don't have a position. I have some residents who are now going on their fourth year. They're like, "We want to stay here. Can you make sure we're going to have a job?" And I'm like, "I'm working on it."

Abby Burns (18:40):
Which is a problem, I think, any behavioral healthcare leader would be envious of.

Dr. Mustafa Mufti (18:44):
I'm sometimes shocked how this has occurred. I think it's a lot of the culture that's been created. I think it's also the health system. It's not only department. We get a lot of respect. Behavioral health is forefront at a lot of the tables and I think that makes a huge difference as well.

Abby Burns (18:59):
Can you talk about what it actually looks like when you say we get a lot of respect? How does that show up? Because one of the things that I would love to do is figure out what are the active ingredients in the way that you've built your program and the way that it functions at Christiana that other organizations that are trying to build healthy med-ed programs for behavioral health can learn from?

Dr. Mustafa Mufti (19:18):
The consult liaison team is I think a very important team within the health system. The consult liaison team is when you're admitted to a medical surgical floor for any heart disease, unless you're having a orthopedic procedure, and there's a behavioral health concern comes up, they're going to consult a psychiatrist. That's a lot of times the first time a patient interfaces with behavioral health.

(19:38):
So I think that that interaction for the patient, and also for the clinician asking for help, is very important. I think that really helps brand behavioral health within the health system. Previously, I think what was happening is our branding was not great. A, the turnaround time was too long and if they came in, the consult was not very solution focused, did not have the resources, albeit there was a lot of things in the system which did not exist. We didn't have a strong outpatient practice, didn't have a place to refer them to. So over time, as things have grown, the patients, the clinicians feel now there's a problem, I'm going to reach out to psychiatry, and they'll figure this out. And I think that's really helped develop that relationship, that trust, and I think that's just trickled down.

Abby Burns (20:27):
So we've talked about making the most of the workforce we have. We've talked about growing the workforce of the future essentially, which is a space that you're playing in, but I also believe that you're of the opinion that those two things alone won't be enough to solve the access challenges that we're facing in behavioral healthcare. How else do we need to be thinking about this?

Dr. Ken Rogers (20:48):
Well, one of the things that we've done, and I want to go back to the virtual care one, 60% of our care now at WellSpan is virtual.

Abby Burns (20:55):
Behavioral healthcare?

Dr. Ken Rogers (20:56):
Behavioral healthcare is virtual. Our goal is to get to 70%. And what that's allowed us to do is our clinicians can be anywhere. And so right now I've got a psychiatrist that lives in Chicago. He agrees to come to Pennsylvania four times a year to see his patients in real life, otherwise he's virtual. We have a lot of folks who are hybrid. So they're in the office two days a week, at home three days a week, and it's become a satisfier to the point where our turnover is next to nothing. You have your choice of four ten-hour days, you could do eight-hour days. It's your call. And so I think that flexibility has actually helped us to one, attract people, and two, to retain folks. So I think that that's been a big one.

(21:41):
The other one is to really think about what kind of folks can provide behavioral healthcare. So back in the day, we thought about having psychiatrists, psychologists, and a master's level person. The problem with that is there are a lot of things that you really don't need a master's degree for. And so how do you begin to think about leveraging those people in the system? We're in capitated arrangements. It's really easy because we could hire a peer support counselor to do lots of the work. We're getting a fixed rate and so we don't have to worry about it. Where we're frequently getting stuck is how do we pay for somebody when we're on a fee-for-service model?

(22:23):
And so, one of the things that we are thinking about, as we're moving into the future, is how much value-based care do we do and how much do we go at risk? Because we feel like that's the only way that you're really going to be able to change the model. And so having more peer support counselors, having more bachelor's level folks that are coming in and doing a lot of our screenings, a lot of our follow-ups with people, you can't actually get into the office. A really well-trained bachelor's level person can do those kinds of things. And so really thinking more outside the box with what other kind of folks can we bring into our clinics.

Abby Burns (22:59):
I think that extends to how you think about partnership as well. And who else is on your team outside of who you employ. Is that fair?

Dr. Ken Rogers (23:08):
Absolutely. So one of the things that we did this past year is we are trying to do collaborative care. And so having a clinician inside of a primary care docs office. With our own internal folks, we were only able to cover about a third of our primary care practices. And so with our collaborative care, we decided to actually partner with Concert Health who does it nationally. And we were immediately able to actually cover all of our practices with that particular partnership. And so part of what we've started looking at is what are the things that we really need to do ourselves, and what are the things that other people can do just as well or better and do it at a lower rate?

(23:52):
And so we've really began consciously thinking about which things to actually offload. Collaborative care was the first place that we did that. The second place that we are looking at it is with therapy. We talked earlier about the fact that you frequently can get somebody in to see a psychiatrist nurse practitioner pretty quickly. We can get somebody in about two weeks as well, but we can't get somebody in to see a therapist. And so we're frequently thinking about how do we recruit therapists outside of our region, and doing things more virtually because there are a lot of people who don't necessarily want to work for a company. They would rather work for a health system, a lot more stability, you know exactly what your job's going to be, it's going to be the same way from year to year to year. Your benefits are going to be the same no matter what. And I can live just about anywhere. And so that's the place that most recently we've decided to start expanding is with our therapy and doing a lot more virtually.

Abby Burns (24:45):
Yeah. One of the things at the beginning of our conversation that Mustafa and Ken you both mentioned is involvement in correctional health as well. I also happen to know that one thing your systems have in common is partnerships with local law enforcement. Ken, can you talk a little bit about how you've worked with local law enforcement around crisis care in particular?

Dr. Ken Rogers (25:05):
We're in eight counties in South Central Pennsylvania. So in those eight counties, we have developed very good relationships with county governments, including correctional healthcare, social services, social welfare, et cetera. And what that's allowed us to do is to become the crisis provider for those counties. And so when it comes to rolling out 988, for example, we're the folks that respond, we're the people that are actually out in the community, which has allowed us to actually decompress our emergency departments. So even though our crisis numbers have gone up, our emergency department visits have actually dropped substantially, which is a fairly high cost of savings for us. So doing that crisis work has benefited the county and us in many, many ways.

(25:50):
The other thing that we've tried to do is to work with them on correctional healthcare, social services, schools, and really embedding more clinicians in places outside of the health system with the goal being, if we are able to do that successfully, then people are going to get better care, and actually it's going to be right place, right time. But I think our relationship with law enforcement is probably the one that has benefited us the most. We actually have several clinicians that are actually out with law enforcement pretty much all the time.

Abby Burns (26:21):
Can you just clarify that is a clinician that's employed by WellSpan, but is there, when they go to work every day, they don't go to a WellSpan facility?

Dr. Ken Rogers (26:30):
They're going to the local police department and they're hopping in a cruiser with a police officer. That's their job. So I think when we think about crisis, there's two ways to think about it. One is, what are the crisis teams that are going out to the homes by themselves without law enforcement, and then the ones that are actually going with law enforcement. The ones that are going with law enforcement are frequently times where it's a fairly volatile situation. We don't know what folks are walking into, and the police are there to de-escalate the situation. So once the police officer goes in, decides it's safe, the police officer literally backs out of the situation. The clinician manages the rest of it.

(27:12):
The other groups where folks are going out are usually calls that have come in. It's either someone we know, or by a phone conversation we've judged that it's relatively safe to be in, and we just send a team of two out to the homes to actually take care of those as well. But I think those relationships with the counties has been one of the biggest booms for us. We're in the process now of actually opening a crisis center that'll be a 24-hour center that's actually going to be adjacent to one of our clinics. The thing that we're most excited about is it will be a one-stop shop for law enforcement. So rather than having to go to the emergency room and actually wait, they'll come to us. The idea is that they'll be out of the door within 15 minutes, and at that point we'll take over care and manage our way through that situation. And so it's become a huge benefit for both the health system as well as the counties.

Abby Burns (28:04):
I have to say, I used to volunteer as an EMT right here in PG County, right outside DC. And the number of times that I waited for more than 90 minutes to bring a behavioral health patient to a bed sitting in the emergency department was, I can't count it on two hands. So that 15-minute time window, maybe isn't significant on your P&L as a behavioral health leader, but that is so significant when we think about the behavioral healthcare system that is serving patients.

Dr. Ken Rogers (28:31):
Absolutely.

Abby Burns (28:33):
Tristan, when we think about emergency care, I have to say medical groups don't spring to mind for me, but that doesn't mean that your patients don't experience crises. And I should say also when we're talking about crisis, what we're talking about is an acute escalation of a behavioral health condition that requires urgent or emergent care. I'm cognizant that sometimes the language crisis care might not always land with folks who aren't in behavioral health every day.

Dr. Tristan Gorrindo (29:00):
So the crisis data tell us that you can divert 80% of ER visits for behavioral with an upstream intervention. And that upstream intervention may be a call with your own behavioral health clinician, that may be connecting with 988, that might be connecting with a service that provides after hours crisis care. And within Optum Behavioral Care, we deployed all three. And the idea really was whether we're embedding in the primary care setting so that somebody who's presenting a crisis to their PCP can connect with the clinician there in the office. That is a great use of a clinician's time, keeping the patient from going to the emergency department.

(29:44):
Within the traditional behavioral health setting, we are currently a predominantly fee-for-service organization, but as we look towards becoming more of a value-based organization, the last thing you want is to be sending your patients to the emergency department. Most behavioral health clinicians in this country, if you call their office after hours, their voicemail is going to say, "If this is an emergency, hang up and call 911 or go to the nearest emergency room." In a value-based world, that is the absolute wrong answer. And so we actually took all 315 of our clinics and contracted with a company that basically just does after-hours crisis care. And so if you call any of our clinics after hours, you press three, you get routed to a behavioral health clinician who will then go through and do some crisis intervention over the phone. We have several hundred thousand patients. We're doing millions of visits a year. We get about 80 crisis calls a month. A month.

Abby Burns (30:44):
Low volume.

Dr. Tristan Gorrindo (30:45):
Two and a half a day. But if you start to think about, well, what does 80 ER visits a month cost times 12, and you're in a value-based arrangement, those savings become significant. So it's been a really worthwhile investment for us to think about the continuity for our patients as well. So the crisis vendor we work with, will actually then send an inbox message to the clinician overnight saying, "Your patient was seen. This was the intervention that was agreed upon." And so then the clinician or the front desk staff can reach out to the patient the next morning to schedule a follow-up. So it ends up being a really nice way of wrapping around the patient and the opposite experience of going to the emergency department, which is oftentimes very stigmatizing. And so we found this to just be a really worthwhile investment.

Abby Burns (31:35):
It sounds almost like an integrated version of 988. And do folks know what 988 is? Somebody want to explain 988?

Dr. Tristan Gorrindo (31:43):
So the first Trump administration signed into law a 988, which is essentially it's the 911 for behavioral health emergencies. So you can dial 988 anywhere in the United States, Puerto Rico, or any of the territories, and you'll get routed to, for the most part, a local crisis team. They have a Spanish-speaking line, they work with closely with the veterans suicide line.

Abby Burns (32:10):
So when I say it's like a system specific or an integrated 988, the after hours crisis call center that you're talking about is providing that next level of support because it's already integrated into your EMR. I think that's really smart.

(33:22):
I'm going to move us to our last topic here, and it is one that we can't really avoid when we're talking about behavioral health. And the question at the highest level is how can we make behavioral health care delivery more financially viable? Because I think there are two versions of this conversation. One is philosophical, and one is practical. And I want to start us off with the practical conversation because behavioral health leaders are running P&Ls every day. They have to worry about balance sheets. And so the philosophical conversation is important when we think about where the industry is going. But I also wonder if we can give some tactical, concrete experience-based guidance around how to make behavioral healthcare more financially viable. And I will add one more thing to this conversation, which is that Medicaid is the number one payer for behavioral health care in the United States.

(34:12):
And so as we see Medicaid cuts coming down the pike, that is going to put a lot of strain on provider organizations and they need to make probably difficult divestment decisions, trade-off decisions, about what they don't invest in. And my concern is that behavioral health is going to be on that list because as a system or a provider organization thinks about preserving their own financial viability, they're going to be looking at the things that aren't in the black every month. That's a big lead-up to a big question. Are there any low-hanging fruit that provider organizations can be looking to, to improve the financial viability of behavioral healthcare?

Dr. Tristan Gorrindo (34:54):
In order to figure out where we need to go, we need to look at how we got here. And so within the behavioral health community, traditionally most behavioral health was provided in solo private practice. So patients would go into therapy, oftentimes indefinitely or for at least for several years. They'd see their therapist weekly. They might go to a psychiatrist. The psychiatrist might manage their meds for years. And so as we look forward, what's happened is a lot of that mentality has moved into the system-level space, and we need to break that mentality, right? There will always be room for private practice people to continue to work in this model, but if you want to work in a system, particularly in a system that's value-based, you can't have patients in therapy indefinitely that don't need to be in therapy indefinitely.

(35:43):
You want an evidence-based, short-term defined intervention that gets them through their course of cognitive behavioral therapy and then steps them down to maybe a coach, or you might have them see a psychiatrist or a psychiatric nurse practitioner to get stabilized on their meds and then pass back down to their PCP for the ongoing management. We have to figure out and leverage ways to make more room in our existing behavioral health workforce for turning over patients, for applying that expertise more broadly. And that's the collaborative care model supports that.

Abby Burns (36:18):
Can you explain what that is?

Dr. Tristan Gorrindo (36:20):
Sure. So the collaborative care model is a very specific model that comes out of the University of Washington AIMS Center, and it basically is a model that sits in primary care. It includes the PCP, a behavioral healthcare manager who works in that clinic, a registry which is helping support data-driven outcomes and data-driven care, and a consulting psychiatrist. There are special codes that the RUC established about seven years ago, and that CMS pays for, all the commercial plans pay for, most Medicaid pays for, it's a really effective intervention for mild and moderate behavioral health needs in the primary care setting for keeping the patient right there in primary care.

(37:04):
And this creates capacity in the traditional behavioral health system for our patients with a lot of comorbidity or more severe illness. And so it's a great model because it's relatively cost-effective, but it also creates a lot of capacity for our sickest patients to be able to access care. And it creates a dynamic that allows us to step patients up and step patients down as they're ready. Behavioral care is not a single thing that you just send patients to, but it's a spectrum of interventions.

Abby Burns (37:33):
And my understanding is that CoCM codes, that's the collaborative care codes, they're not actually turned on for Medicaid in every state. Is that right?

Dr. Tristan Gorrindo (37:41):
That's correct. They're not turned on in every state.

Abby Burns (37:43):
So I think that's where I've seen a lot of advocacy work take place. So if anybody has been dying to find a new advocacy cause, turning CoCM codes on for Medicaid is one of these. I mean, it's not low-hanging fruit to get it turned on, but once it's turned on, you can get Medicaid reimbursement for services you might be providing. Ken, you mentioned collaborative care and when we were talking about integrating behavioral health into primary care, can you talk a little bit about what your experience has been since you were able to increase, with Anna's help, the uptake of primary care referrals and things like that?

Dr. Ken Rogers (38:17):
Yeah. So one of the things that we found is that we actually tried to do a collaborative care-like model. By using our existing clinicians to actually be in primary care, having some psych interns there, et cetera. What we found is that we were losing about $3 million a year and we were losing it because of exactly what you're talking about. We tried to build regular codes looking at interventions that we were trying to get billed for, and from a time standpoint, it wasn't cost-effective. But Tristan said something earlier that also struck me was we frequently think about behavioral health as this ongoing long-term thing that people are going to do forever and ever and ever and ever and ever. Whereas we find that if you look at the data, usually three to five sessions, most people are actually well enough to go back to their primary care doc and be managed in the office there or using other community-based interventions. And so by turning on the collaborative care codes, and by doing the partnership with Concert Health, what we found is that we were seeing a lot more people in the primary care offices.

(39:27):
Those services were provided in that location. Primary care docs felt supported at the same time. And we found that by turning on the collaborative care codes that our costs became not a loss of $3 million, but zero. And actually we ended up benefiting slightly from turning on primary care codes and partnering with Concert. And so that was actually one stage in what we were trying to do because you were talking about whether behavioral health could break even or not. And one of the things that I walked into WellSpan in 2022, so about three years now, and the first thing that they said when I was walking in the door was, "We want you to cut $20 million from behavioral health over the course of the next three years."

Abby Burns (40:12):
And welcome.

Dr. Ken Rogers (40:12):
And I looked at him and I said, "Are you crazy?" But then I started thinking about it and digging into it. But if you look at behavioral healthcare, it's often disjointed and it's not integrated across itself. If you can use collaborative care codes, and they stay in the primary care practice because the primary care doc is billing, it's not touching the behavioral health budget, et cetera, and it's fine. But then it opens up all these other appointments that are available and you can bill in a very, very different way.

(40:47):
And what we found is as we were able to decrease ER utilization, as we were able to increase our crisis services, and as we were able to move people out of care in an appropriate way with community supports, we were able to actually drop about $12 million from our budget just from some of those initial interventions, which didn't really require changing our services in terms of quality in any significant way. We were able to gain better access. Our quality scores stayed pretty high, our patient satisfaction scores stayed in the place we needed them to, but it was really about trying to find those efficiencies right here, right place, right time, that really got us there.

Abby Burns (41:30):
Yeah. Mustafa, this is reminding me of the consult liaison role that you were talking about earlier. How do you think about that role, or the integration that Ken was talking about, when you're thinking about financial viability for ChristianaCare?

Dr. Mustafa Mufti (41:44):
So the financial viability is only going to get more and more challenging because if you have a clinician that's currently working for you, now you're telling him, "Hey, you know what? I'm going to have to drop your salary." That's not going to be received very well. And we've actually had that conversation within this past year.

Abby Burns (42:00):
Wow.

Dr. Mustafa Mufti (42:01):
So we switched from our view-based model, and I had a number of my clinicians, and we dropped some salaries by 10, 15, 20%.

Abby Burns (42:09):
Wow.

Dr. Mustafa Mufti (42:11):
As we switched over to the RVU-based model, one thing that comes to mind when you talk about, and they spoke about the value-based care, but at the ground level, culturally, we've been into this thing where we just go see our patient, leave. We don't maybe pay attention to documentation, et cetera, and the work is actually all there. When I went back and looked at the notes for outpatient, inpatient consults, the notes are there, the work is there, but the billing was incorrect.

(42:39):
And when I looked at those folks and we switched over to the RVU-based model and these folks that were slated to lose money on their base pay, but we switched to an RVU-based model for a portion of our salary, all of them are today now making more money than they were, and they're not that they're doing a lot more work, it's just they're getting the credit for the work that they're doing. I think that that's a very important distinction. Now we're setting the expectations, teaching the individuals how to document these things, where to document these things, how to bill for these things, I think is essential.

Abby Burns (43:10):
Which it strikes me. I mean, those are muscles that other clinicians across your enterprises have built up because that is not specific or unique to behavioral health. You might apply it in a different way, but that is a skill set that I think isn't service line specific.

(43:26):
As we wind down our conversation, we said from the beginning, we wanted to share examples of progress and of steps in the right direction. We don't just want to have a problem-focused conversation about behavioral health. We want to have a solutions-focused conversation about behavioral health. In that spirit, and in the spirit of motivating others to make investments and to figure out how to address behavioral health at scale, my last question to each of you is, what is one ongoing piece of work at your organization or beyond that you are particularly excited about for its ability to impact your people, your patients, your communities?

Dr. Ken Rogers (44:03):
I think for us, it's going to be more digitization of what we do. I think as we continue to look at whether it's virtual care that we're doing, whether it's more app-based care, I see that as the new frontier for us. At first, I was very reluctant to move in this direction, and at first I was like, that's not behavioral healthcare. But the more I think about it, we really are meeting the need that person's actually expressing. And so I've had to get out of my own head and defining mental health care for me, which may not be what it is for the person sitting across from me. So just trying to be more open to ways of actually treating what's going on.

Abby Burns (44:44):
Awesome.

Dr. Mustafa Mufti (44:46):
For us, I think the excitement that I'm noticing is continued growth. When I took over the service line, we were slated to lose X amount of money. We were, behavioral's in the red. I think we're now losing, I want to say 3 or $4 million less than what we were projected to, But we've grown substantially. And that's where I've spoken to people. I said there's no shortage of patients. There's no shortage of volume. I'm also very cognizant of the fact that I'm not going to be able to open an outpatient behavioral practice right in the middle of the hospital. Or so I think using things like collaborative care apps, I think there's a lot of different venues to generate revenue in behavioral health. We just have to think a little differently and also understand that we are not going to have the same rate of reimbursement from an orthopedic procedure or a cardiovascular procedure. But that's not to say that there's not financial viability within behavioral health. I think there is. It just takes longer and it's a slower return, but I think there is definitely a return in it.

Abby Burns (45:50):
Yeah. Awesome. Tristan, bring us home.

Dr. Tristan Gorrindo (45:53):
Yeah. I think the most exciting part for the field in general and as well as the work we're doing at Optum is really an acknowledgement of putting the patient with behavioral health needs first and then wrapping the care around them, as opposed to having them try to navigate the system by themselves. So you have a patient with depression, whether they're getting treatment in their car, in their primary care office, after hours from a crisis line, through an app, or in a traditional behavioral health setting, that we now are moving towards a much more integrated way of connecting all those point solutions to really wrap around the patient, meet them where they're at, at that moment, and acknowledging that their needs are going to change and we can change with them. As the patient gets better, we will help support them in a less intensive environment. If they get worse, we will support them in a more intensive way. And that's really exciting. I mean, when we think about what behavioral healthcare looked like in the late '80s or early '90s, it's hard to imagine how we got from there to where we are today, but it's really a much more patient-centered focus and hope to continue to see that grow.

Abby Burns (47:07):
I've said it before, and I'll say it again, to make our behavioral healthcare system stronger, we need to talk about examples of what progress looks like, what it looks like to try new models, approach the same old challenges through fresh lenses, find and work with new partners, or the same partners in new ways. That's what we heard Dr. Gorrindo, Dr. Mufti, and Dr. Rogers talking about. And I would argue that this conversation is more important now than ever. Because of the steep financial cuts that provider organizations are facing, a lot of them are going to be looking at rationalizing services, and for many, behavioral health is going to be in the crosshairs. We need to think about behavioral healthcare differently, and I hope the conversation you just heard helps you do just that. And remember, as always, we're here to help.

(48:17):
New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating and a review. Radio Advisory is a production of The Advisory Board. This episode was produced by me, Abby Burns, as well as Rae Woods, Chloe Bakst and Atticus Raasch. The episode was edited by Katy Anderson, with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. We'll see you next week.