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How to Make Behavioral Health Integration Financially Sustainable for Your Practice

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Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.

Chris Botts: Hello, I'm your host today, Chris Botts, senior manager of care delivery and payment here at the AMA. Today on the podcast, we're joined by guest Dr Yun Boylston of Burlington Pediatrics, and our topic is how to make behavioral health integration financially sustainable for your practice.

Dr Boylston, thank you so much for joining us today. Why don't we start with you telling the listeners a little bit about yourself, your background, and your practice's journey with BHI, particularly as a rural private practice.

Yun Boylston, MD: Sure. Chris, thank you for having me. It's great to be here. As Chris mentioned, I'm Yun Boylston, and I'm a primary care pediatrician in North Carolina at a practice called Burlington Pediatrics and Mebane Pediatrics. And we are a 14-provider, primary care, independent, pediatric practice with three office locations.

Our journey with integrated behavioral health has definitely been colorful. It's been lengthy. We've had lots of ups, some downs. And being realistic about that, I think for us just having that lens has been really helpful just knowing that this is the long game.

Our journey really started at least 10 years ago, definitely a little bit longer than that but about 10 years ago. One of our partners who's now retired, she just had this vision for a robust early childhood mental health program at the practice. We were seeing a lot of behavioral needs, even in our younger kids at that time, and we really felt like we didn't have the right tools to address those needs, and we felt that we were obligated to do that and felt compelled to do that as a medical home.

Being a private practice, a heart is willing, but we have limited resources and significant constraints. And so, I think being scrappy, we reached out for any and all resources that we could obtain for our practice that didn't have significant financial investment upfront. And so, luckily for us at that time, we participated in a SAMHSA launch grant. That helped us gain an embedded early childhood mental health specialist within our practice for a defined number of years. And this was really critical for us because it allowed us to pilot and scale our behavioral health program with limited risk.

I recognize that as a very unique situation, but my life philosophy is chance favors the prepared mind. And so, reaching out, making connections within your region, within your community partners, I think that's really been essential for us to take advantage of opportunities that may not be really evident.

And so, applying for that grant and being awarded that grant was really the start of more programmatic payroll health within our practice, and we haven't looked back since. And so, since that time when the grant ended and we were prepared to take on the financial costs, it's important when you have these opportunities that you're doing a lot of shadow billing on the backend, seeing exactly how the numbers are going to play out if you don't have that kind of resource. And so for us, it was a fairly smooth transition into just doing our own work without the support of a grant.

Next steps beyond that was we needed behavioral health specialists within the practice. And for us just being in a fairly rural area, rural suburban area of North Carolina, recruitment was probably the biggest challenge for us. Probably the other theme for us is just doing the best with what you've got. And so, it actually took us probably about two to three years to recruit a behavioral health specialist. And so, we were really fortunate to do that.

And then, we continued with building our program, developing workflows, because having an embedded behavioral health provider is really different than having another MD. Their schedule looks different, the coding is different. You got to work through with your insurance plan to make sure that you're being paid for those codes. And so, that was a really rich learning curve for us as well.

And then currently where we are today, we have a fairly robust behavioral health program. We actually have a department now called our care team, and it's led by a senior manager. For us, it's MoRhonda Foxx, and her title is manager of care transformation.

Botts: Amazing. It's amazing to see how you've gone from vision to actions and that long journey. It's pretty incredible. I think at least that vision is mirrored by many practices across the country, but making that into reality can be challenging. I think one of the common barriers you alluded to a little bit with behavioral health integration is the financial component, the financing. And yet, you all have been fairly successful of making it financially viable, sustainable within your practice.

So, maybe you can tell our listeners a little bit about some of the specific steps that you all took to make that happen, including some challenges that you all may have faced along the way, both in terms of coming off of the grant, but also as you've sustained it well after that and how you all have worked on overcoming those challenges.

Dr Boylston: Sure. I think for us as a very lean practice because we're independent, any venture that we have, it's got to be tied to the bottom-line fairly quickly. And so, with that lens, a lot of our listeners are very mindful of that as well.

A few things that we've done that I think are really essential, and they can do this today actually, number one, really assess if you're getting paid for the work you're doing. And so, when you take on behavioral health management, that in and of itself is a higher complexity than seeing a child for pink eye or some of the other fairly low acuity conditions that you have, and so really making sure that your providers and your billing department understand what it takes to have accurate E and M codes, evaluation and management codes. Any BHI program, and this is all baked in, you're going to have a lot more skew into the higher reimburse codes such as 99214, 99215 just by the very nature of the conditions that you're treating. And so, make sure that you're being paid for your time and being paid accurately.

For us, we run quarterly reports on the coding spread across our providers, and it's nothing punitive, it's not individual-based, but that will give you a lot of information on potential, because that's also revenue capture when you're utilizing the codes that you're already being paid for.

The other part that I think a lot of people tend to dismiss, but I think is incredibly valuable, is get with your billing team and see what your payments have been like for the survey administration codes. And so, every time you do a PHQ-9 or a GAD-7, there's a CPT code attached to that.

And so, for us in pediatrics, the common codes are 96110, 96127. We just reviewed this in the past month. For 12 rolling months, our revenue from those codes was over $110,000. And so, it seems very menial for each. You might get paid $8 a survey to administer and to review. But cumulatively, it really adds up. And when you're thinking $110,000, that's like two staff members potentially.

And so, thinking about if you don't systematically utilize those surveys, then, one, you may want to look at your workflows to see how you could really promote universal screenings; maybe implement that first, because then you'd have a really good idea of the potential for what those codes are like.

And then, the third part about the financial aspects for a standard practice, there's only one profit center that exists within the organization, and it's the providers. So, profit centers are those that are accountable for generating revenue and cost, and pretty much every other department is a cost center because they are unable to generate revenue. I think for us, BHI is a really unique opportunity. For example, we have a collaborative care model, and so our behavioral health care manager has become a profit center. She's putting the legwork in, and the monthly codes that she uses for her time are actually billed under the providers. And so, really thinking about other ways to create additional revenue streams and optimize revenue streams that you currently have.

Botts: That's great. I think as you talked a little bit about, there's a number of factors both internally with the practice, recognizing the availability of these codes, potential workflows, staffing, and being able to set that up appropriately based on the codes that you're pursuing, but there's also the ability of engaging outside the practice, especially with your health plans, to be able to ensure that the things that you're doing internally are matched by actually getting those payments in a timely way and hopefully limiting the burden in terms of pursuing those payments.

But I also know in some of our other conversations that you've also been able to leverage the BHI program more globally in terms of the negotiation. So, maybe can you talk a little bit about both any steps or tips that you may have in terms of that engagement with those health plans and your all's ability to leverage the BHI program or efforts as part of those broader potential negotiations with those entities?

Dr Boylston: Yeah, absolutely. I would say for a lot of intangibles for the practice, our BHI program has really been fruitful in so many other ways that also have financial value tied to them. And so, we recently completed our round of negotiations with our private health plans. So, those would include United, Blue Cross, Aetna, Cigna. And when we approach negotiations, we're always very assertive about this is the value we bring to your patient panel, these are the things that we provide, and recognizing that when we have same-day, urgent behavioral health visit appointments, when we're able to evaluate and treat behavioral health conditions in-house and showing that we actively manage this, that essentially results in less referrals to specialists, less ER visits.

And so, we're very vocal about the value that we bring to their patients, especially now with behavioral health access being such an issue that's at the forefront of everyone's minds, including the health plans. We were able to really take advantage of our brand promise that this is part of who we are. I think we were really fairly rewarded for that, and that was part of the feedback that we received during the negotiation. So, that's a really tangible way that our BHI program has benefited the practice.

Dr Botts: Absolutely, and I think it's something that isn't always discussed and talked about. There's a lot of the discussions about the P and L of the programs and even potential other values within the practice itself, but I think this ability to be able to leverage this program given the access needs and the recognition really across these different stakeholder groups, including health plans, the value that you all bring to your area and market and to their network, I think, is something that I think is undersold often with these programs and the benefits that they can bring.

We would love to hear a little bit more about the ultimate purpose of doing these programs, the impact you've seen on your patients as well as the members of your staff in terms of the journey and the 10-plus years you all have been doing this and the ultimate impact that you've really been able to see in terms of the long efforts and time and energy that you've put into creating the program.

Dr Boylston: Sure. I think at the end of the day, it's got to work, and the numbers have to work. But really, we do it because it just makes our day better.

I think that everyone on our team would agree behavioral health, it's so deflating when patients come to you with what is essentially their primary issue and you're not able to help them. I think that, for me, was the biggest motivating factor, that I'm supposed to be a healer and I'm not able to address the thing that is really affecting you right now. And so, I think taking it upon ourselves to, one, get the training so you can do this competently... For a while, I think early in my career, I had a little bit of deep-seated resentment, if I can be honest. I would say, "I'm not a psychiatrist." And I think that I really had to have a heart-to-heart with myself and say, "Hey, whether you like this or not, this is the need." And so, either you can be grumpy about it, or you can embrace it and say, "I'm really going to lean into this and help my patients and meet them where they are." I think that that really was a turning point for me as a physician.

But behavioral health visits are very unlike other visits. There's so much emotional labor involved. But when you become more experienced, when you become more proficient, then I think that the rewards are really incredible. When patients come back, for me the most visceral feelings that I've had are seeing the improvement that patients have when they're able to better manage their anxiety. When you hear stories about kids who they have been deathly afraid to go to a sleepover, and they're 12 years old, and they successfully did this for the first time, you really see the impact that you have in helping this child thrive and live their best life. And so, I think for me it's incredibly gratifying. Those stories, they're way more common than maybe some of the challenges and difficulties.

A lot of the patients that we manage, they need help and they benefit from that, but they don't need complex specialty care. And so, for us to be able to manage that... Really for us, I think behavioral health has become what is essentially blood pressure management. Not everybody who has high blood pressure needs to go see a cardiologist or a specialist. Most of that should be able to be managed quite effectively and quite well within the medical home. And so, we're really pleased with that.

I think for our staff, they also see it too, because a great example would be our triage nurses are the first ones to get that very tearful phone call, "My child just told me that they want to hurt themselves. What am I supposed to do?" And so, really helping our staff to train them to become knowledgeable, because at the end of the day, we're all human and many of us are parents too. And so, really being able to be there for our families in their time of need, I think that's really been an affirming thing for all of our staff and really reinforces why are we all here in the first place. And so for us, it's been just a really, really positive experience.

Botts: That's amazing. Going from recognitions, be able to have that action, really have that impact not just on the care team, obviously, but the patients, I think is really critical. And as you noted, just grounding the reasons why to pursue this in the very beginning, I think that recognition is not uncommon with practices across the country. I think the challenge is what to do about that recognition and what is it that folks should pursue or prioritize to be able to make this more of a reality for their practices.

So, to help round us out a little bit, are there any other practical tips or pearls of wisdom other practices or system leaders should be thinking about or pursuing to make behavioral health integration a reality for the practices, particularly thinking about the financial component that really enables all the positive outcomes that you just outlined occur?

Dr Boylston: That's a great question, Chris. I think it's so important that leaders really understand what's happening, where the work is actually happening, and so taking time to meet with staff and with clinicians and figuring out what the pain points are. For every practice and maybe for every system, the needs might be different. Behavioral health encompasses a lot of conditions. Really understanding where the needs are is really important as a first step. It might be my patients have a really hard time accessing therapy. My patients have a really hard time getting into psychiatric specialists. And so, figuring out what the urgent needs are and maybe prioritizing those, I think is incredibly important.

That also engenders engagement because the providers and the staff recognize that the system is receptive to their feedback and to their needs. And so, I think that's a really important first step.

I think the other thing that's really important about starting with the BHI program, everyone's constrained with staffing. It's really difficult, even if you have the resources, to all of a sudden think that you're going to hire out this full team to engage in the work. And so, I think one thing that we've been really good at is to take advantage of our stars. McKinsey uses this term a lot. There are other consultants that use this. But stars are basically skilled through alternative routes. We have several really shining leaders who may not have certain degrees at our practice, but they're basically doing the work of behavioral health for 10-plus years, and they've really embraced all the trainings and the modules and things that don't give you a degree but really deepen the experience of what they're doing. And so, they're the ones with the experience that we've been able to promote and really drive the work of our behavioral health program.

Botts: Excellent. Yeah, I think one thing we hear often in the work that we've been doing is don't let perfect be the enemy of good. There are plenty of evidence-based models and practices out there to be able to implement and really have this impact that everybody's striving for. There's a number of entities that may be included that have a number of resources that can help people along that journey.

So, I just want to thank you again for joining us today.

Dr Boylston: Thank you for having me.

Botts: And for those of you that would like to learn more, the AMA has a number of resources to help you on your integration journey, including implementation and coding guides, which you can access by viewing the episode description or searching behavioral health on the AMA's website.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.

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Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.


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