In this episode, we’re pleased to welcome Array Behavioral Care’s Vice President of Sales, Scott Baker, and Physician Executive, Dr. Brian Schurgin, to share tele-behavioral health trends, applications, and best practices.
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Highlights of this episode include:
- Where to access behavioral healthcare
- The clinical and financial implications of coverage gaps
- How gaps in coverage affect the emergency department
- How med/surg floors and inpatient units are affected
- Behavioral health solution for hospitals
- Financial benefits
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Scott Baker, vice president of sales for Array Behavioral Care, and Dr. Brian Schurgin, physician executive with Array Behavioral Care. As vice president of Business Development, Scott Baker leads a team of business development executives tasked with building relationships across the continuum of care to increase access to quality behavioral healthcare services. Scott has worked in the telebehavioral health space since 2012 and focuses his attention on identifying and innovating the latest opportunities for improving care via telehealth. He frequently shares telebehavioral health trends, applications, and best practices at speaking engagements across the United States.
Dr. Schurgin is a clinically active and board-certified emergency medicine physician who has extensive experience with the use of telepsychiatry in his daily practice. He earned his medical degree from the University of Michigan Medical School and his master’s in healthcare administration from the University of Illinois, Chicago. Dr. Schurgin works often with hospitals and health systems to design virtual behavioral healthcare programs to deliver timely and clinically appropriate care to patients in emergency departments requiring acute psychiatric intervention.
Thank you for joining us today, Scott and Dr. Schurgin, to discuss making a business case for virtual behavioral health.
Dr. Brian Schurgin: Thank you so much.
Kelly: Well, gentlemen, let’s jump into it today. This first question is to Scott. The growing need for mental healthcare is widely recognized, as is the shortage of psychiatrists and other mental health specialists. Given this, where are patients currently turning to access behavioral healthcare?
Scott Baker: Yeah, it’s a very interesting time and place in the healthcare market. It was a trend that we saw even before COVID but was certainly accelerated by COVID, where you’re seeing more and more options for a consumer that might be digital-enabled tools. But at the end of the day, we still find that the vast majority of individuals seeking behavioral healthcare direction and services are still looking to the trusted institutions in their communities, like the hospitals, health systems, and clinics that have been there for decades and are a pillar in kind of the fabric of healthcare delivery in their community. So specific to hospitals and health systems, we’re seeing behavioral health patients present with increasing incidents, acuity, and complexity to hospital emergency departments. A fair amount of that is legitimate and appropriate. But we also do see some behavioral health patients seeking care in the ED, frankly out of necessity or frustration because of a lack of timely, convenient, or even affordable options in the community. Hospitals also see a fair amount of behavioral health patients and needs within their inpatient medical floors. And a lot of hospitals and health systems operate and are investing in expanding their ambulatory footprint both within outpatient primary care as well as outpatient behavioral health service lines. And certainly, that’s a much-needed resource in the community for patients with behavioral health needs to be able to seek and receive care before they’re in a position where they may be decompensating or at risk and have an acute need. So those are the most common settings for behavioral health patients to seek care.
Kelly: Okay, well, thank you for that. And Dr. Schurgin, from a hospital perspective, where are you seeing gaps in coverage for behavioral health patients, and what are the clinical and financial implications of these coverage gaps?
Dr. Schurgin: Well, good question or questions. So, first of all, as Scott indicated, patients are turning to hospitals specifically because of difficulty obtaining access to timely psychiatric care. So, the patients typically present to the emergency department. Some are in acute crisis and are being brought in by family members or paramedics or police. And the vast majority of them come in voluntarily seeking help for depression, substance abuse disorders, psychosis, anxiety, and so forth. The emergency department has become their de-facto home for access to care. And because of that, it’s created a gap in coverage for most emergency departments across the country. With rare exception, the amount of psychiatric patients presenting to the emergency department, especially in the aftermath of COVID, has overwhelmed the resources that are available at most community, or for that matter, even teaching hospitals. So big gap in coverage, especially in the evening hours and after hours after midnight, which is when a lot of psychiatric patients, in fact, a lot of patients, even medical patients, arrive in the emergency department. The biggest time of arrival for patients in an emergency department is the late afternoon and evening. And psychiatric patients tend to come in even a little bit later than that. So, they’re coming in at a time when resources are scarce within the hospital. Those who are day workers have gone home. So now you’re subject to people who are on call or are willing to come in after hours. And obviously, that resource or that capability is much smaller than the capability that we have during the day. So, these patients who are very vulnerable are coming in at a time when resources are scarce, even at the best-staffed hospitals.
But as we know, over time, behavioral health has never had the financial endorsement, if you will, of other service lines or beneficial financial support of other service lines. So, because of that, there’s always been a lack of front-line workers in behavioral care, and especially as we talked about in the evenings and after hours and especially in response to the increasing presentation of behavioral care patients in the emergency department in the aftermath of COVID. So, it’s almost like– I know you’re in Florida right now being hit by a hurricane, but it’s almost like a hurricane occurring where you’ve got all these forces coming together at once, lack of access, coming in at hours where the hospital isn’t fully staffed, and an increasing need because of the aftermath of COVID and what’s happening with our economy and so forth. So, I find the biggest gap is in the emergency department. We are seeing gaps on psychiatric inpatient floors as well, and that further compounds the problem because, if patients have to linger in the emergency department and can’t get up to an appropriate inpatient site bed, then they need more care in the emergency department. We already identified the fact that resources are scarce. So, it is a bit of a hurricane or tsunami effect where we’re overwhelmed with these patients. We can’t admit them often, or we can’t transfer them because there aren’t enough beds available to care for all the psychiatric patients that need admission, and it’s difficult to discharge them home because there aren’t community resources that can see these patients in a timely fashion. So that’s where the biggest gap is in the emergency department followed by the inpatient department.
And then, obviously, there’s a need in the community, in the clinics to see these patients. So, what does that mean for the emergency department? The second part of your question was, “What are the clinical and financial impacts of these gaps of coverage?” Well, the first and foremost thing is acute psychiatric patients stay in the emergency department considerably longer now than they did a couple of years ago. It’s not uncommon for patients to wait three, four, five days in an emergency department to be placed into an appropriate inpatient psychiatric bed. Whereas, when I first started emergency medicine 25 or 30 years ago, patients would be admitted in a couple of hours. Or if they had to be transferred, those beds were identified and patients were transferred in a timely fashion. So that boarding, if you will, of psychiatric patients leads to several things. First of all, clinical outcomes are always worse the longer a patient remains in the emergency department. It is a difficult place to receive care. In that, patients are vulnerable. They’re frightened. They don’t get the one-on-one attention that they might get on an inpatient psychiatric floor. They’re not receiving often their home medications or being advanced to new medications that they might require. So, their needs are basically going unmet over those several days that they linger in the emergency department. So, the clinical outcomes are poor for those patients, but that backup leads to other patients in the emergency department having delays in care because, if resources are being devoted to psychiatric patients that are in the emergency department longer than they should be, there are less resources for the remaining patients in the emergency department. So other patients with very complicated medical issues as well are often facing delays, and that includes patients with chest pain and stroke and even patients that present with trauma.
So, as you can imagine, delays in seeing those patients and delays in giving those patients the resources they need will lead to increased morbidity and mortality of those patients. There’s been numerous studies, a large study done in Canada, several in the United States that show that as the ED length of stay goes up for a medical or surgical patient that requires admission to the hospital and ultimately maybe surgery or acute intervention, every hour they remain in the emergency department, their morbidity, mortality goes up fairly significantly. So, this is a big problem, not just for psychiatric patients, this lack of access or these gaps in coverage, but for all patients that present to the emergency department. So, this truly is not just a mental health issue, but it’s a population health issue. It’s a community health issue. Being able to care for these patients appropriately and timely impacts all patients at the hospital and community level. And then, financially, it’s pretty clear that the longer these patients stay and the more resources they require, the more expensive the care is for them. And this care is provided in the emergency department where care per hour is more expensive than it is in other departments in the hospital. And it’s being given to patients for very long periods of time because of these gaps in coverage. So we talked about the financial impact and the clinical impact.
There’s a third impact, and that is on the staff and morale of the hospital. So, emergency providers come to work every day wanting to do their best for every patient in the emergency department. And it becomes very frustrating and demoralizing at times when they’re not able to do that. So, if resources are diverted to one subset of an emergency medicine population and other subsets are suffering because of that, it’s, like I said, very demoralizing, very disheartening for the nurses and physicians that are caring for those patients. It often leads to physician burnout and nurse burnout. It leads to patients leaving that particular hospital. And that becomes a big problem for the hospital to now recruit and retain new providers. So, there’s a lot of impact of these patients on all aspects of the hospital. Security, janitorial services, food services. The longer these patients remain in the hospital, it impacts virtually every department in the hospital and starts to strip away resources from those departments as well.
Kelly: Well, those are some very interesting insights. Thank you. And as a follow-up, as a practicing emergency department physician, how do these gaps in coverage affect the emergency department?
Dr. Schurgin: Well, as we talked about the staff and morale issues, we can talk about how the backup impacts other patients, the medical or surgical patients in the emergency department. It also can affect the safety of the psychiatric patient. The longer those patients stay, the more agitated they become. They often require restraints, whether that restraint is through medication – we call that chemical restraint – or if that restraint is physical. Those restraints can impact the safety of the patient and the safety of the nurses, physicians, security guards, and other ancillary staff. So, it’s a profound impact on the emergency department in hospital the longer these patients remain in the emergency department for all the reasons we just talked about.
Kelly: Okay, makes sense. And this one’s over to Scott. Your colleague just described the impact on the emergency department. Can you speak to how other parts of the hospital are affected, particularly med/surg floors and inpatient units?
Scott: Absolutely. And I think Dr. Schurgin did an excellent job of painting the different perspectives involved within an ED setting. When you have this fundamental disparity between an increasing demand from behavioral health patients and a shortage that’s just completely getting overwhelmed, a shortage of behavioral health clinicians, you have long legs to stay. You have impacts not only to the behavioral health patient population as well as the medical patient population. You also have consumption of services, right? Having a behavioral health patient stuck in an ED bad for a period of time longer than is necessary to stabilize and evaluate disposition, it has a tangible cost associated with that as well, right? And some studies have been replicated that are frankly a bit dated now that suggest a direct cost of approximately $100 per hour. That study was done back in 2012. And so you really do have a direct cost to the ED unit when you have behavioral health patients languishing there. You have an opportunity cost because, every hour that behavioral health patient is remaining in an ED bed, typically, they’re boarding there waiting for an inpatient psych resource to open up. You’re not getting the bed turnover needed to get more medical patients into those beds. And I think we all know just how much the ED is the front door to the hospital, right? Having poor bed turnover, poor throughput, high left-without-being-seen rates has substantial direct and indirect costs and opportunity costs to the hospital.
And the other element to consider within the ED from a financial perspective is we’re finally at a point with telehealth and behavioral health where reimbursement is nearly universal and positive for the types of services that we provide in an ED setting. Now, it’s rare that a fee for service reimbursement model will constitute the entirety of the cost of services, but it’s now a pretty meaningful element in considering financial implications of ED. Now, when you move your focus over to an inpatient med/surg floor, typically, the business case or the financial implications are a bit different. So I guess, maybe to start from a clinical standpoint, what’s the use case on an inpatient medical floor for a behavioral health patient? And it really falls into two categories. One is the most predominant, where a hospital has a patient on a medical floor with a primary physical health complaint that has an underlying view of health concern, that is challenging the treatment of the patient for their primary medical condition. And I would suggest that– for those listening to the podcast, I would challenge you to actually go and look for what the incidence is of a comorbid behavioral complaint with a physical health condition on your inpatient medical floor. It will probably surprise you just how common that is. And your hospitalists are clamoring for support, for consult, liaison support to help them to ensure that they have the right diagnosis and treatment plan to address the underlying behavioral health complaint of that patient.
And I think one of the most significant asks that we get on the medical floor is for a clearance evaluation, right? “Is this patient ready to go home? Are they safe to go home? Are they capable of understanding? And do they have an intention to follow through on discharge instructions so that the hospital is not at risk of recidivism or other HEDIS measures if that patient does not fare well when discharged?” And I think we all know that patients with a comorbid behavioral health complaint on a medical floor are really at risk of overstaying their DRG if the hospitalist is concerned of the safety and appropriateness of discharge and if they are delayed in getting that psychiatric clearance evaluation. I promised two categories. That was all relevant to the first category. The second category of a scenario where behavioral health need presents on a medical floor is for those hospitals who really have no choice but to move a patient with a primary behavioral health condition up to the medical floor just to keep their ED moving. It’s somewhat rare, from my experience, to have hospitals do this. But when a hospital is forced to move a psychiatric patient to a medical floor, it really has substantial impacts. What we’ve heard from the market is that these hospitals have a much more difficult time getting that patient accepted on an inpatient psych unit when they’re on the medical floor. And these medical floors really just aren’t designed to advance the care of a psychiatric patient. It’s rare that hospitals will have the degree of medication intervention from a psychiatrist or psych nurse practitioner therapy services available to advance the care of the patient. And so hospitals that are forced to make these trade-off decisions really need support to help prevent moving those patients up to the med floor unless they truly have a medical condition to be addressed.
Kelly: Okay, thank you. That makes a lot of sense. And Scott, can you please describe what an effective, well-managed behavioral health solution for hospitals looks like?
Scott: Sure. So the reality is that behavioral healthcare does not occur in a vacuum. Behavioral health is a condition that really, truly presents in a continuum of care. And an effective, well-managed behavioral health solution mirrors that in having a solution that is multifaceted. Here at Array Behavioral Care, we’re very proud of the scope of services that we’ve developed over our 22 years of experience delivering virtual psychiatry and therapy services. And so for any hospital or health system, stakeholders, or leaders who are engaging in the podcast today, I would challenge you to think about your acute and your ambulatory needs. And so well-designed solution has the right type and capacity of behavioral health clinicians and processes to support those clinicians to be able to provide timely and effective interventions within your acute settings like your ED. Now, here at Array, our on-demand service model provides reliable and expedient response times from clinicians 24/7/365 to ensure that for those behavioral patients who are seeking care in their ED, that their disposition to the most appropriate, least restrictive level of care and for those patients who do meet criteria for inpatient psychiatric admission, that stabilizing treatment is considered and initiated and managed as quickly as possible so that that patient is not really just sedated and waiting for a bed.
Further, you need strong consultant liaison support services that are available and have a strong rapport with hospitalists. And then, when you have the luxury of thinking beyond your acute settings, you really have to consider the needs that are upstream and downstream of your emergency department. And so we find that a lot of hospitals and health systems right now are reconsidering the strategy implications of their primary care and outpatient behavioral health service lines. Those hospitals and health systems that do not yet have outpatient behavioral health service lines, most of them are thinking about establishing them now and are concerned about the ability to recruit and retain clinicians in their community. And those who have outpatient behavioral service lines, most are considering expanding them. And so the right well-managed behavioral health solution for your ambulatory clinics is not only that foundation about patient psychiatry and therapy because you need that. You really need a dedicated capacity of psychiatrists, especially psychiatrists and therapists in your community, for your primary care physicians to refer to. But then you also have to look to, “How can you support your primary care physicians, your pediatricians, and your other clinicians on the front-line of delivering primary care to patients?” Because there is a subset of patients in their caseloads who can remain within their caseloads so long as you give your primary care physician support and consultation.
And at Array, we have experience with a variety of different models for behavioral health integration as well as for collaborative care that allows us to spread that scarce psychiatric resource as far as possible to be able to reach as many patients as possible. And one last thing that I’ll mention is that we’ve seen a lot of hospitals and health systems engage in retail, direct-to-consumer-type telehealth services. It’s really an excellent way for a hospital to expand its catchment area, to engage patients in its communities that don’t yet have an affiliation with the health system. Oftentimes, hospitals and health systems are looking to urgent care, right, teleurgent-care types of options to accomplish that function. And I would challenge folks to not be intimidated by including behavioral health in that direct-to-consumer offering as well. Here at Array, we’ve had a lot of success at rolling out what we call Array at Home, which is essentially a direct-to-consumer outpatient behavioral health practice that offers longitudinal care from child and adult psychiatrists and therapists directly to patients in their homes. We’ve been very fortunate to have gained substantial payer partners in this space that allow us to address needs from patients that have Medicare Advantage or commercial insurances, and in some cases, managed Medicaid. And we’ve really found that that’s a missing piece in a lot of care continuums to be able to introduce a virtual outpatient behavioral health option for primary care physicians who are looking for referral options for patients as well as for stakeholders in the hospital who are looking to discharge patients.
Kelly: Wow, that sounds fantastic. And Dr. Schurgin, in keeping with the title of this episode, Making the Business Case for Virtual Behavioral Health, what are the opportunity costs associated with the inefficient management of behavioral health patients? And what are the financial benefits of a solution like the one Scott described?
Dr. Schurgin: Well, we’ve touched on this a little bit earlier in the podcast. But by having an inefficient solution to behavioral health, most patients linger in the emergency department. We talked about how that impacts the clinical outcome, right? The longer a patient remains in the emergency department, for the most part, the worse their clinical outcome is, the worse their experience is. So, their satisfaction as a consumer goes down significantly the longer they stay in the emergency department. So, we know from lots of studies that all of those are true that patient satisfaction is almost linear. The longer you stay in the emergency department, the worse your experience is and the worse that you rate your overall experience and the less likely you are to come back to that emergency department and the less likely you are to refer friends or family. So, if you’re not having a comprehensive solution like Scott talked about and these patients remain longer than they need to in the emergency department, backing up the overall flow of the emergency department, it can have a dramatic impact on the bottom line of the emergency department and the hospital. First of all, the cost of care goes up in a way that it’s not being reimbursed. As Scott indicated, if patients stay beyond their DRGs because they weren’t properly managed in the emergency department, that care’s being reimbursed. As patients linger for days in the emergency department, that care’s being reimbursed. So tremendous waste of resources leading to a tremendous drain on the financial resources of the hospital. So, cost goes up exponentially as these patients last in the emergency department. And more importantly, you are less likely to get the medical and surgical patients the care they need, which then is a huge opportunity cost.
So, if patients are waiting in your emergency department in the waiting room because they can’t get in, because beds are being used by psychiatric patients that should be transitioned inpatient units or discharged home, those patients in the waiting room over time are going to leave. So, you are losing patients that could produce revenue in the forms of medical or surgical admissions, of procedures, of radiology imaging, and lab testing. All of that is walking out the door the longer those patients are waiting in the emergency department. So, I would ask anybody on the podcast to go back and look what their left-without-being-seen rate is in the emergency department. If it’s above 1.5%, then they are losing patients unnecessarily that would otherwise translate into medical or surgical admissions. And that can have a huge impact on the bottom-line success of a hospital and the financial success of the hospital. So, a huge opportunity cost, both in caring for these patients and in losing patients that would otherwise come into your emergency department if the waiting times were more appropriate. In addition, we talked about the patient experience that suffers as these throughput issues manifest over time. As patients have bad experiences, that is the beginning of a very difficult spiral for a hospital to get out of. If there is a bad feeling in the community that when you get to that emergency department, there’s going to be a long wait and the emergency department is not viewed as being efficient and effective, you’re not going to come back. If you have an alternative to care in your community, you’re going to seek that out. Over time, hospitals that struggle with lengths of stay issues ultimately struggle to maintain the vitamins they need to stay viable financially.
So, it’s all really tied together. And the solutions that Scott was talking about, which is making sure that those gaps in coverage are met, both on the inpatient side and in the emergency department and, quite frankly, in the outpatient setting, will allow for timely access of care for behavioral health patients. They will move through the emergency department and hospital in an appropriate time, receiving effective care in a timely fashion, therefore, freeing those resources up to move other patients through the emergency department and hospital, which is really the lifeline of the hospital. 60% of all admissions for most hospitals come through the emergency department. So, if your emergency department is not running efficiently, then you’re losing a huge opportunity to grow your hospital through medical and surgical admissions as well as psychiatric admissions. So, I think those are the main aspects that a well-thought-out, well-structured, well-supported, comprehensive behavioral health solution can bring to the hospital, decreasing those direct costs, and enhancing those revenue opportunities by moving patients through the emergency department in an appropriate and timely fashion.
Scott: And if I may, Kelly, for the longest time– here at Array, we started doing this back in 1999. For the longest time, that concept of building a business case for investing in a virtual psychiatry solution to hospital EDs, we were collectively having to make that case conceptually with our hospital partners. And we found that, over the past four or five years, that really wasn’t sufficient anymore. There was a higher bar for demonstrating ROI, for quantifying to a hospital, “What is the current cost exposure to me of inefficient poor resource management to be a rough patient? And where should I look for offsetting reimbursement, offsetting value elements to justify the case? And at the end of the day, what’s the ROI? Give me the number.” And so a few years ago, we went out to the market and really engaged some expert consultants and building some business case tools to be able to help us to do those very things. And so I think we’ve all seen these ROI tools that are really just a marketing sham where you click the button and it says, “Buy, buy, buy.” This is not one of those tools. It’s really been a valuable asset to Array and to our hospital prospects who need to truly build a justifiable business case for the investment that they’re seeking.
Kelly: Yeah, no, that makes a lot of sense. It sounds really interesting. Thank you both so much for joining us today and for sharing all this valuable, awesome information with us.
Scott: Thank you very much for the opportunity.
Dr. Schurgin: Thank you so much.
Kelly: Great. And for both of you, if someone wants to contact you or learn more about Array Behavioral Health, how best can they do that?
Scott: Well, that would be great. I would encourage folks to please visit our website at (arraybc.com) . And if you scroll to the bottom, there’s a Contact Us link that comes directly to my inbox. Would love to talk shop, answer questions, or engage with folks who are interested with what we talked about today.
Kelly: Fantastic. Thank you. And thank you, all, for joining us for this episode of The Hospital Finance Podcast. Until next time…
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