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[EPISODE]
Christopher Habig
Hello, everybody, and welcome to another episode of Healthcare Americana. I am your host, Christopher Habig, the CEO and co-founder of Freedom Healthworks. Welcome to the show.
As many of our listeners will know and understand, mental health is something that I like to talk about a lot, especially as it relates to direct primary care and concierge physicians. I'm a big believer that mental health falls on a spectrum of, let's say, 1 to 10, 10 you’re a danger to society and 1, you're having the best day of your life. There is no problem that you can't get by with. We tend to, in society, when we're talking about mental health initiatives, we tend to discount who I'm going to call kind of the front door, the gatekeepers of our healthcare system, and that is the primary care physicians and providers out there. Too many times we talk about mental health, we loop a lot of different things into, or we group a lot of different things into the same type of discussion and think that we have to be treated at specialty care. Which is honestly pretty indicative of US healthcare in general. When there isn’t anything wrong with us, we want to go to the specialist and really discount that person who knows us and our family and our history the best.
But diving deeper into this conversation, we're talking today with Dr. Cynthia Horner, the Chief Medical Officer of Amwell, which provides service and software to enable digital care. Dr. Horner is joining us to discuss the vital role of primary care physicians and providers in mental health and the importance of integrating behavioral health into the primary care settings.
Dr. Horner, welcome to Healthcare Americana. Welcome to the show.
Dr. Cynthia Horner
Fantastic, thanks Chris. Delighted to be here.
Christopher Habig
Now, primary care providers, and I don't think anybody's gonna really disagree with me when I say they're kind of the gatekeepers, and all too often we see that those gatekeepers are treated just like that, very expensive triage in order to get past them and get a referral into specialists. So when we talk about the front door to healthcare, that's kind of the realm that we're operating in. I'm curious about your thoughts. Why are primary care physicians so in supporting really the early detection, gosh, the treatment of disease, chronic condition management, even preventing big issues in healthcare in general, but also within mental health.
Dr. Cynthia Horner
Yeah, great question. And I would start by saying I really like the way you framed the term gatekeeper. Primary care in its, is designed in its best iteration to be far more than just a gate. You get to go on to the next level of care. You have to stay. That's such a negative perspective on what the first place, the patient centered medical home really can and should be.
Most individuals when they have a primary care provider, will see that individual as somebody that they can talk about their issues with, hopefully get them addressed. In the case of most primary care clinics or relationships, roughly 75 to 80% of the conditions can be addressed within that location or within that particular relationship. So it makes sense because the primary care provider has a breadth of understanding of the continuum of care and it's not siloed or fragmented. They know when the person has recently been dealing with say an acute issue. Maybe they just got out of the hospital because they had a complicated issue with their heart. Maybe they also have had some medical condition with their sinuses. They understand the surgeries. They understand the cultural context within which all of these healthcare issues are happening. And just as importantly, they are, in the vast majority of cases, the first place where patients will come to talk about, my gosh, I'm dealing with some anxiety. There's a whole host of reasons we could unpack about why, but they often are the first place where that conversation is brought up, where the diagnosis may even be made, and they are very prepared because of the training, which is the second piece. Primary care training really helps to empower those clinicians to address the bulk of what they're going to be seeing in their day-to-day practices.
Christopher Habig
I want to just at least talk about the fact that there's a lot of Americans out there that, you when they hear us talking about, see your physician, go see your primary care provider, they kind of chuckle and say, yeah, right, that you're living a pipe dream out there. How crucial is access to a primary care physician or primary care provider? How crucial is that when you talk about these different initiatives of creating that relationship and having a doctor who knows you. Lots of Americans don't use primary care like calling them up their private office. It's just not an option for so many different people out there.
Dr. Cynthia Horner
There's a couple of issues that we could unpack in there. One is access. know, there is a disconnect in the number of primary care providers. There's a shortage of primary care providers across the United States and it's particularly acute in what are known as healthcare deserts. Certain rural areas or actually even certain urban areas that don't have access. That's one of the ways that the company that I've worked for really helps to address this. That's Amwell with our virtual primary care.
That aside, you know, I think just like any kind of long-term or continuity care, finding the right primary care provider really makes a big difference. And it takes time. It's a relationship that you're building. So if all you do, if all a person does is go to see their primary care provider for their required physical or their, I've got a sinus infection and it's just transactional, then it is gonna be problematic. And really that relational piece is critical. And what I usually tell folks is if you're finding that you're not developing that relationship or there's just not a good connection, I don't care who the provider is, whether it's primary care provider, whether it's a therapist, any one of those relational longitudinal pieces, keep working. You gotta find somebody that you can actually trust because frankly, outcomes are being driven by trust. And we can really get into that when we start talking about mental health.
Christopher Habig
I love the word trust, especially as it relates to healthcare. Our company's built on trust, having a physician trust us to help set up their business and help them find the patients. then patients have to trust them. And you mentioned access, and that's a huge theme right now. A lot of different initiatives boiled down to how does a patient access a trusted physician? And a lot of that is unfortunately built around health insurance and what this little card in my wallet allows me to go do or see. And there's a lot of misconceptions around that.
Weaving in this topic of mental health because it is something that I think society has really put on a back burner for the vast majority of our history up until, goodness gracious, World War I, it was shell shock. And then we actually figured out it's more of a PTSD and there's actual neural pathways that are disrupted in warfare. And that leads to all kinds of different stuff. Fast forward to today with NFL and football and CTE and brain injuries. And that leads into mental health and all kinds of different things. And then social media. Teenagers. And it's all this stuff is just like hitting us right now as we move from less of a physically talented society into something that is you know using our brains more and more and less of our bodies to get things done. Mental health seems to just continue to come up and bubble up to the forefront of any type of healthcare and medical conversation. With that I think there's a lot of misconceptions around what exactly mental health is. I'm curious based on your medical school and your training…how do you really define what mental health is? I think that's a good place for us to kind of have our next leaping jump off point for our conversation.
Dr. Cynthia Horner
Yeah, sure thing. The concept of mental health is broader than just, do you have an ICD-10 diagnosis of anxiety disorder or depressive disorder or any one of the myriad in the DSM-5.
Really, mental health talks about the behavior patterns and thinking patterns that contribute to a person's life and their lifestyle. And when they become maladaptive, you have a mental health issue. So addressing those maladaptive patterns of thought and behavior, and really helping to turn those around is really the crux of what mental healthcare is all about. And some of that involves developing coping skills. Some of it involves unpacking the root causes of those maladaptive behaviors. Maybe they weren't maladaptive when they first came up. Maybe they came out of an automatic neurologic response to a traumatic episode. Either way, gaining the understanding of what happened, how it is impacting an individual today and how they are thinking about themselves, interacting with their world and interacting frankly with others and how that interaction impacts their relationships and therefore has a cyclic effect. So all of that becomes really critical. It becomes critical both from a…how do I feel as an individual about myself, my life, my future…but also how do I engage with others? And then how do I take care of myself?
So for example, a diabetic, a family physician or a primary care provider is not going to be able to see a diabetic and talk about lifestyle changes in healthy eating patterns effectively without really helping to unpack some of the what are your eating patterns. And why are they that way? And what helps drive them? And I'll tell ya, primary care docs that are dealing with a 15-minute appointment don't have time to be unpacking your thoughts about your body habit, habitus and how you engage with food. So in our current traditional models.
Christopher Habig
Yeah, and let's go there because one of the hallmarks of the model that we use is, let's have 30, 45, 60 minute visits or let's be able to have a text message where you talk to the same doctor every single time. You build that relationship, you build that trust so that physician needs, you know, gets to know you on there. You know, that is again, it's a big barrier to a lot of people being able to see that. So, if most Americans who are able to establish a primary care physician, will just focus on that subset, but only have 15 minutes with that doctor and they want to bring up something that is outside of their, there's me air quotes behind camera, know, free preventive visit. How is that even supposed to work? I just don't understand it. I know you and I see eye to eye on this one, but you talked about 15 minutes with a doctor and say, need to have a conversation to unpack what is causing me the most stress and anxiety in my life. How is that even supposed to happen for most Americans that do have doctors?
Dr. Cynthia Horner
There are several different ways that that needs to happen, but the first way that shouldn't be happening is, I'm sorry, you have 15 minutes, you're here for your hypertension, let's focus on the hypertension and then schedule another appointment with me and we'll talk about that. There are lots and lots of ways and we train our providers how to begin to triage some of these issues without ending up with a 45-minute visit even within a traditional model.
There are other models that leverage allied health professionals to help address some of the issues. So the primary care provider can log the concept. You know, sounds like you're having some real stress related issues. You know that that actually has an impact on your diabetes, your high blood pressure. It may not be fully driving it, but we really need to unpack that because until we do, we're probably not going to get this taken care of. And then you take the top key pieces of it and either, one of a couple things, either you provide some information in that visit…it doesn't mean you can't schedule follow-up time, but you really need to engage the patient and make sure that you've given them something to take away with. If you have the time, say for example in a direct primary care model, to be able to address it right then and there, that's even better.
You can also leverage, there's a whole host of digital tools, and in my world as a chief medical officer of a digitally enabled company, there's a whole host of ways that you can do this that still retain the personal in it. And engage people in some of those lifestyle modifications between visits. You can have integrated behavioral health folks in the office, a whole bunch of different models that are out there. But one way or the other, you have to address it. And it's probably not going to be in, we're going to just in a traditional model.
Christopher Habig
Do you agree or disagree? So in my introduction, I mentioned that I always view mental health on the spectrum of kind of one to 10, where 10, you're a dangerous society, one, you don't have a stress or a worry. You're basically a three-year-old at that point in time. Like, you don't know what nightmares are. Nothing's ever wrong. I mean, am I okay simplifying the wide range of mental health issues in that approach?
Dr. Cynthia Horner
Absolutely. And even when you look at the diagnostic manual on what the criteria are for getting an official diagnosis, there's a whole range of things within before a person actually qualifies for a diagnosis of, say, generalized anxiety disorder. But there’s pre-diagnosis elements that can actually, that we know will lead people to an official diagnosis if you start, if they're not addressed. So I think that's even true and frankly the spectrum of health is not an on-off switch. I mean you have pre-diabetes and you've got diabetes and then you've got severe diabetes. I mean it's true across much of what we do. So many of the things that preventative interventions that primary care clinicians do in their “wellness” visits, and I'm putting air quotes around wellness, is to help uncover and address a lot of those precursors to potential problems down the road. And some of those, you know, some of the questionnaires that we will be asking in those visits and that frankly, NCQA and Joint Commission are saying you need to screen for this, you need to screen for that. The whole reason for that, even in the mental health sphere, is to find out what is this person at risk for so that you can deal with it when they're in your description, the maybe 1 to 4 range.
Christopher Habig
Yeah, and that was kind of my next question. So, from a primary care standpoint, if we're saying, all right, everything is a 1 through 10. And again, I'm probably oversimplifying a lot of that out there. And a lot of it is subjective. And there is no one size fits all approach for anything in healthcare, whether that is at a single person or how to pay for healthcare or what the role of insurance should be. So there's a lot of heavy topics out there.
What numbers can be actually covered at a primary care office, if we look at that from a one to 10?
Dr. Cynthia Horner
Yeah, and I'm going to pull away a little bit from your 1 to 10 because I want to normalize it with the diagnoses that many of your listeners would recognize.
I think most primary care providers are going to be comfortable with mild to moderate anxiety and depression. A subset of primary care providers may be comfortable with a stable bipolar patient, but it really depends on how the person is doing. Some primary care clinicians, particularly in pediatrics in a more rural area, may be comfortable dealing with, or even in adult medicine, may be comfortable dealing with other areas, whether it, mean, the list of possible diagnoses is very long, eating disorders, et cetera. So I think really the issue is less of a let's name the diagnosis that belongs in primary care and more about what is the acuity and how stable is the diagnosis.
So, you know, as a family physician when I was in brick-and-mortar care, and I was in a more rural area at the time, I had a schizophrenic patient that I was seeing. He was very well managed. He'd been on the same medication. He was an adult that was in his 40s at that time. And this was, you know, several decades ago. But and they really wasn't a lot of extra management that needed to happen so it made sense that he could continue to see me for all of his care.
That said, if I had a brand-new patient that was where the diagnosis really wasn't clear or the standard methodology of our leveraging diagnosis was not getting us to a place where it was clear what his treatment plan should be or the treatment plan that the primary care clinician is implementing isn't really getting the results. That's typically when you're going to refer to a specialist. Sometimes the specialist will say, here's what you need to do, take them back and I'll see them in a year. So it's really more of an acuity and a stability question.
Christopher Habig
We're talking with Dr. Cynthia Horner, the Chief Medical Officer at Amwell, covering the role of primary care in addressing mental health across the United States. I like the way you broke that down. And again, I'm like, I'm oversimplifying with 1 through 10. So moving into more clinical diagnosis is a welcome, welcome input on this conversation.
So working within primary care. And again, this is something that affects so many Americans, whether they like to admit it or not. It's becoming easier to admit from anxiety and stress and depression all the way up there. The role of the specialist, because every time I talk to somebody at the state level or somebody at the federal level, mental health is a huge, huge problem and it permeates all aspects of our society. If I'm a mental health specialist, psychiatrist, behavior health, psychology, what am I doing knowing that I have a massive wait list? You know, are they in there saying, like you just said, like this person should be seen at the primary care level? Or are they saying, yeah, I'll come talk to everybody whether I think you should be handled up here at the specialist level or whether your primary care doctor should be able to figure it out.
Dr. Cynthia Horner
You know, I think in general, the American Psychiatry Association and National Institutes of Mental Health, several of the key governing bodies all recognize that there is a significant shortage of psychiatrists across the country and therapists across the country. I think the, my, with the colleagues, the colleagues with whom I work within those specialties are not trying to sort of keep hold of patients. They're just trying to get through the patients that they can see on a regular basis. If a primary care provider is referring somebody to them, they want to be able to respond to that. And so we've got a shortage. So that's a whole policy issue and coverage issue. There's also some opportunities for digital care within there. And I think a lot of the payers are really looking at how can they, how can they model some of these more hybrid care options to provide that access across the country? But you know, when you look at some of the statistics, I think it's…having that collaborative approach even within a community, having for example, there are some models where some primary care offices will pull in a therapist into their office and really do an integrated primary care model, integrated behavioral health model. But we know that currently there are 150 million people that live in federally designated mental health professional shortage areas. It's 150 million people that can't get access and it's not because the psychiatrist and the therapist are just trying to hold on to these patients.
One statistic that I read basically said that in Nebraska, you might have to wait several months, and this is not just Nebraska, for an appointment, even for people who are fairly ill. And that was from an individual, a psychiatrist at the University of Nebraska Medical Center. I can't tell you how many people I talked to where it's not only several months, it's 6 months that we're talking about.
For therapists, the Kaiser Family Foundation estimated that 47% of the US population, which is 158 million people, live in a mental health workforce shortage area. So again, it's a problem across the healthcare ecosystem and it places stress on those mental health professionals in addition to the primary care provider, some of who feel like, I don't have the time to deal with this.
Christopher Habig
Yeah, there's a shortage all over the place and, you know, just curious, you mentioned some policy ideas. Why is there such a shortage of mental health professionals anywhere in the United States?
Dr. Cynthia Horner
You know, I think there's a whole combination of reasons. I think some of it has to do with the current reimbursement models, some of it has to do with the acuity of patients that are coming through and the severity and the not only the lack, do we have a lack of providers, we have a lack of facilities to be able to care for patients that really need something more than just outpatient care. And it's because of the payment capabilities. Our payment models are broken when we're talking about mental health issues. The fact that primary care is oftentimes it's a mandated required. You have to have some sort of baseline payment capability through the Affordable Care Act has to be available. Mental health, there is no such similar legislation and regulation around that in most places.
Christopher Habig
Well, it seems, especially from the ACA standpoint, when any time the government comes in and mandates something, the price just skyrockets, and the supply just decreases right there too. So I'm like, I don't know. It's a double-edged sword. And that's why I was kind of wondering. And again, I have these conversations because we have a shortage in primary care. There's a shortage in pediatrics. There's a shortage in internal and family and everything along the lines. And it's not like people just decided, hey, I don't want to be a doctor anymore. Like that's not going on. There's still people who want to be physicians and want to be therapists and want to go get their PhDs out there. But it just baffles me because I don't think there's any simple solution in healthcare rather than just starting over and that would be its own absolute mess. But yeah, these shortages happen. I'm like, gosh, there's got to be some type of solution where we can leg into it rather than just recognizing the problem. And maybe I'm crazy for saying that.
Dr. Cynthia Horner
You bet, and there are some great solutions. No, not at all, and there are some great solutions that are out there. And I think part of the problem is we are stuck in between the old traditional models where it's just providers have to work harder and have more throughput, see more patients in order to get the reimbursement for what they're doing. And it's not all about money. I mean, these providers actually really do care about their patients. But at the end of the day, they often have businesses that they need to keep alive. They have families that they need to support. So there is payment that's important as a part of this. And the reimbursement models are historically based on how many patients can you see in a particular period of time. They’re not necessary outcomes driven.
So we started off this conversation by you mentioning a direct primary care kind of model. That's one really excellent model where you leverage the primary care providers to take care of those that are appropriate within primary care and build some of the reimbursement methods through, you know, direct primary care, as you know, is enabling, it's a set fee structure for a set type of condition, set number of conditions. And it's a flat fee in addition to or outside of you know health coverage and patients need health coverage. They get hospitalized they're going to need something for that. But it enables the provider to really work with the patient to drive those outcomes and it's not just let me see you again let me see you again. Those unintentional incentives are removed in that situation.
So there's also integrated behavioral health as I mentioned before where you pull a behavioral health specialist into a visit. So a primary care provider may be seeing somebody with anxiety as part of their wellness. They say, here are the couple of things I want to deal with but do you have 15 more minutes? Because I'm going to pull my therapist in that's here in the office and have her talk to you about a couple of coping skills that I want you to do and then we're going to follow up with you in whatever way. Maybe it's a phone call, maybe it's a digital visit, maybe it's an automated care sort of algorithmic AI based and they're really good. Before folks start sort of getting hives over this, there are several that are really good and not just bots. But.
Christopher Habig
You said the AI trigger word there. Next you're going to start talking about data and really throw everybody into a frenzy here.
Dr. Cynthia Horner
I know. But anyway, there are several models, and I think we need to really get intentional about starting to leverage these models.
Christopher Habig
I love that aspect from the integrated approach of, hey, let the primary care doctor be your quarterback. And you know, it takes a team to move the ball down the field. And sometimes you gotta hand the ball off. But it's not just running the same darn play every single time of you go to a hospital doctor, great, you have headaches, great, go get an MRI. There's a machine down the hallway and $3,000 later, you just need to drink more water or whatever it is, right?
And so we're getting outside of the system where people are kind of waking up to the fact that most hospital systems are a massive conflict of interest. Let's work within people who actually care about me, understand me, and are incentivized to keep me healthy. And, you know, I think that's where the DPC model really, really thrives is aligning those incentives. And, you mentioned you mentioned hospital care in the worst day or worst day of your life when you have a bad accident or whatever happens to you. Yeah, unfortunately, you're going have to need that health plan because you know as much as the hospitals like to complain about their margins and how bad a customer the insurance companies are they still refuse to do business with them so they're not refusing to do business with them. So I'm always that guy in meetings to say well if this guy's only paying you 50 cents on the dollar stop selling your stuff to him. Maybe that's just me, you know, from the kind of burn it all down type of crowd.
Wanted to talk about your work here at Amwell as we close our episode. So you are working specifically on a digital platform to help enable access to these types of services that we've been talking about from the mental healthcare aspect of it.
I am curious when we talk about access, how important is it to have a tool like what you've been working on in place so that when somebody reaches out it's not just a hotline going to an anonymous person? It's something that can happen immediately to a physician or provider who is trusted who can help address that specific need right then and there. How important is it to have, I'm not going to say near instant access because I don't think people are chained to their desks or anything like that. But talk a little bit about what Amwell has been able to build and how it is enabling that interaction between a patient who needs it and a provider who knows that patient.
Dr. Cynthia Horner
I hope so. Yeah.
You bet. So there's a whole host of different types of care that a hybrid care model can bring. As a family physician that worked predominantly in brick-and-mortar to start, I would suggest that their digital care will never replace, and this is not really rocket science, what I'm about to say, digital care will never replace that brick-and-mortar experience, that face-to-face in the same room. But there are things that can be done that can be done through a virtual visit, even including, shockingly, a physical exam. Not necessarily the full wellness exam, but parts of a physical exam can be done.
So how do you do this? Well, if you want to keep your patients within your provider group, within your population network. One of the best ways to do so is to ensure that your group is available when they need you and at those times. And some of it can be putting somebody in your office available for sort of what we used to call the walk-ins, but these are digital walk-ins. And there's so much more efficiency when a patient is right there because they're sitting at home. You don't have to wait for them to drive over to your office. And your provider, whoever's running that particular digital schedule that virtual schedule. They're right there documenting in your healthcare system's EMR and being able to access all of the information and being able to kind of coordinate more carefully. So there's lots of different ways to do that.
Separately, there's a whole host of ways to ensure that, for example, maybe if you're doing chronic care, you have your behavioral health provider be a digital provider that you can pull in as part of these visits. And they are pulled in for digital visit. There's lots of ways that we could, you know, we could sort of brainstorm that.
Similarly, you could also have other allied health professionals. If you've got a diabetic and you really need to get them in to see a nutritionist, maybe there are ways that you can leverage a digital nutritionist as a part of this and you've got a set number of hours where that person is going to be available. A whole host of different things that can be leveraged with this. The key is data sharing, access to your patients because they want. And if they don't get it from you, going to be looking, they'll find it. So keep it in house, is what I say.
Christopher Habig
Dr. Horner, Chief Medical Officer of Amwell. Dr. Horner, I appreciate you joining us here on Healthcare Americana to share your insights on a topic that is so relevant and it's something that I talk about almost daily, if not every other day in the normal course of business of let's unshackle our physicians and providers out there, give them the time and let people get the healthcare that they need. So thank you for coming on the show and sharing your insights with us.
Dr. Cynthia Horner
Thanks, Chris. It was great to have this conversation with you.
Christopher Habig
And to our listeners, thank you for joining us on this episode of Healthcare Americana. We hope you found today's discussion insightful and inspiring. If you enjoy the show, please leave us a rating and review on your favorite podcast platform. For more episodes and latest updates, visit our fantastic website at healthcareamericana.com.
I'm Christopher Habig, reminding you to stay informed, stay healthy, and stay empowered. Until next time, take care.
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