This article is sponsored by PointClickCare. This article is based on a Behavioral Health Business discussion with Dr. Benjamin Zaniello, Chief Medical Officer at PointClickCare and Dr. Samit Desai, Chief Medical Information Officer at Ascension. The discussion took place on March 16, 2023 during BHB Value. The article below has been edited for length and clarity.

Dr. Ben Zaniello: There are roughly a little less than 30,000 skilled nursing post-acute facilities in the country. The core EMR of the skilled nursing community post-acute is PointClickCare. We’re the largest EMR player in that space, however, a couple of years ago, given the scope in senior care, PointClickCare moved into what I would call the loose association of Medicaid safety net and behavioral health.

I came over from a company called Collective Medical, which was acquired by PointClickCare in 2020. Some of you may have worked with Collective data because we operated in 20-plus states as a combination data hub in care collaboration platform focusing in the Medicaid space. We’ll go into a little more detail on care collaboration, but I’d like to introduce a close friend, Dr. Samit Desai, why don’t you talk a little about yourself and what you do?

Dr. Samit Desai: I work at Ascension Health, and I lead what we think of as clinical experience. I worked in the health information exchange space, regional, and state-based health information exchange. If you know that world, there is a lot of emphasis in that community in supporting clinical data exchange, behavioral health data exchange, given the importance of moving that data to care for patients across what’s a very fragmented and evolving ecosystem.

I’m an ER doctor by training and so a handful of days a month I live the crisis that you all are trying to solve.

Dr. Zaniello: We have overlapping biographies, which is, I was the chief medical information officer at Providence. The company Collective Medical that is now part of PointClickCare, focused again in the behavioral space, but particularly in the emergency department space. We would in fact overlap at emergency department conferences. This is when I say I am not an emergency room doctor, I’m an infectious disease doc.

Currently, I mainly do urgent care and HIV primary care, which is, as many people know, primarily behavioral health focused as is so much of healthcare. I was a little surprised that no one talked about the ER in behavioral health.

We all want to keep behavioral health diagnoses and behavioral health patients out of the ER. It’s often for me totally unrealistic given the volume of BH diagnoses in the ED today. What are your thoughts on that?

Dr. Desai: We talk a lot about safety nets, and the ER is the ultimate safety net for behavioral health patients and care. I see an increased focus on solving the behavioral health crisis in the ED for a number of reasons. One is, as we all know, healthcare generally is under great duress. I’ve been saying this more recently. There’s always so much talk about how healthcare is broken and how it needs to be fixed.

Ascension lost a billion dollars last year, and we’re going to lose another billion dollars. We are under true duress. Focusing on clinical operations and getting efficient care to take care of everyone is a big deal. You would think, “Well, wasn’t it always a big deal?” It was, but it wasn’t the focus. There were all kinds of other areas to focus on. Connecting to behavioral health, we all see very deeply that the ERs are seeing more behavioral health patients. We continue to struggle to care for them well, and disposition them to the best sites of care.

We are, as an organization, thinking about the ED length of stay problem, and thinking specifically about how we better integrate with the behavioral health community because it is the core of this overall problem. I see for us increasing focus on better management of behavioral health patients in the ED and trying to figure out ways to leverage technology and leverage networks of providers to do that.

Dr. Zaniello: Can you talk a little bit about specific diagnoses? Certainly, in the press today, we read a lot about the opioid epidemic, which worsened during COVID as anything mental behavioral health related did. Are there any mental health specific things that you all are doing?

Dr. Desai: Yes. It’s been a few years now, but surely, you’re all familiar with SBIRT (Screening, Brief Intervention and Referral to Treatment). It’s amazing. I’ve probably been here about 15 years, and when patients with substance use disorder would come in, we would give them a pat on the back, say a few sentences, maybe have some materials, and be like, “Good luck.” It was awful but thankfully, through communities like this, and just increasing awareness of the management of substance use disorder, language has changed, and the stigma has been reduced. Everybody knows about the opioid crisis, and so, there’s been a very real shift in mindset and resourcing.

In the state of Maryland, we were able to mobilize funding to a smaller state. We could drive consensus more effectively to employ staff, individuals sitting in our ER, to perform the evaluation of patients who clearly either come in for an overdose or were there for alcohol use disorder, and really speak to them as peers, and then connect them. They became experts in connecting these patients to what was a still small but enlarging community of service providers in a way that never existed before.

Now, yes, it is important for our clinical community physicians to learn about what SBIRT is, and different treatment modalities that began in the ED, like buprenorphine and things like that. There’s only so much you can stuff into any given provider when they’re learning a million things, and so, having expert staff that can take the ball is important. I don’t think you will find a person that doesn’t believe this has been a game changer. The good news is it’s not one of those programs where people came in and there was some funding, and six months later, everybody’s gone. They’ve been here consistently for years.

It’s something we’re doing in a few sites across Ascension and are hoping to scale, and I hope, very intentionally because of funding. We’re a big system, but in pockets, it’s been pretty good.

Dr. Zaniello: I feel that that particular approach, and I think the loose term is ED bridge, this idea of bridging into the community. It’s most striking as part of, for example, the opioid crisis, like the pat on the back that you would give. So much of this was the recognition that this person was in deep pain, but there was an inability to help them in a progressive way. Accessing the community resources so that they move from a moment in crisis in the ED to an outpatient clinic that can then provide care and hopefully reduce their need to go to the ED.

Hopefully we can implement this across the country, and it will be exciting, but it remains to be seen if it can be systematized. It’s interesting, the ED is almost a little bit of a transactional part of healthcare, which is the unfortunate part of how emergency medicine has been treated.

Can you talk a little bit about your perspective of making the emergency department a part of value-based care and population health?

Dr. Desai: That’s a great question. I have this fortunate experience in that Maryland is a forerunner as a state in emerging care model and payment redesign. Without going too in depth, we did run a multi-year experiment in which hospitals were given global budgets and had to manage patient care and were sensitive to total cost. The ED became a fulcrum of that out of the gate. My experience is this: the chaos of the ED and just managing the influx of patients coming in makes it poorly suited for some of the systems.

We implemented many programs, and they were hard to sustain because of where the mindshare of the clinical staff was and just trying to get people through and service the community. Now, a couple things are changing. It’s less about what the ED community will do, and more about what the community will do to integrate with it in terms of providing services, and in terms of the technology that we can embed into the systems, like the EMRs or others that the ER staff uses. That’s how this will evolve.

The other thing that’s happening from my view, is that there is downward and real pressure on physician salaries for a whole bunch of reasons. I do wonder if the ED community will begin to seek value-based deals with plans or through other vectors for purely financial reasons, and it may mean they’re willing to then make space and time to better integrate with care management that may exist outside the hospital across the continuum. I could see that happening.

Dr. Zaniello: It’s a silver lining a little bit. It’s funny you talk about Maryland because, of course, Maryland is a little bit unique. It’s public health-oriented and their reimbursement model is so different.

I’d love to hear your perspective as you sit in the Ascension system and look across multiple states. I know it’s going to be a shock to everyone here, but we have a red state and blue state divide in this country. A lot of that filters into healthcare fever, service, value-based care and safety, net reimbursement, Medicaid expansion and the like. I feel Ascension is sitting across an incredible variety of states in reimbursement methodology. What are your thoughts on that?

Dr. Desai: Our approach and our strategy to date when it comes to this space has been all about integrating with the pretty vast primary care network. We employ 9,000 physicians. About 60% of that is primary care and our strategy has been focused on screening identification.

Then when we identify that patients need higher screening, identification upskilling our primary care staff, top of license type of stuff that everybody does. We don’t employ a large swath of what would be traditionally thought of as behavioral health professionals. To your specific question of where our focus has been, there is a problem when you try to administer an IDN across 20 states. It’s hard.

There are all kinds of inefficiencies and things you don’t do well with scale. Then there are things you can do well with scale. We’ve often focused on Medicare because we can follow rules at scale with Medicare better than we can with state level Medicaid variation. The intersection of senior care and behavioral health is where we’ve tried to focus our attention in making this space better. The red/blue thing washes away a little bit just because of where we can focus. Even though we’re a vast organization, we can only focus in so many places.

Dr. Zaniello: Specifically, are you talking about Medicare fee for service, Medicare Advantage or dual eligibles? Is there a specific target in those?

Dr. Desai: Yes, I would say Medicare Advantage is a flashpoint for us for a whole bunch of reasons. Everybody sees the trend in MA, it’s undeniable and in terms of dollars at risk for us, for the first time, MSSP dollars have converged with MA dollars and so all our executives are focused on MA. We talk less about the duals, but I could see that emerging for us as a cohort that we need to hug more deeply and solve those problems with more focus, but I would say MA right now.

Dr. Zaniello: Another topic that came up that I thought was interesting was, again, we had what I would call the payer group. A lot of us were in that session with CVS, Aetna would throw things at me as would Optum, if I called them mostly payers, given that they have large provider networks. Then UHS, which is mostly providers, talked a lot about data and how to align reimbursement and to drive successful outcomes.

The term was “measurement of success.” They talked about needing more access to data, and I wasn’t exactly sure what they were driving at and I’d love your thoughts. I feel you spend a lot of time in the “free the data” space.

Dr. Desai: There are Ascension specific problems, which I don’t want to belabor because they’re not everyone’s problems. You work with so many different health plans, work with CMS, trying to onboard data, they even want to give you hard data to manage. Ingesting it, normalizing it, that’s just work. It’s a lot of work and we struggle with that, but putting that aside, from the provider side, we don’t have claims data and so there’s been a lot of focus on claims. We have our clinical data.

The focus to date has been working with health. There are a few things to note. One is ingesting large claims data sets from the Anthems and Uniteds of the world. CMS has done a better job in making their data available through APIs and that sort of thing. We’re starting to get clinical data from the ecosystem, which here is being defined as outside of us because we know patients go everywhere. What I often say is, Ascension’s big, but we’re small.

We have 150 hospitals, but the country has 5,500. In any market we have to work with the ecosystem. We are starting to invest in getting clinical data from everyone else and there are now tools to do that and networks to access. There is increasing funding and energy and that’s where I spend a lot of my time.

The other thing that’s happening is that we’re starting to see the vendor community, particularly the EMRs, integrate directly with health plans in a way that we love because it scales better. One of our big ambulatory providers is AthenaHealth. They run probably 60% of our practices and they’re doing deep integrations with, for example, Humana back to MA. Humana is all in on MA and they’re just exchanging. We are the providers using it. There are things we’re doing to ingest and put that data in big Google Cloud databases. The final thing I’ll say is everybody knows that when it comes to moving behavioral health data, there are regulations around it.

Dr. Zaniello: Just speaking very candidly, when any organization is under financial straits, weird things happen and reorgs are constantly taking place, with strategies changing every week. One of the good things I’ve seen for us is the latest strategy was unveiled. Behavioral health was quite high. You can only focus on so many things. I think because of the way behavioral health can support senior care management, because of the way it could support value-based care, and the need to do better with it, I think everybody said, “Hey, if we can wrangle some of the problems in this space, we will do a good thing because we are providers first and we are mission oriented. Then we can also serve some important strategies that right the business so that we can sustain ourselves.”

I found a lot of hope. We’re hiring executives, we’re investing and focusing on it, even in a time where you would think every conversation is about money just so we don’t lose it. One more thing I would say is you can see all of us have been around to see the level of dialogue around any given thing that maybe isn’t preeminent.

Even over the course of five years, behavioral health rolls off the tongues of more and more leaders within health care. They know about it. It occupies some consciousness, which means more and more investment attention. Those are all net positive things.

Dr. Desai: I’m excited that you mentioned the senior care piece of it. My company has moved across from senior care into behavioral health with various acquisitions. I’ve been struck by the opportunity. Certainly, this group knows that this artificial separation between physical health and mental behavioral health, the data is great.

You absolutely cannot treat a depressed person’s diabetes. Throw whatever pill, or any number of appointments, but if you don’t get their depression managed, you will never lower their blood sugar. As a clarion call of recognizing that whole person care and whole person approach is so important.

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