Virtual Care and Mental Health: Dismantling Silos to Strengthen Delivery of Care

July 11, 2023

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00:00Topic cannot be more true than in the
00:02next session that we're about to pivot to,
00:04which is virtual care and mental
00:06health dismantling silos to
00:08strengthen the delivery of care.
00:09And I'm so delighted that Doctor John
00:12Scott is agreed to moderate this panel.
00:15John is the Chief Digital
00:17Health Officer for UW Medicine.
00:18He's also a professor in Allergy
00:20and infectious diseases at
00:22University of Washington.
00:23I've known him for a long time,
00:25got to know him a lot better.
00:26Through the pandemic,
00:28as we shared best practices
00:30and learn from each other,
00:31he's been doing the Project ECHO
00:35since before 2010 has really
00:37made an impact in serving rural
00:40and underserved areas for.
00:43You know common diseases,
00:45complex diseases really built out a
00:47a terrific model that was robust to
00:50low bandwidth challenges as well.
00:52So I'm delighted to have you John.
00:54I think he may be joining by video
00:57more than audio due to some technology
01:00challenges himself in the the
01:02digital desert of his hotel room.
01:05John, are you there?
01:07Yeah, I am. Can you hear me?
01:08Awesome. Yes, perfect. John,
01:08I'm going to turn it over to you.
01:11Thank you. Thank you. Yeah,
01:12I'm a a victim of the digital divide and
01:14and I'm currently located in Washington,
01:17DC, eight blocks from the White House.
01:18So it's not always in the rural areas where
01:21you have challenges to getting broadband.
01:23So we're going to talk about
01:25virtual care and mental health.
01:27And we have 3 distinguished speakers today.
01:31Our, our objectives are threefold.
01:33First, I want to introduce the concept
01:35of this collaborative care model.
01:37Which may be a little bit of a new concept
01:39to folks especially on the East Coast,
01:41but something that many,
01:43many folks are doing on the West Coast.
01:46The next thing we want to talk about
01:48just why are there silos between
01:51mental health and physical health and
01:53you know why is why is that happen?
01:56And then lastly want to want to
01:58be sure to talk about the Ryan
01:59Haid Act and how that might impact
02:01your your care of telemedicine.
02:03So I'm going to introduce
02:05our speakers and I'm
02:10have them give their presentation,
02:11then we'll have the Q&amp;A at the end.
02:12I do want to remind folks, we do have a
02:1410 minute break between 3:20 and 3:30.
02:17So thank you for your patience.
02:20And but we do have a break coming up.
02:22So our first speaker is really
02:24a legend in telehealth,
02:26that's Doctor Peter Yellowly's.
02:28So Peter was the past president of
02:31the American Telemedicine Association.
02:33He was the inaugural Chief
02:36Wellness Officer at UC Davis.
02:38He's now a Distinguished Emeritus
02:40professor of psychiatry at UC Davis,
02:43where he directed the fellowship
02:45program in clinician wellbeing,
02:46a really timely topic.
02:48He's currently the CEO of Async Health,
02:51which is a telemedicine
02:52company that he cofounded.
02:54He's going to be our first speaker.
02:56Our second speaker will
02:57be Doctor Daniel Becker.
02:59So Dan is a professor of clinical
03:00psychiatry at the University of California,
03:02San Francisco and the School
03:04of Medicine there.
03:05He's also Vice Chair for Strategy
03:07in the Department of Psychiatry.
03:10His specialty is in the adolescent
03:13psychiatry and addiction psychiatry.
03:15So look forward to his perspective
03:18and his talk.
03:19And then our third and final speaker
03:21would be my colleague in Washington state,
03:23Doctor Chris Chen.
03:25So Chris is a internist.
03:27And also Medical Director from Medicaid
03:29at the Washington State Telehealth,
03:31I'm sorry,
03:32Washington State Healthcare Authority.
03:34So I'm going to turn it over to
03:36Peter to give the first presentation.
03:38Peter.
03:40Good. Well, thank you very much indeed.
03:41It's a real pleasure to be here.
03:43And I really look forward to the
03:45feedback and the discussion section
03:48in particular because I think this is
03:50a really interesting topic for this
03:52particular symposium because we're talking
03:54a great deal about collaborative care,
03:57which is really I think to a great
03:59extent a West Coast thing started
04:00in at the University of Washington,
04:02obviously the AIMS center and is
04:04now spread widely across the West
04:06Coast and it's certainly the primary
04:08way that we provide.
04:09Care at UC Davis, I'll,
04:12I'll be talking about that and
04:14and talking about the benefits
04:16of hybrid care as well and other
04:18people will will take over after me
04:23next slide disclosures.
04:25As I say, I'm the CEO of Async Health
04:28Inc which is actually a company
04:31that's commercializing asynchronous
04:33telesychiatry and the an editor
04:34of this book from which some of
04:36the talk is taken. Next slide.
04:41Two major learning objectives for me.
04:43The 1st is just to overview
04:46collaborative care in the virtual
04:48world and then comment on some of the
04:52increasingly strong evidence based
04:55for both hybrid and asynchronous
04:57care that have occurred particularly
05:00during the COVID-19 era. Next slide.
05:04So what is collaborative care?
05:06Basically it's team based care.
05:09That's my way of looking at it.
05:11It's it's essentially a team of
05:14mental health professionals supporting
05:17primary care physicians and advanced
05:20practice providers in primary care.
05:22And obviously it started to offer
05:24as an in person process many years
05:26ago has been large numbers of papers
05:29written about its effectiveness
05:31and it's increasingly moved into
05:32a a series of virtual models.
05:35In recent years and these virtual
05:38models for the collaboration can involve
05:40any of the long list of potential
05:42technologies that you see on this slide.
05:45So they can be either
05:46real time or asynchronous,
05:48so they can be remote patient
05:50monitoring and of course hybrid
05:51care really means some form of in
05:54person care plus any of the above.
05:57Technologically focused approaches, so.
05:59So really we're talking here about a,
06:03a virtual team working with the patient,
06:06but with the primary care physician
06:09ultimately providing the care,
06:11doing the certainly medication
06:14management as necessary,
06:15although some of the virtual team may
06:19be providing therapies as appropriate.
06:21So moving on to the next slide.
06:24Now there's been a whole lot of
06:27work certainly at UC Davis looking
06:30at how do we use asynchronous
06:33telepsychiatry as a component of this,
06:35what you could also call stepped
06:37or integrated care.
06:38So it's just one form of providing
06:41this team based care assisting
06:43primary care physicians.
06:45Here's a paper from 2018 talking
06:48about this and and the next slide.
06:53There is a review article
06:55that I wrote with Steven Chan,
06:57a longstanding colleague,
07:00and essentially looking at the
07:03many different approaches to
07:05asynchronous virtual technologies
07:07in mental health care,
07:08and really was a large number
07:11of possible approaches.
07:12The next slide.
07:15Very important that everyone is,
07:17is aware of the evidence base for
07:20telepsychiatry in general and this
07:22is just some examples of the the
07:25various different guidelines that
07:27have been developed by the American
07:30Telemedicine Association and the
07:32American Psychiatric Association.
07:33So prior to COVID,
07:35quite a strong evidence base but mainly
07:37focused on real time video conferencing.
07:40Next slide.
07:42And along comes COVID and this
07:44was really a forced experiment.
07:47You know,
07:48many of us have spent many years
07:50trying to convince our colleagues
07:52to use technologies with patients
07:54and it really did take a pandemic.
07:56We, as you all know,
07:57we saw an immediate expanded access to care,
08:00particularly to underserved and
08:02and racially racially diverse
08:04communities and the use of telephony,
08:06which is extremely important,
08:08particularly for follow up visits.
08:11Large numbers of Medicare
08:13patients have received care.
08:14We've seen reduced costs for for
08:17both patients and providers.
08:19And perhaps the most important thing
08:20that COVID has done for all of us,
08:23it's it's driven innovation
08:24at new models of care,
08:26which is what we're really
08:27talking about today.
08:28Now we know that there will
08:30be an extraordinary number of
08:32psychiatric consults during the the,
08:35the,
08:35the COVID pandemic hopefully that these
08:38numbers will you know maintain at A
08:41at a fairly close level in future.
08:43And it's also challenged a lot of our
08:46payment models and and an increased
08:48move to value or calculated care.
08:51And interestingly there's there's a
08:53large number of papers now coming out
08:56demonstrating high levels of convenience.
08:58And satisfaction for for all involved.
09:01And from UC Davis,
09:02we actually have just such a paper
09:05with over 90,000 consultations
09:07assessed for satisfaction.
09:08That's been published in the next few weeks.
09:12And and that paper showed that people
09:14were just as satisfied with video
09:16care as they were within person care.
09:19So the next slide.
09:21So what really is
09:23asynchronous telepsychiatry?
09:24You can see here that the
09:26two different models,
09:27synchronous telepsychiatry is just
09:28straight to the patient seeing
09:30them maybe in their homes somewhere
09:32else in the community and I think
09:34that's a great way of practicing.
09:36In asynchronous telepsychiatry,
09:37somebody else apart from the psychiatrist,
09:41interviews the patient.
09:42We record that interview,
09:44send the video to a psychiatrist,
09:47and that person then writes A
09:49consultation note with treatment
09:50recommendations.
09:51Next slide we've shown in two trials now.
09:57In both primary care and in nursing
10:00homes that this is a feasible
10:03practice and in the primary care
10:06program we actually showed that it
10:08was just as clinically effective
10:10as synchronous telepsychiatry.
10:11We're currently finalizing results
10:13from the the skilled from school
10:17nursing home trial but we we know
10:19that the clinical outcomes are are
10:22likely to be as good next one.
10:25Now we've written a whole series of
10:28other papers looking for instance at
10:30the primary care physician adherence
10:32to telepsychiatry recommendations and
10:34and we found that in fact they are they,
10:39they adhere to about 60%
10:41of the recommendations,
10:42whether the patient was
10:44seen synchronously or
10:45asynchronously.
10:46It's actually very interesting.
10:47There's very few papers about this
10:50in in the general literature.
10:53Looking at how effective the recommendations
10:55are at the primary care level.
10:58Next slide, we've also described all
11:01of the training processes and and and
11:05needs for the interviewer that does the
11:08asynchronous telepsychiatry interviews.
11:10So this is it's effectively A
11:13relative new role for a mental
11:15health provider and the next slide?
11:18And we've done this across
11:20languages so that we've been,
11:21we've seen quite a number of
11:24patients in Spanish with a Spanish
11:27speaking provider interviewing them
11:29then using automated translation
11:32systems and as well as interpreters.
11:36To take that,
11:39that video was done in Spanish
11:43and translated into English.
11:45What we've shown there is that
11:48whilst with simple language,
11:50current translation systems
11:52like Google and Microsoft.
11:55Are are fine.
11:56So that's for very simple interviews.
11:59For for psychiatric interviews,
12:01they're really not good enough and they,
12:03the translation systems cannot cope
12:05with synonyms and metaphors and
12:08and complicated language that we
12:10tend to use on a regular basis in
12:14in psychiatry and the next slide.
12:17And so where are we going?
12:19We,
12:20we're convinced that asynchronous
12:24approaches where we don't see
12:27somebody in real time but record
12:29interviews electronically via video
12:32or or or potentially telephony are a
12:35really good way of going to provide
12:38this form of collaborative care.
12:42We have written actually about
12:4415 publications.
12:45You can find all of these if you
12:47just put my name into Pub Med.
12:49And we're now starting to
12:52commercialize this process because
12:54we really think that this is a much
12:57more efficient way of working and
12:59is a way of reaching more people
13:01who you know in this post COVID
13:04era certainly need our help.
13:06So I'm going to finish at that stage
13:07and we'll move on to the other speakers.
13:11Great. Thanks, Peter.
13:12I'm going to turn it over to Dan
13:16Okay again. I'm Dan Becker,
13:19I'm a psychiatrist and I work at UCSF.
13:23I'm going to start by telling you a little
13:26bit about the supply demand problems
13:29that we face in in psychiatric care then.
13:32Talk about some of the ways that we mitigate
13:36that that gap between supply and demand.
13:39It will echo some of what Doctor
13:41Yellow he's just spoke about.
13:44Then I'm going to say something
13:46about how we use virtual care to
13:50to facilitate filling that gap and
13:53to make it a better system of care.
13:57I will talk also a little bit about how.
14:00That you know how we deal with,
14:02let's say more acute, sicker,
14:06complex patients and and how virtual
14:09care helps us there touching
14:12on addiction treatment.
14:14And and then we'll wrap up with what we
14:19learned at UCSF during this pandemic.
14:21To start with the supply demand problem,
14:24if you go back to the middle
14:25of the previous century,
14:26there wasn't really a supply demand.
14:29Issue for psychiatric care.
14:30There wasn't a great deal of demand.
14:33There was some supply.
14:35Most people who wanted care could get it.
14:38There were state hospital systems that
14:41provided care for people who are quite ill.
14:44Things evolved,
14:45including that there was gradually with the,
14:49let's say, the gradual destigmatization of
14:52psychiatric problems and psychiatric care.
14:55More and more demand and more and more,
14:57therefore more and more utilization,
14:59more and more individuals and
15:02agencies getting into that market,
15:04so to speak.
15:05And then in in the 1980s when
15:07managed care became a thing,
15:10it certainly became a thing
15:12for psychiatry as well.
15:13And one of the tools that were used,
15:15that was used for managing behavioral
15:17healthcare was to carve it out in others,
15:20to to take the management of psychiatric
15:23care and place it in a different company,
15:26perhaps a subsidiary of the larger
15:28insurance company or a different agency.
15:31And to manage it under separate rules,
15:34maybe limited number of sessions per year,
15:38lifetime caps that were lower,
15:41annual caps that were lower.
15:43Restricted diagnoses that were
15:45covered and so forth.
15:47So that carving out I think was one
15:50of along with the stigmatization that
15:53preceded it was one of the sort of
15:56the bases for what we now have is
15:58a as a siloed system in the 1990s
16:04as managed care techniques became
16:05more and more mainstream within
16:07healthcare management generally.
16:09There,
16:09it was felt to be less of a need to
16:12carve behavioral health out from
16:14other other types of medical care.
16:17And then again because of increasing
16:20demand and concerns that patients
16:23wanted more coverage than they were
16:25perhaps getting under the limited benefits.
16:27Many states, including California,
16:29in which in California it was a B88,
16:32was the law.
16:33But many states had these laws that
16:36took certain diagnosis and move them.
16:38Into a situation where they needed
16:40to be covered at about the same
16:43level that other types of medical
16:45disorders were covered.
16:46So then as a response to that
16:48the carve out
16:49kind of went the pendulum swung
16:51the other way and since then in the
16:53past decade and a half we've we've
16:55seen more and more demand in part
16:58driven by you know consumer desire
17:01and codified by largely federal.
17:05Laws, including more recently
17:07the Affordable Care Act.
17:09Let's move to the next slide, excuse me.
17:12So what we have now is siloed
17:15systems of care.
17:16The payer systems are separated
17:18for that reason because it's
17:20hard to not just hard to access,
17:22but if it's hard to get benefits
17:24reimbursed at an appropriate level
17:26many multispecialty groups and
17:28health systems are staying away from.
17:31Psychiatric care, if they're getting into it,
17:33perhaps not at the level that they
17:35would need to get into it in order
17:37to cover their their full population.
17:39As a result of the disintegration,
17:40there's less less focus on screening,
17:44early intervention prevention,
17:45some of the tools that have been
17:47extremely helpful in the last few
17:49decades with respect to other
17:50areas of medicine at the same.
17:52So that's the that's the supply
17:55side on the demand side.
17:57Gradual, Gradual, Reduced Stigmatization.
17:59Perhaps that's less true for addictions,
18:03but certainly across most of psychiatry.
18:06Much less stigmatized than it was,
18:09you'll say, 50 years ago, and therefore more.
18:12More desire for care and more valuative care.
18:16Let's move to the next slide.
18:18There are many ways to address this.
18:21Doctor Yellowly's did a very nice job just
18:23now talking about collaborative care,
18:25which is a way to get.
18:27One way to think about it is the
18:29way to get more behavioral care to
18:32patients earlier in the course of
18:35their of their psychiatric difficulties.
18:38I I have some experience with not
18:41exactly the model that he's describing,
18:44but an integrated model that again
18:47makes use of primary care physicians,
18:50master's level therapists,
18:51nurse practitioners, and.
18:53Us you know judicious use of
18:56physician specialists.
18:57If we could go to the next slide this,
19:00I'm not going to go through this,
19:02but it's it's basically a financial
19:04model how we developed a financial
19:06model and you can make models like
19:09this work as long as they're run
19:11fairly tightly with clear sense of
19:14how you maintain flow keep patient
19:16keep patient access going and in
19:19order to do that you need to have.
19:22People working at the top of their
19:24scope and and the right clinician
19:26at the right place at the right
19:28time for the right patient.
19:30That is something When we developed
19:32these models many years ago,
19:35they were at least in my experience here
19:38in California they were in person models.
19:41But we've quickly found out that
19:43in the outline areas,
19:44in the more rural areas,
19:45in the small clinics that were further
19:49further removed from the larger.
19:51City settings that it was hard
19:53to have the right provider there
19:55at the right time because because
19:56the numbers were just too small.
19:58And for that we used virtual care
20:00and it worked amazingly well to keep
20:02the model going and ultimately to
20:04keep it affordable.
20:05Let's go to the next slide.
20:08Now if we move off of integrated care,
20:11which focuses at least in my
20:14setting on primary care and to
20:16some extent to a large extent
20:18on secondary care as well.
20:20In the more complex care settings,
20:21typical academic, Medical Center,
20:23psychiatric clinic such as
20:25where I'm sitting right now,
20:29virtual care has been
20:31incredibly helpful as well.
20:33We have many patients with mobility
20:36and transportation challenges.
20:37We have many patients,
20:38as all specialties do,
20:40whose responsibilities make it difficult
20:42for them to leave loved ones at home.
20:45And as long as people have a.
20:47A reliable connection and are comfortable
20:50with the video communication.
20:52We've done amazingly well in complex
20:55care settings using using virtual care.
21:01Virtual care has worked less well
21:03perhaps for brand new patients,
21:05patients who might benefit from an
21:07in person evaluation initially and
21:10in order to sort of facilitate the
21:12the connection with the patient.
21:15It also works less well,
21:16we have found with our youngest
21:18patients and with others with verbal
21:21communication difficulties such that they,
21:25we and they rely on nonverbal
21:27cues more than we might be some
21:30of our adult or or young adult
21:33or even later teenage patients.
21:35Also, it works less well for cute
21:38or subacute patients for reasons
21:39that are probably obvious.
21:41Next slide.
21:44I'll say a word about addictions.
21:47You know,
21:47I I think of addiction treatment is
21:49basically a special case or a subcase
21:52of other types of specialized care.
21:58There's some advantages of of
21:59virtual care and addiction treatment.
22:01One is that similar to what model that
22:04Doctor Yellow Lee's presented and what I
22:07was saying a moment ago about integrated
22:10models and multispecialty clinics.
22:13In addiction care,
22:14we use a lot of interdisciplinary
22:16collaboration and again in order to get
22:18the right team together at the right
22:20place with patient that can be challenging.
22:22But when you do it virtually it,
22:25it becomes much easier.
22:27Also the issue of stigma
22:29I I mentioned in passing,
22:31I think that stigmatization
22:33of addictions has persisted,
22:35has been more tenacious in the case
22:38of addictions than it is with other
22:41types of psychiatric disorders.
22:43And some people are just loathe to
22:46walk into a a clinic setting that's
22:49associated with addiction treatment
22:51are much more easy to engage if
22:53you can work with them virtually.
22:55On the flip side, there's, you know,
22:59again, looking at stigmatization,
23:00there are people who are are hesitant
23:04to do a video visit from their
23:06home because there's somebody who
23:08lives with them that they're not.
23:10Willing to disclose that they're
23:11getting help for an addiction.
23:13So in those cases they do better
23:15if they come in person.
23:16Also, and this is an important one,
23:18I think addiction treatment makes use of of,
23:24you know,
23:25medications that have traditionally
23:27often been
23:30dispensed or or administered
23:32within the clinic setting.
23:34A good example would be medications
23:36for opiate use disorders.
23:38And in order to treat those
23:41patients through virtual modes,
23:43accommodations need to be made
23:46in terms of how the protocols for
23:48how we manage those medications.
23:50Finally, I I think motivation and is,
23:54is it difficult with any clinical
23:57relationship including in psychiatry,
23:59but I think it's especially
24:01salient in in addiction treatment
24:04and sometimes it's difficult.
24:06Again at least initially to establish
24:08that therapeutic relationship
24:11if it's not in person and that varies
24:13quite a bit from clinician to clinician,
24:16patient to patient. Finally,
24:18last slide we during the pandemic what
24:22did we learn at at at Langley Porter,
24:26Well 99% at the at the peak of it more than
24:2999% of our site clinic visits were virtual.
24:33For the vast majority of it worked
24:35very well with with greatly reduced
24:38cancellation or no show rates.
24:40In some instance it did not work that well.
24:43Some of the some of the reasons had to
24:45do with younger patients or patients who
24:47were more disorganized and benefited
24:49from the from the in person environment.
24:54We found that we served our patients
24:55best when we thought of virtual care,
24:58not really as a model of care but as
25:01a tool for providing better care.
25:04You know, for for all of us I think who
25:07are on this involved in this symposium,
25:09our aim is to provide the best
25:12possible care for our patients.
25:14Virtual care is a very powerful
25:16tool which can often not always
25:18but often aid us in that.
25:20I'll wrap it up there and again
25:21at the end if there's time,
25:23be glad to take questions on these topics.
25:27Great. Thanks, Dan. We're going
25:28to move on to our final speaker
25:30which is Doctor Chris Chen. Chris.
25:33Thanks, John. Hi everyone.
25:34Nice to be here with you today.
25:36Again, my name is Christopher Chen.
25:38I'm an internist and I work as a
25:40Medical Director for Medicaid at the
25:42Washington State Healthcare Authority.
25:44A little bit about the Healthcare authority
25:46before we dive into today's presentation.
25:48The healthcare authority is wears a
25:51number of hats in Washington state.
25:53We we cover over a third of the population
25:57of the state of Washington through.
26:00Through two main programs,
26:01one, through our employees and
26:03retire benefits program,
26:04that's all our public employees
26:05and school employees.
26:06So about 800,000 covered lives
26:09on the commercial side.
26:10And also as a Medicaid agency,
26:12we cover about 2.2 million lives
26:15in our state Medicaid program.
26:17And so in addition to being a public
26:19purchaser and a state Medicaid agency,
26:21we're also a state behavioral health agency.
26:23We administer a number of mental
26:26health services, Sud services.
26:29Population based services such as crisis
26:31response as well as recovery supports
26:33and we're also a health IT agency.
26:35And so we administered a significant
26:37component of the high tech
26:39funding that came into Washington
26:41State to support meaningful use,
26:43promoting interoperability programs
26:45and EHR technology for providers.
26:49So we have an interesting perspective
26:50on telehealth and behavioral health
26:52and today I'll be speaking a little
26:54bit about that from the Medicaid
26:56perspective on the next slide.
27:00So just a little bit as a background
27:02and overview, pre Pandemic,
27:04we had a very flexible telehealth policy
27:06that was applicable to many types of
27:08services and providers in different settings.
27:11As someone alluded to in a prior talk.
27:14We can't as policymakers we can't
27:16always anticipate the innovation that
27:18is happening at the clinical level
27:19and having a flexible policy enables
27:22some of that innovation to happen.
27:24For example,
27:25maternity telehealth was was something
27:27that was kind of cutting edge here in
27:30Washington state even prior to the pandemic,
27:32and we've had telemedicine parity in place
27:35for audio visual services since 2018.
27:38Additionally,
27:38we had regular engagement with partners
27:41in our community and regularly attend
27:44Doctor Scott's Telehealth Collaborative,
27:46which is a multistakeholder forum
27:49for discussing telehealth issues
27:51in Washington state.
27:53And we also implemented the collaborative
27:55care model and I think we're among
27:57the first in the country to do so,
27:59which has been critical to breaking down
28:01silos and increasing the integration of
28:04primary care behavioral health services.
28:06Also pre pandemic,
28:07we've been on a journey to in fully
28:11integrating physical and behavioral
28:13health under our Medicaid program.
28:15And so under our integrated managed care,
28:18which we've have had in place since 2016.
28:21All services are coordinated through a
28:23single health plan including physical health,
28:25mental health and substance use disorder
28:27treatment and we feel that's really
28:29critical for members integration of services.
28:32With the with the pandemic as
28:35many states did,
28:36we had a number of policy changes to
28:38support continuity of care during during.
28:40During the pandemic we expanded the
28:43number of modalities that were available
28:46to clients and providers to communicate.
28:48For example, patient portal visits,
28:50audio only services,
28:53text messages and we had while we
28:56had previously covered ECONSULT,
28:57we expanded the population for that.
29:00As well as implementing
29:02audio only services broadly,
29:03we also provided more direct support
29:06for providers and patients kind
29:08of recognizing that the behavioral
29:09health provider world can be
29:12fragmented in in certain ways.
29:14We we directly provided zoom licenses
29:16and made them available free of cost
29:18for behavioral health providers.
29:19Among other providers in Washington
29:22state issued over 2000 zoom licenses
29:23and I think the vast majority of them,
29:26over 70% were utilized by
29:28behavioral health providers.
29:30Who that's kind of a critical lifeline
29:32to be able to continue delivering
29:36services and we also directly were
29:41able to issue hardware to providers
29:43and patients who are in need.
29:45Our MC has already had programs
29:47where they could work with Lifeline
29:50and and issue cell phones.
29:51We additionally issued 6000 cell
29:54phones also over 800 laptops and and
29:57kind of coordination was provided.
29:59There,
30:00we did additional collaboration
30:01with partners in telehealth.
30:03The UW Behavioral Health Institute
30:05provided technical assistance
30:07directly for behavioral health
30:09providers who needed to adapt their
30:12different models of care and clinical
30:14workflows and also partnered with
30:17their MC O's and their telehealth
30:20vendors and communication channels
30:23to facilitate the rapid shift to
30:26telehealth on the next slide.
30:29This is obviously been a very active
30:31space for the agency as we think about
30:34transitioning to a post pandemic phase.
30:36In addition to all the other things
30:37that the agency is managing,
30:38including the end of the unwind
30:41of the PHE and ensuring as much
30:43access to coverage as possible,
30:46we continue to implement new telehealth
30:49policies and adapt existing ones.
30:51For example,
30:52remote patient monitoring is something
30:53that we recently implemented.
30:55And just to call out here just kind
30:58of given the audience today that
31:00state agencies really rely on the
31:03availability of good evidence and
31:05there was illusions previously to
31:07kind of the importance of evidence
31:09based practice and and and that
31:12and really and good evidence we
31:14we really appreciate and value and
31:16and that informs policy making.
31:19And ongoing evaluation and learning
31:21is critical to the agency as we kind
31:24of continue in this and in expanding
31:28virtual care and behavioral health
31:3111 issue that we identified earlier
31:33on in the pandemic was that the
31:36data infrastructure just wasn't
31:37really there to answer all of the
31:39questions that we had about the
31:41effectiveness of telehealth.
31:42And for example,
31:44while on the meta,
31:46on the physical health side,
31:47there were a couple of limited
31:49phone codes to delineate which
31:50services were provided audio only,
31:52there really wasn't that kind of
31:54specificity on the behavioral health
31:56side in terms of individual psychotherapy,
31:58group psychotherapy,
31:59other interventions.
32:01And so we as a as a state agency
32:04had advocated for the creation of
32:06an audio only modifier which was
32:08subsequently granted by the American
32:10Medical Association and so kind of.
32:12Usage of the auto only modifier
32:14provides provides a kind of a
32:16critical foundation for evaluating
32:20effectiveness of care and utilization.
32:22We're we're working on a part on a
32:25formal evaluation of audio only services
32:27in conjunction with the University of
32:29Washington and the Office of Insurance
32:31Commissioner with an eye on on utilization,
32:34access, disparities,
32:35clinical appropriateness and kind of
32:37answering some of those critical questions.
32:40We continue to be interested in
32:42applying our lessons learned.
32:44You know, I think the pandemic has taught
32:46us a lot about value based payment
32:49and a number of providers found that
32:52they had more resilient models under
32:54VVP as well as the flexibility to more
32:57quickly adapt to delivering telehealth.
32:59Also recognize that there are a number
33:02of unique challenges in behavioral
33:03health as it pertains to VBP appointing
33:06to some of Doctor Harold Pincus's work
33:08here in terms of the need to develop
33:11more robust behavioral health quality
33:13measures And and we kind of witnessed
33:16this part to administering high tech
33:18funding but high tech left a lot of.
33:20Behavioral health providers out and
33:22it really was able to finance some
33:25of or provide a financial support for
33:27hospitals and and medical clinics.
33:29But behavioral health providers have
33:33lowered that adoption of robust EHR
33:35technology as a result of that and not
33:39surprisingly more siloed data sources.
33:43So kind of addressing some of those
33:45unique challenges as well as the need to
33:47think about breeding complex funding streams.
33:49In addition to Medicaid which
33:51has state and federal dollars,
33:52we also have state only dollars,
33:54block grants,
33:55state and local sources of funding that
33:57all have to kind of be considered as
34:01well as supporting providers beyond payment.
34:04And this is something that the healthcare
34:06authority is very much interested in.
34:09One example is our our partnership
34:11with University of Washington and
34:13the Seattle Children's Hospital
34:14in providing support for primary
34:17care providers in in mental health
34:21and psychiatric consultation.
34:22Our Psychia Psych consult line helps
34:24prescribing providers who want to seek
34:27advice for adult patients and it's
34:28operate operates 24/7 and provides
34:31primary care providers with a Direct
34:33Line to consulting psychiatrist.
34:35As well as our partnership access line,
34:37which is for children,
34:39adolescents and that's kind of
34:41critical again to breaking down
34:43silos and integrating behavioral
34:44health and physical health.
34:47Additionally,
34:48we we have an initiative going on
34:51where we're trying to issue a standard
34:54assessment for clinical integration
34:55for outpatient physical health and
34:57behavioral health settings using
34:58the ME half tool and and that has
35:01been progressing as part of our
35:03health AT operational plan.
35:05As well as exploring other ways that we
35:07can support behavioral health providers.
35:08From a health IT perspective,
35:11we we work in partnership with our
35:14Department of Social and Human Services
35:16research and data analytics group
35:18to continue looking at what quality
35:20measures can be developed and in a
35:23more robust way in behavioral health.
35:25And just kind of collaborating
35:27with others and things that
35:28Medicaid can do alone and
35:30that's building access,
35:31building workforce etcetera.
35:35So, yeah, so that's,
35:36that's my slides and look
35:37forward to the discussion and
35:39happy to answer any questions.
35:42Great. Thanks, Chris.
35:43So I think we're going to open it
35:45up now for Q&amp;A. And if you have a question,
35:48you can enter it in the Q&amp;A box and I'll
35:51ask Kara and Lee to help monitor that.
35:54But I'm going to make sure we want to,
35:56I want to make sure we cover the Ryan
35:58Haid act because that's pretty timely and
36:00maybe I can ask Dan to kind of kick off.
36:03That that particular question so so
36:05Dan what is the Ryan hate act and
36:08what's happening at the end of the PHA
36:12great. Well thanks Ryan hate and and
36:15there may be others on our panel who
36:18are thought more about it but Ryan
36:21hate is I think it was 2008 and it's.
36:25It regulates online Internet
36:27prescriptions and and also relatedly
36:30the prescription of controlled
36:33substances through telemedicine.
36:35It specifically requires any practitioner
36:39issuing a prescription for controlled
36:42substance to conduct an in person
36:45evaluation To are some exemptions for
36:48that and and then you know with the.
36:53Ending of the public health emergency the
36:56basically the waiver or the exception
36:59to that would would go away and and
37:03then I think many people who have
37:06been receiving controlled medications
37:09through Tele telemedicine telepsychiatry
37:14would would find that they suddenly
37:16are without appropriate providers
37:18but I know doctor Yellowly's you.
37:20You've thought about this one a bit.
37:22Do you wanna comment on this?
37:24Sure.
37:24Look, thanks. Thanks very much indeed.
37:27Yes, I mean, I've literally sort
37:29of had discussions with the DEA on
37:32and off for over a decade because,
37:34you know, Varian Hate Act is a
37:36really good act in most respects.
37:37It was put in place to shut
37:40down overseas pill mills.
37:41Which was where Ryan Hate was able to,
37:45you know, obtain narcotics
37:47that led to his demise.
37:49Unfortunately, you know,
37:50in the original act,
37:52there was a discussion of putting
37:53in a waiver for it for telemedicine
37:56providers to be able to continue
37:58prescribing controlled substances.
37:59And the DEA has just been,
38:01I think, disgraceful.
38:02Over the last, you know,
38:0410 years plus by not ever implementing
38:07that waiver for telemedicine
38:10practice and I'm not genuinely
38:12actually not sure what exact
38:14stage it's at now because you know
38:17with the the going away of the
38:20regulatory changes post pandemic,
38:21I assume that will go back to you
38:24know the original place which will
38:26mean that there is no way for possible
38:28and we won't be able to provide
38:30controlled substances over telemedicine.
38:32I think that's just awful.
38:34And the DEA really needs to,
38:35you know, get its act together
38:38and listen to clinicians.
38:40We need to use the evidence that's
38:42been developed during the pandemic of
38:45the for the importance of prescribing
38:48controlled substances over video and
38:51they need to provide these waivers.
38:56Great. Thanks, Peter. So I'm going to
38:59steal. These ideas in this
39:01question about the magic wand.
39:04So I'm going to give you an
39:06imaginary magic wand that
39:08grants you one wish relating to
39:10telemedicine and mental health.
39:11So what would it be?
39:12Let's let's start with Peter.
39:15I think one wish would be that it
39:18would be funded and available at the
39:20same level as in in person mental
39:23health care everywhere in America.
39:27Thank you, Peter. Dan, what's your wish?
39:30Well, you know picking up on that,
39:33but maybe thinking about with
39:35a slightly different twist.
39:36I think that utilizing virtual care
39:40when we do so would would grow
39:42from an understanding between the
39:45patient and the provider that it
39:47offers a better care experience for
39:49the patient towards better access
39:51and or improves quality of care.
39:54I would again look at it as a
39:57very important tool that we have.
39:59That has the capacity to get more people
40:01into care or make it more accessible
40:04to improve the quality of care,
40:07to preserve the sort of the
40:11maintenance of care and to just treat
40:14it like any other really valuable
40:16tool that we have in medicine.
40:20Thanks, Dan. And finally,
40:21Chris, what's your wish?
40:24Thanks Sean. I think you know from the
40:25from the payer purchaser perspective,
40:27our desire would really be for an
40:30increase in adoption of value based
40:32payments that under alternative payment
40:34models that really allow providers to
40:36have the flexibility that they need
40:38to communicate with clients while
40:40providing parameters around ensuring
40:42quality of services and and quality
40:43as measured not just by process
40:45outcomes by true clinical outcomes
40:47and being able to have that kind of.
40:50Exchange of of data and and continuous
40:54learning to facilitate those kinds of models.
40:58Hey, John, it's Lee. John.
40:59John, can I have a magic
41:00wand on this session too?
41:02Yeah, you sure can.
41:04My magic wand would be that we
41:07valued and respected and reimbursed
41:09mental health in the same way that
41:12we do other types of healthcare
41:14regardless of the relative payments.
41:17I just think it's a huge gap
41:18in our healthcare system.
41:19And so much of what falls through the
41:22cracks in our other care delivery
41:24models is so strongly mediated and
41:27influenced by behavioral health issues.
41:29So that that would be my wish
41:31that that's probably the needs,
41:32the biggest wand of all.
41:33So I'll, I'll turn it back
41:34to you to close the session.
41:37Yeah, big Amen to that, Lee.
41:40So I wanted to thank our speakers again,
41:43Doctor Yellow Lee's.
41:45Doctor Becker and Doctor Chen.
41:47So hopefully you learned a little
41:49bit about collaborative care.
41:51You understand a little bit about
41:53the history of of the silos and and
41:56you know some of the the important
41:59initiatives are underway to break
42:01down some of the silos and then just
42:03to understand how Ryan Haid act might
42:05apply to you in your health system.
42:08So Lee and car,
42:09I don't know if there's any
42:10questions in the Q&amp;A and if not.
42:12I'll I'll just kick it back to you, Lee.
42:15Great. No, I think we're good.
42:17Wonderful session.
42:17Thank you so much.
42:19So we get a 10 minute bio break,
42:23go refuel, get your steps in,
42:26drink your espresso and come back
42:29rejuvenated for our next panel which
42:32is also going to be really exciting and
42:36and stimulating journey and conversation.
42:38So thanks to all the speakers so far.
42:41Make sure you come back after
42:42the break, everybody.