Subscribe to The Podcast by KevinMD. Catch up on old episodes!

Join Tom Zaubler, a psychiatrist and physician executive, for a discussion on the shortage of behavioral health professionals in the United States. We’ll explore its impact, the surge in mental health care demand, and the role of technology in measurement-based care. Discover how we can address these challenges and create a brighter future for mental health care.

Tom Zaubler is a psychiatrist and physician executive.

He discusses the KevinMD article, “Maximizing care amidst provider shortages: the power of measurement-based care.”

Careers by KevinMD is your gateway to health care success. We connect you with real-time, exclusive resources like job boards, news updates, and salary insights, all tailored for health care professionals. With expertise in uniting top talent and leading employers across the nation’s largest health care hiring network, we’re your partner in shaping health care’s future. Fulfill your health care journey at KevinMD.com/careers.

VISIT SPONSOR → https://kevinmd.com/careers

Discovering disability insurance? Pattern understands your concerns. Over 20,000 doctors trust us for straightforward, affordable coverage. We handle everything from quotes to paperwork. Say goodbye to insurance stress – visit Pattern today at KevinMD.com/pattern.

VISIT SPONSOR → https://kevinmd.com/pattern

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://earnc.me/nUJOLr

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Tom Zaubler. He’s a psychiatrist and a physician executive. Today’s KevinMD article is titled “Maximizing care amidst provider shortages: the power of measurement-based care.” Tom, welcome to the show.

Tom Zaubler: Thank you very much. Pleasure to be here, Kevin.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey.

Tom Zaubler: Yes, Kevin. I’m Tom Zaubler. I’m a psychiatrist and chief medical officer at NeuroFlow. NeuroFlow is a technology company focused on creating a digital infrastructure to improve identification, triage and access to behavioral health care across a multitude of clinical settings and a range of acuity. We work with payers, providers and health systems. Prior to that, I was a department chair for 21 years, and I’ve been immersed in the world of integrating psychiatry and behavioral health for about three decades now. So measurement-based care and improving access to behavioral health care have been a lifelong mission of mine.

Kevin Pho: So talk about that transition from more of a clinical role into the CMO role.

Tom Zaubler: Let me share with you how I got there in the first place. I was spending a lot of time seeding these population-focused, measurement-based, treat-to-target models of care, integrating psychiatry and behavioral health into medical settings, for decades, and I recognized that there were real limits to what one can do without technology. So I was looking for a technology partner to deploy and scale these models of care, and in the course of doing that, I came across the company where I currently work. I was taken with the platform and realized that I could really impact a much larger population, literally millions of individuals, as opposed to the tens of thousands I was reaching before, and I was very excited by that. To me, it’s a way of improving access to behavioral health treatment on a much, much larger scale and surfacing underlying illness. It’s been very exciting and eye-opening for me, coming from the world of health care in a large health system. Things move much more quickly in industry, as I’m sure you’re aware, than they often do in academic environments or large health systems.

Kevin Pho: All right, so let’s talk about how you move the needle. The KevinMD article is titled “Maximizing care amidst provider shortages: the power of measurement-based care.” Tell us how your article came together.

Tom Zaubler: Let me give you a little background, just for a minute, on some of the statistics. We know that psychiatric illness and behavioral health disorders are incredibly prevalent. About 20 percent of the population has an underlying psychiatric disorder, about 58 million people. We know that before COVID, about one in 10 individuals described having symptoms of anxiety and depression; after COVID, that number has shot up to about 40 percent of the population. The rate of suicide has gone up significantly; last year it was 49,000, and it just keeps growing. There were 111,000 overdose deaths last year. With these deaths of despair, the average lifespan in the United States has gone down, for the first time since the 1920s, from 79 years to 76 years, and a lot of that has to do with these deaths of despair.

Psychiatric illness is the leading cause of disability in the world, and it rarely occurs in isolation. Depression, for example, co-occurs with stroke, diabetes and heart disease. You can’t have good physical health without mental health. And we know that psychiatric illness drives the cost of care up significantly: People with chronic medical conditions and co-occurring psychiatric illness cost two to three, or even six, times more than those with the chronic medical conditions without the underlying psychiatric illness. So it’s really, really prevalent.

Then we have these barriers, these problems with access to care. There’s stigma, which is still an issue, though it’s getting better. But we have major workforce challenges. There are just not enough psychiatrists. Fifty-five percent of all counties in the United States report having literally no psychiatrists, and 77 percent of counties report a significant shortage of psychiatrists. The state of Maine, as an example, had a 50 percent drop in the number of psychiatrists from 2015 to 2020. Wait times can be as long as 18 months. That’s just not acceptable. And, like myself, 70 percent of psychiatrists are 50 and older, so this is just going to get more pronounced.

We know that patients with underlying psychiatric illness present with their problems in medical settings; they don’t present in behavioral health settings. The irony is that 95 percent of behavioral health providers work primarily or exclusively in behavioral settings. So we really need to think about ways to integrate care, which is a lot of what the article talks about, and to identify the 20 percent of individuals who account for 80 percent of all health care costs, because the vast majority of those individuals have underlying psychiatric illness that drives their increased utilization. The reality is that in this country, 60 percent of people with psychiatric illness, and 90 percent of people with substance use disorders, receive no care whatsoever for their underlying mental or substance use disorders. Imagine if that were cancer, diabetes or heart disease.

So the reason we submitted the article is that it speaks to the importance of surfacing underlying psychiatric illness, doing that in a methodical way with screening and measurement-based care, which I can touch on in a little bit, and doing it across a multitude of settings, not just behavioral health settings but medical settings as well. I’ll go into some of the solutions, the population-focused, measurement-guided models of care and the technology, but that’s a little of the background on why we feel it’s really important to address these issues and bring this objective, measurement-based type of assessment to much larger populations.

Kevin Pho: Absolutely. I think what you say rings true. I’m a primary care internal medicine physician myself, and that lack of behavioral health care has only gotten exponentially worse during COVID. So in terms of the model you propose, tell us more about it.

Tom Zaubler: There are these population-focused, measurement-guided models of care. Collaborative care is the most well-studied model, with over 90 randomized controlled trials showing its efficacy, and it has been around since the 1990s. I had the good fortune of actually being at the University of Washington when it was first being created. It’s a tale of two cities: On the one hand, it’s a wonderful model, but the uptake has not been great. Only about 20 or 30 percent of primary care practices have any sort of meaningful behavioral integration, so there’s a lot of work that needs to be done.

These models of care entail a team: a primary care doc, though it could also be an oncologist, a GI doc or a cardiologist; a behavioral clinician integrated into the practice; and then a psychiatrist. That psychiatrist is actually not seeing patients directly. They’re providing caseload consultation to the clinician and clinical decision support to the primary care physician, or the oncologist or whoever it is, to make sure a large caseload of patients can be seen. So you have a psychiatrist consulting just a few hours a week and covering literally thousands of lives, whereas if they were seeing the patients directly, they would not see nearly so many.

A critical component of these models of care is universal screening with standardized scales, like the PHQ-9 for depression and the GAD-7 for anxiety. The reason this is so important is that patients don’t get better if you’re not tracking outcomes. We know in primary care, and Kevin, I’ll defer to you on this, that first of all, most depression and anxiety is missed, and when it is detected, only about 20 percent of patients get better, because follow-up is hard. When appointments are spread out three or six months apart, patients go off antidepressants, the dose of the antidepressant isn’t adjusted, and they’re not getting the psychotherapeutic support they need. So these models of care are really critical, providing objective assessments of how patients are doing over time so that treatment can be adjusted if patients aren’t getting better.

It’s like this: If a patient has COPD, we’re getting pulmonary function tests. If a patient has diabetes, we’re checking glucose levels or hemoglobin A1Cs. There are objective measures of how patients are doing. In behavioral health, sadly, 80 percent of the time behavioral clinicians are not practicing measurement-based care, and that creates a lot of subjectivity, an impressionistic sense from the snapshot you get when you’re with a patient. So measurement-based care is really critical for surfacing who in large populations has psychiatric illness, and for ensuring that patients are getting the right care at the right time and are being triaged to that care. I can talk with you about some of the technology that makes this possible as well. There are multiple models of behavioral integration; collaborative care is the best studied, but there are many that are immensely helpful and effective.

Kevin Pho: So before getting to some of the technological solutions for implementing that, give us your ideal scenario in the primary care setting. If I were to see a patient in my exam room, for instance, walk us through a hypothetical scenario that would meet your ideal.

Tom Zaubler: I may touch a little on technology in this question, if I may. The ideal is that every patient in that primary care practice is being screened for psychiatric illness. It’s not a question of handing patients a pen-and-paper assessment when they come into the practice and doing it right then and there. You’re doing it with everyone. So if they’re coming in for an annual wellness visit or any other visit, you already have some information about how they’re doing, and you can say to that individual, “We noticed that you’ve scored at this level on these scales for depression and anxiety. We provide holistic care. We really believe in looking at the whole person, and we want to introduce you to someone who works in our practice. This is a behavioral clinician, and we feel it’s really important to provide whole-person care. Because of the way you answered the questions on the scales we sent to your home through our technology, we would like to engage you on an ongoing basis, with technology but also with this clinician in our office, who can help you therapeutically as well as do care coordination, if there are any outside providers we need to contact, and ensure that you get the care you need.”

That individual is then going to be tracked with assessments that can be done remotely through digital tools. The behavioral clinician, what we call a behavioral care manager in a collaborative care context, will meet with that individual periodically as needed. Some meetings might be very brief, by phone; some could be in person or virtual. What you see is that this model of care surfaces a lot more underlying depression, anxiety, PTSD and bipolar disorder. There are studies now looking at a range of psychiatric problems, and patients get better. They really get better.

Kevin Pho: So you mentioned technological solutions to screen that patient population. Talk more about those.

Tom Zaubler: For decades, I was using pen-and-paper assessments and Excel spreadsheets, and it’s really, really tough. It’s a burden for the physicians and a burden for the medical assistants, and it’s really hard to do. Technology now has the ability to send these remote assessments via an app that someone can look at on their phone or on a desktop. There are many ways of doing it, and they can complete those assessments in the comfort of their home, and that gives a much more accurate picture. When patients present in medical settings, there’s a level of nervousness that can influence how they complete those scales, and sometimes they’re reluctant to share things. What we see is that when you provide these assessments in the comfort of their homes, at a time that’s convenient, they’re not going to feel as rushed or as pressured, and you’re more likely to get an accurate response, and more likely to get a response, period.

So technology can provide those scales to patients for depression and anxiety, and of course there are a multitude of other scales for other psychiatric disorders. Then, when patients score positively, there can be digital self-management tools: digital cognitive behavioral therapy for depression, anxiety, insomnia or substance use disorder; journeys, galleries and video content to help patients manage their anxiety and depression. There can be content that a clinician working with an individual on their depression or anxiety can use to provide assignments, homework and so on. A lot of that is driven by AI, so it can be automatic, and some of it can be manually assigned. So there are self-management tools as well as assessments.

Those assessments occur on an ongoing basis. It’s not just the initial index scores that surface the underlying psychiatric illness; it’s the ongoing assessments, as I said before, to make sure patients are getting better. If they’re not getting better, there are alerts and triggers that can let the primary care doctor, the oncologist or the cardiologist know, “You know what? The patient is not doing so well. We need to modify treatment,” and treatment can then be modified, so everyone is operating at the top of their license. And very importantly, if patients are at immediate risk for their safety, and this is something I’m really passionate about, it can alert the physician and everyone else in the practice to the risk, and there are mechanisms to respond with caring contacts and human support in the moment for those individuals. Without sounding melodramatic, that can literally save lives.

So there are a lot of ways technology can be used. That’s the patient-facing side. There’s also the data analytics side, where technology can look at claims data and discrete data from medical records and identify patients who are at risk, not only now but five months, six months or a year from now: who is a distressed, high-utilizing patient, and who is going to become one. There are algorithms right now that technology can deploy for those predictive analytics, and then provide support for individuals with rising levels of risk, so the risk doesn’t continue to rise and they’re preempted from becoming acutely ill. Finally, all of that can populate registries that show how patients are doing and integrate with EHRs, so the physicians, the behavioral clinicians and the practice can see all of it and make sure that everyone is operating in sync, and again at the very top of their license, as efficiently as possible.

Kevin Pho: So tell me about typical patient response rates and some patient feedback. Sometimes, when patients schedule an appointment with me, they get several texts reminding them of the appointment, and after the appointment they get several texts about patient satisfaction scores. In general, what’s their feedback? Do you worry that with so many different touch points and so much outreach to the patient, there’s a little bit of fatigue? In general, what kind of experience do you see when this is implemented?

Tom Zaubler: I think that is a concern. I think part of it is the digital interface you have with the patient. If it’s a very friendly, inviting, non-clinical digital interface, and even that word is overly clinical, if you can invite patients to a platform that feels friendly, inviting and engaging, with gamification and tokens they can redeem for cups of coffee and that sort of thing, it can make a real difference. It starts to feel a little like a game, and it’s interesting. Then you add value, because you’re providing support in the moment. Let’s say someone isn’t scoring positively for depression and anxiety, but they’re having difficulty with insomnia; there’s digital content for managing that insomnia that’s useful. If someone is feeling lonely and wants to look at ways to build relationships, or needs mindfulness meditation, there’s wonderful content out there that can be delivered digitally in a very user-friendly way.

So I think it really comes down to what the interface is like and how it gets sent. It’s really important that physicians champion the technology. Physicians are really burned out, and we know there’s a bias against technology in some ways, because EHRs are a source of burnout. So it’s really about reframing the way we think about technology, as a way of extending the work that goes on in the practice into the patient’s home. What we see is engagement rates of 60 percent, and patients remain highly engaged over time. We’re seeing individuals who were not getting treatment suddenly getting treatment and getting better. And then what happens is that the tinnitus, the back pain, the headaches, the things individuals present with in primary care that are really driven by underlying psychiatric illness, start to dissipate. The calls go down, the administrative burden goes down and physician satisfaction goes way up, so it becomes a win-win.

It’s something you have to be sensitive to. I don’t believe technology alone is the answer. I think it’s a combination of technology and human beings, high tech and high touch. That’s absolutely critical. But technology is clearly a big part of the picture, and a growing part of it.

Kevin Pho: We’re talking to Tom Zaubler. He’s a psychiatrist and a physician executive. Today’s KevinMD article is titled “Maximizing care amidst provider shortages: the power of measurement-based care.” Tom, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Tom Zaubler: One take-home message is recognizing that, as I said before, you can’t have physical health without mental health. It is really incumbent on everyone in the health care ecosystem to recognize that and to come up with mechanisms to surface underlying psychiatric illness and improve access, since we have major workforce challenges. So the message is: Recognize the importance. Recognize the disability. Recognize that you can’t manage diabetes, you can’t manage heart disease, you can’t manage a whole range of medical problems without addressing the underlying psychiatric problems. That’s one message.

The second message is about change management. We recognize that it’s really tough. Primary care physicians in particular, oncologists and cardiologists are working hard. We can’t just expect them to take on these models of care, and that hasn’t happened without a lot of support and help. That’s where technology comes in. It makes it seamless. It makes it possible to do these models of care in a way that unburdens physicians, economizes on their time, creates tremendous efficiency and ensures that everyone operates at the top of their license, and it provides the ability to extend the work that goes on in the practice into patients’ homes, with digital self-management tools for patients. So that’s another take-home message: Let’s look at ways technology can help scale and deploy these population-focused, measurement-guided models of care that are so immensely effective.

Kevin Pho: Tom, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Tom Zaubler: My pleasure. Thank you for having me.