Should primary doctors play a bigger role in providing mental health care?

Companies like Quartet Health and BetterHelp are reducing the time it takes to get an appointment

During The Future of Mental and Behavioral Health, the first salon of 2019 held by Vator and UCSF Health Hub, one of the topics of conversation centered around the role of the primary care physician (PCP). 

Often PCPs don't have specialty in mental health, and the processing of referring patients to a mental health provider is a long process. That's why PCPs end up administering the majority of drugs and antidepressants, because that's all they know how to do to help, but that might not be what is best for the patient. 

The role of the PCP, and how services are trying to help them give better mental healthcare to their patients, came up in the third panel of the night, moderated by Bambi Francisco Roizen (Founder & CEO, Vator) and Archana Dubey (Global Medical Director at HP), featuring panelists Eva Borden (Managing Director, Behavioral and Medical Solutions, Cigna), Ofer Leidner (Co-Founder and President, Happify Health), Alon Matas (President, Teladoc's BetterHelp.com), Brent Vaughan (CEO, Cognoa), and David Lim (Chief Mediacal Officer, Quartet Health)

Dubey asked Lim how Quartet Heath is helping to empower the provider.

"As a practicing physician in primary care, the tools, the time and the education, all three are kind of the missing piece for the provider. How are you addressing that?" she asked.

He responded that Quartet has two components, a business side as well as a clinical side. On the business side, Quartet's paying customers are the health insurance companies.

"Our commitment to them is that we engage the comorbid population into a better mental health care path. And since the health plans pay for our fee, we can provide our technology and services at no cost to providers or to patients," he said.

On the clinical side, he noted that primary care physicians want to help their patients with mental health, but often don't have the time, or the understanding, so they prescribe drugs as a stopgap measure.

"PCPs will typically recognize mental health conditions, they be very compelled to act on it, but their understanding of the mental health provider community around their clinics is very minimal, and they many times have to start with an antidepressant or some psychotropic and then they tell that patient to please call the insurance company to find a mental health provider, and that’s not, unfortunately, what we would call standard of care," said Lim.

Quartet's whole mission is to change that, and it does so by deploying software that allows the PCP to send information about the patient, which Quartet will then use to help get them in touch with a mental health provider who then "has a very limited time window to review the patient, call that patient and then make an appointment."

"If they don’t do that we pass it quickly because speed to care is paramount to success when engaging with mental health. The burden is taken off the patient, and all the information is transmitted now by this care team on our platform. We have social workers available as well to support that patient along any part of the journey, whether they’re per-contemplative, contemplative, etc," he said.

"Really, at the end of the day, what we’re doing is really providing services and technology that really gives resources to the PCP and their staff, so they can really have piece of mind about what’s happening with patients."

As a result, Quartet is able to take the process of a patient finding and getting an appointment with a mental health provider from two months to just a few weeks. 

"The way we’re treating this is in multiple ways; we’re making sure the patients that are sent to psychiatrists aren’t just very, very mild depression or anxiety, but rather the more severe cases. We’re also working with a lot of mid to large mental health provider organizations that really view a partnership with Quartet as a way to expand business. And many of these prescribers actually love that the patients are tied to a PCP because they pick up on physical health findings many times, and, a lot of times, there’s an elevated glucose. They’re actually obligated to work that up and they’re not very equipped to do that, so they actually enjoy that with Quartet."

Francisco then turned to Matas and asked him how BetterHelp is able to help direct people to a provider.

"It sounds like there’s people falling through the cracks. Two weeks or three weeks is better than the current model but they can go to BetterHelp and, hopefully, be directed immediately. So are you getting people falling through the cracks or is there a way that you can also work with a payer who is clearly seeing a number of these people, if they’re administering 70 percent of antidepressants?" she asked, citing a a blog post from Quartet Health that mentioned that figure. 

"Our average is actually 10 hours between the time that you start and the time they start talking with the counselors. It’s definitely a huge improvement. We’re not so much in the psychiatry and prescription space, so this is talk therapy which is counseling, still it provides a completely different experience, and, yes, there are so many people who fall through the cracks," he responded.

Partially, that has to do with the fact that going to a therapist isn't fun and people will generally try to avoid if it they can.

"They go to the PCP, and the PCP would not necessarily recognize a mental issue, but even when they do and they tell the patient, ‘You should talk to a therapist,’ the chance of that person actually going, finding, setting an appointment, and coming to that appointment, is extremely, extremely low. Nobody wants to do therapy, it’s not fun for anyone, it’s something that you can always find an excuse to avoid," he said. 

To help solve this issue, BetterHelp isn't trying to remake therapy but to solve the problem of accessibility.

"For most people, they will avoid unless it’s easy, unless it’s accessible and affordable and we provide all these values. You’re talking with the same therapist you go into the office. There are many disrupters here, we’re not trying to disrupt therapy, we’re not trying to make a new model," said Matas.

"What we’re trying to do is to take the same tried and true offerings that have been studied for 100 years or more, and make it more accessible. Solving this access problem I think is the most important thing to have improvement on how people get care today."

Francisco then asked Borden what she and Cigna would need to see from a company like BetterHelp, in terms of stats and outcomes, to have it be something they would offer to their network of patients and providers. 

Borden responded that there's a spectrum of ways that Cigna partners with companies, from being a true strategic partner, to a company that would be a smaller partnership "from an offering perspective.’

That being said, she noted that of the things they would look for includes behavioral health quality, which, she admitted, is “really hard to measure.”

"There’s definitely intrigue about how you measure that. A lot of its going to be customer experience viability. One other thing, any time you start working with a payer, becomes wildly important is privacy. If you can’t overcome the hurdles when it comes to HIPPA, let alone 42 CFR Part 2, which will likely hit you if you’re in behavioral, you’re going to face a really hard time. So, for us, when we’re looking at, if I think about our biggest challenge right now, it’s access and availability. Definitely a massive challenge," said Borden.

"And when it comes to access, what kind of care do you want? What’s the modality that I want to go after? Do I want text, do I want face-to-face, do I want video? And the adoption, though I appreciated the stats we had earlier, to think about what those stats would have been five years ago till now, I venture they would have looked dramatically different, so how will they continue to evolve? That’s what I would think about, that spectrum of partnerships. What are you bringing forward? How are you going to demonstrate quality in a world that’s really, really hard to demonstrate quality?"

(Image source: peakbraininstitute.com)