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MGMA Insights: Transforming Patient Care Through Behavioral Health Integration

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Daniel Williams:

Well, hi, everyone. I'm Daniel Williams, senior editor at MGMA and host of the MGMA Podcast Network. We have an MGMA Insights episode today, and we have a new guest to the show, doctor Jonas Bromberg. He's a PsyD, and he's a principal at Crossroads Health Consulting. And I had an opportunity to moderate his presentation at our recent summit event.

Daniel Williams:

So many of you may have seen him there. We just hit it off. And I was so interested in what he had to say about behavioral health integration and how that can be applied to medical practices. So we have him on our show today. So, Doctor.

Daniel Williams:

Bromberg, welcome.

Dr. Jonas Bromberg:

Thank you, Daniel. Thank you for having me.

Daniel Williams:

And for our visual listeners, we use both audio and video. I asked you the same question at Summit. You have a beautiful background. And tell us about that. What are we looking at, and what does this space mean to you?

Dr. Jonas Bromberg:

That's a view of the skyline of Boston, Massachusetts where I reside, and that's looking across the Charles River at the part of the city called Back Bay. Okay. And it's a city I've been in for over thirty five years and now call home.

Daniel Williams:

Wow. That is beautiful. And we talked about this. MGMA in the last seven years has had our annual conference twice in Boston. And I told you back in 2018, I was with a group that had rented out a little yacht, little boat, and we just cruised around just where your images are showing.

Daniel Williams:

And it was so much fun. And everybody that was there got great photos. We went right it was one of those sunset and sunset mimosas or something like that. I don't know exactly what it was, but it was a lot of fun. And what a beautiful city.

Daniel Williams:

I just I love Boston. And dating myself a little bit back in the eighties, I was just a fanatical follower of Larry Bird. I just loved the Celtics, the Bird Celtics, and I actually got to go there. Not in Boston, but, the Celtics played in Atlanta, which was closer to where I lived. And so I drove over there and got to see them when I was still in high school.

Daniel Williams:

So it was a lot of fun. So

Dr. Jonas Bromberg:

That's fantastic.

Daniel Williams:

Yeah. So you've been there thirty five years. That is fantastic. So tell us a little bit about your background first. You have a PsyD.

Daniel Williams:

Tell us about maybe a little bit of that academic background and where you got involved where you were really thinking about behavioral health.

Dr. Jonas Bromberg:

Sure. So PsyD is a type of doctor of doctoral degree in psychology. It's actually a doctor of psychology rather than a doctor of philosophy PhD. And the PsyD model of training sort of emerged in the seventies as an alternative to more traditional academic PhD type training. And it was, you know, more of a clinician focused training, training people to do, you know, psychotherapy, psychological assessment, you know, hands on clinical practice.

Dr. Jonas Bromberg:

And so that was the type of program I chose. It offered a lot of practical experience while you're doing your academic training, and I trained here in Boston. That's what brought me to Boston and trained primarily in academic medical centers. And very early on, I had some training experiences in with the Department of Behavioral Medicine at Boston Children's Hospital, did some training at the Dana Farber Cancer Institute where I worked with children and families that were dealing with cancer, worked in a cardiology program. There was a joint program between children's and Brigham and Women's Hospital.

Dr. Jonas Bromberg:

So had a lot of opportunities to work at that intersection of mental health and medicines or taking care of the the emotional life and spiritual life of people that were also being cared for by physicians for some primary medical reason. And that's sort of what got me into into behavioral health integration, which I would many years later, you know, helped launch a program at at Boston Children's Hospital that was integrating mental health clinicians directly into pediatric primary care practices across the statewide network of practices that were affiliated with the hospital.

Daniel Williams:

Okay. So we both have used that term behavioral health integration. Let's define it. What is that? What does it look like in practice?

Daniel Williams:

Just so all of our listeners know exactly what we're talking about.

Dr. Jonas Bromberg:

That's a great question, Daniel, because it's one of those terms that

Daniel Williams:

It gets thrown around.

Dr. Jonas Bromberg:

Umbrella term and, you know, a lot of different things. You know, there are there are different models of behavioral health integration. There are different levels of it. And to be very specific, you know, it's way of working. You know, it's something that primary care tends to be the medical place where most of behavioral health integration happens.

Dr. Jonas Bromberg:

Although, you know, I was integrated at Dana Farber, I was integrated at, you know, on the Boston Adult Congenital Heart Program, so it can happen in specialty medical programs as well as primary care. But probably most of it, you know, is happening in primary care. It's really a systematic way that the clinical team works with a mental health specialist in the practice. Okay. So they're seeing common patients, documenting in the same electronic health record, being able to directly consult with each other in the moment or in a scheduled time, you know, follow-up with patients at, you know, whatever intervals.

Dr. Jonas Bromberg:

And so it's really an ideal venue for treating any kind of mental health related concern and including substance use concerns. Primary care is, you know, one of the main locations where those problems are detected, come to light, Parents especially turn to their pediatricians first when their children are struggling with behavioral issues, emotional issues. And so it's really an ideal location to get involved in caring for somebody with a with a mental health or substance use concern really early on. And obviously, you can get involved and care for somebody, provide treatment, you know, early on, it's gonna be an easier treatment. They're gonna benefit from it.

Dr. Jonas Bromberg:

You know, it's you change you really have an opportunity to get involved early. You know, a lot of physicians, they'll take a wait and see approach if it's not really interfering with a person's life because they don't know what to do. So, part of what we did in our program was provide a lot of education to physicians to help them not only detect mental health problems with greater accuracy, but also to be able to ask patients better questions to elicit that information. We taught them how to conduct routine screening around various types of mental health and substance use concerns, you know, so they can really, you know, be that first line. I mean, that's what primary care is designed to do, be the first line of care.

Dr. Jonas Bromberg:

And so why not provide mental health in that same way that we provide physical health? The mind and the body are connected.

Daniel Williams:

They are so connected and it just it brings me back to some health issues I had about thirty years ago. I kept having stomach issues. And after the second or third or fourth oscopy that I had, you know, there were the different ones that I had, The doctor finally, after not finding anything there, coming up on the diagnosis there, really saying, well, maybe this is more of a mental health issue. And maybe with this integration, just giving that as an example for you, if it was already integrated and you had some a patient like me coming in with stomach problems and tests being done and different question and answer sessions with that patient, what does it look like if you have that integration? Because this went on for, I would say, a couple of years before they finally said, the doctor just pulled me aside and said, hey.

Daniel Williams:

We're not good news. We're not finding anything physically in your stomach or in that area there. However, you're still having a lot of pain and a lot of problems with your stomach. So what would that have looked like if we had had that behavioral health integration right off the bat?

Dr. Jonas Bromberg:

That's a good question. It's very likely, Katie, that you could have spoken to somebody much earlier on and gotten some guidance around managing the physical symptoms you're having through a behavioral approach or making lifestyle changes. You know, many medical conditions can be, you know, helped by lifestyle behavior change whether it's, you know, exercise or diet or, you know, relaxation or, you know, doing something to help calm the body that's connected to the mind.

Daniel Williams:

And that that's what they eventually found with me. It was very stress related. I was literally stressing myself out, you know, and just not handling stress, life, whatever in a very productive way. So it would manifest itself, as you were saying, that mind body connection just having incredible stomach pain and other things like that. Yeah.

Dr. Jonas Bromberg:

So it's interesting many what it made me think about many years ago, I was involved in a project where we created a website to help people with migraine headaches do things to, you know, manage their conditions, you know, with self management to teach them self management skills to manage their headaches. And we did some rig rigorous randomized control research around this, looked at people before we intervened with them and then afterward. And the really interesting finding from that research was while we weren't able to reduce the reported level of physical pain related to their migraines, a lot of different things like feeling more in control of it, more confident that they could do things to manage their pain, You know, those scores went up incredibly. Even though when we didn't change the level of pain, we made people feel better, feel more confident and capable of managing their pain, which, you know, led them to, you know, also report a greater quality of life. So significant finding even though he didn't change their physical symptoms and helped them live That's wonderful.

Daniel Williams:

So let's talk about another aspect of behavioral health. And there are some stigmas related around that. Some appear to be going down a bit, particularly what I've noticed anecdotally in reading articles during the pandemic, people feeling more vulnerable in a way and openly vulnerable to say, hey, I'm struggling. I'm feeling sad. I'm feeling depressed.

Daniel Williams:

I'm feeling anxious about all that fear that was around COVID nineteen and issues related around that. Talk about how having a behavioral health integration in a practice can help perhaps reduce or at least address some of those stigmas around behavioral health.

Dr. Jonas Bromberg:

Yeah, no, that's a really important connection that you're making there. And certainly, you know, the idea that we would convey at a very high level was mental health is health. Again, the mind and the body are connected. And, you know, we would teach doctors to say things like, you know, we're we're just as concerned about how your emotional health as we are about your physical health, and we can address all of that right right here. Tremendous amount of stigma around going for help for mental health concerns, maybe even more about substance use concerns.

Dr. Jonas Bromberg:

And, you know, we live in a world that has a lot of different kinds of people in it. Some of them grow up in cultures where you don't talk about this kind of stuff, you know, just naturally. It's not part of what you do even when there's recognition you could benefit from that kind of thing. You may not even recognize it, I guess. But, you know, making it part of the culture of primary care, you know, really helps, you know, convey that message.

Dr. Jonas Bromberg:

You know, every part of your health is why you're here. Mental health, physical health, all of it. And it just makes I don't know. I can't cite the percentage, but it's a lot of people that get referred to a mental health specialist that never follow-up. And, you know, many people go and, you know, particularly people that live in rural communities where there's a very identifiable mental health center.

Dr. Jonas Bromberg:

They don't want it they don't want their car to be seen parked in the lot of the health center. Right? They don't want people to know. But if you're only going to your doctor, that can be for any kind of reason. And it just lowers the lowers the bar, makes it easier.

Dr. Jonas Bromberg:

And again, part of the approach that we try to help practices evolve is to say, you know, really so the patients get the message that, you know, mental health is health and you can come here for any kind of concern, and that's normal. We wanna care for you in that way.

Daniel Williams:

Okay. Let's define one more thing because we've we've used the terms behavioral health integration. We've used behavioral health, and then you're also using mental health. Are those the same? How are or if they're not, how are they different?

Daniel Williams:

They

Dr. Jonas Bromberg:

get used interchangeably. Both of them can be correct. I would say behavioral health is kind of a bigger umbrella term. Mental health might be a large component of behavioral health, but I also would put in in under the behavioral health umbrella things like, you know, lifestyle change, people that are seeking to reduce weight or exercise more, change their eating behavior. Those would I would consider those more behavioral health issues related to somebody's behavior rather than mental health.

Dr. Jonas Bromberg:

So I would say mental health may be a a subset of behavioral health, but they can be used they are used fairly interchangeably, but it's a it's a good point. I would say behavioral health would also, you know, include substance use and addiction sort of under that umbrella. That's a bigger, broader term, but often is used in place of mental health.

Daniel Williams:

Okay. Thank you for clarifying that. So health care is about caring for patients, but there is also a bottom line component to it. So what is in it for providers? If they go, Okay, I'm hearing what Doctor.

Daniel Williams:

Bromberg's saying, maybe I'll consider this. But what is this going to look like when they think about their practice, the model of their practice, and perhaps from the financial side of it. Let's just start with the model of it first, and then we can look into the revenue side of it, the bottom line part.

Dr. Jonas Bromberg:

Yeah. You know, the model that I have worked most most of the work that I've done is helping practices implement what's called a primary care behavioral health model, PCBH. And the emphasis here again is really, you know, fulfill the same functions as primary care. This is the first place people are gonna turn or gonna take a shot at understanding what's going on and trying to intervene. But recognizing like this is primary care, and in the same way a doctor might begin to intervene if you had a medical problem but then pass you off to a specialist, we're going to try to do this here in an easy simple way, especially if it's something you told us is really in an early stage.

Dr. Jonas Bromberg:

We can probably take care of that in a primary care type model. So it involves having one or more mental health clinicians, you know, a licensed psychologist or a licensed clinical social worker in the practice and available to see patients as these things come up. Ideally, the mental health practitioners that I think are most ideally suited to work in this type of environment, like their primary care medical counterparts or or generalists, you know, anything that walks through the door is sort of the ethos of primary care. Try to handle it here. And if we can, we send you the the appropriate specialty place to have it taken care of.

Dr. Jonas Bromberg:

But you wanna be able to that old adage strike while iron's hot, knowing that many people don't follow through with a referral to a psychologist or social worker. If you can say, wait a second. You know? I know you you know, you just told me or I see on the screening form that you completed that you're struggling with anxiety or depression or something. I have somebody here that can talk to you right now and help me by talking to you, you know, in a little bit greater depth to find out a little bit more detail about what's going on and really start to help you today.

Dr. Jonas Bromberg:

I mean, you can leave the office today with some with some guidance on how to manage this. So that's the opportunity we're trying to seize. These clinicians really to be available right there when patients need them. And obviously, you know, once you start getting involved with patients in that way, they may need some follow-up. So the model actually builds in some scheduled follow-up as well.

Dr. Jonas Bromberg:

And, you know, it's creating this balance between that real time availability to, you know, step into the room and meet the patient right now while they're there because they might not come back. Right. Take take the opportunity when you can. You know? And and many people need more than that one shot consult, so you have some scheduled time that you can also see them for follow-up and help them, you know, in in in a little bit more longitudinal kind of way.

Dr. Jonas Bromberg:

Okay.

Daniel Williams:

So let's go to that part two of that question, and that is the bottom line part, the billing part. So what do our listeners need to know as far as the billing, if there are any codes they need to know about how to how to bill, how to get reimbursed just so they are compensated for the work that's being done?

Dr. Jonas Bromberg:

The program that I directed for more than a decade so when we started that program, one of the things that we made available to every practice was some billing consultation. And the person that we had, they used to say, it's different but not difficult. Any of many of the standard business practices that you would use to make sure that your revenue cycle is well managed on the medical side is gonna be very similar to what you're gonna do with this mental health stuff too. Verifying insurance ahead of time, making sure that there's coverage for the things that you're the services you're gonna provide. So, you know, all those things that you routinely and rigorously do to run your medical practice, you're gonna do many of those similar things on the behavioral side.

Dr. Jonas Bromberg:

The tricky you know, probably the trickiest thing in behavioral health is sometimes the actual insurance benefit may be carved out. So the bills might be sent to a different entity than the primary medical insurance. Once you understand that and figure that out, it's just different, not difficult. But I think early on, that's often something that billers in a medical practice may not have ever encountered before, but it's not a difficult concept to master. You know, there's really about you know, in the work that we did, I would say it's much simpler than medical billing.

Dr. Jonas Bromberg:

They're probably seven to 10 procedure codes that make up like 90% of your billing. So, you know, once you figure out those codes and the modifiers you need to use and, know, again, there's there's a little trial and error maybe, but hopefully not trial and error. Hopefully, there's good knowledge out there. Every insurance company, you know, is a little bit different in terms of the modifiers and, you know, you have to decode what their instructions are and, you know, to be able to do that regularly. And, you know, and, you know so beforehand, we made sure that that mental health visits were gonna be able to be billable the same day as medical visits in the practice.

Dr. Jonas Bromberg:

There was maybe a small number of insurance companies we needed to, you know, make a stipulated sort of change in a contract. But otherwise, you know, because they were different types of services, mental health and medicine, medical services, that that largely wasn't a problem. But, you know, it was a concern or something people thought about. You know? And and again, once bills are submitted, that same sort of just disciplined revenue management stuff following up, knowing how to, you know, deal with claims that are sent back in a in an efficient way.

Dr. Jonas Bromberg:

And, again, it's a learning curve, and it's it's just different, but not not difficult. Almost every single practice that we taught to do this was at least able to break even, if not add to their bottom line a little bit. I don't think anybody's getting rich do it providing mental health services, but, you know, many programs were able to derive a level of revenue from that that integrated work that not only supported the mental health clinician, but allowed them over time to add other staff resources, coordinator type people that would focus on, you know, that population, you build, you know, sort of the administrative staff to support the behavioral team in the same way that, you know, there's a sort of a legion of people behind every physician on the back end that do things. And programs that were really successful were able to, you know, generate enough revenue to cover their clinician. And sometimes, you know, those those special staffing positions that, support the behavioral clinicians in the practice.

Daniel Williams:

Okay. Now you said that a practice may not get rich or so by integrating it. However, what are some of the measurements? How do you know if you're succeeding in what you're doing? What what should a practice be looking at?

Dr. Jonas Bromberg:

Generating revenue is is one way of looking at the value proposition. Well, there is a a managing partner in one of the practices I worked with for many years who said, it doesn't matter to me if we break even because this frees up physician time. You know, I think every one of my doctors can see one or two more patients a day when they're able to, you know, not get bogged down in one of these mental health things they can hand off in real time to somebody else that can take over, and then they can go on and not get their schedule backed up and see more patients, be more efficient. Another way of looking at the the value and what can be added, if a physician can be more productive, you don't need the the revenue from the mental health person maybe to be as great. Families absolutely love having this kind of access.

Dr. Jonas Bromberg:

What it does in terms of creating loyalty and satisfaction on the patient end is just enormous. I mean, you should you know, testimonials of patients, families would offer were just incredible about how helpful it was to have, you know, somebody be able to be there right away for the family. And certainly when, you know, urgent things come up to be able to access somebody right away, they really value it. So those are other ways of looking at the value. So remind me again of where you wanted me to go.

Dr. Jonas Bromberg:

What was the next question?

Daniel Williams:

Yeah. So, no, I think you answered that. I was looking at how do you measure it and it sounds like patient satisfaction and also provider satisfaction by really freeing up those providers for questions that they're going to have to refer anyway when they start hearing that mental health aspect of the visit coming up. They can move them into that next room and have that professional work with the patient in that capacity. Yeah.

Dr. Jonas Bromberg:

And it reminds me of something, a conversation I had with one of the pediatricians who said, you know, the integration of behavioral health and medicine, he thought was the most important thing to happen in pediatrics since the invention of the vaccine. Wow. And I said, John, really? There's been a lot of advances in pediatric medicine since the invention of the vaccine. He says, no.

Dr. Jonas Bromberg:

This is the most important thing because what it's done to sort of teach me about how to take care of my patients and empower me to do that is is is remarkable. You know, I'm I'm way more, you know, capable than I was earlier in my career. And, you know, when I thought about it, yeah, that's incredible. You know, every at the beginning, I was really thrilled about how many kids and families were getting care. You know, the volume of care that we were delivering was enormous.

Dr. Jonas Bromberg:

But then I thought, you know, this comment, each one of those doctors we taught, they touch hundreds or thousands of lives. So to empower these doctors to take care of thousands, hundreds of thousands of patients we care for in our network, you know, that was really something. That was, you know, to empower doctors in this way felt really important. And we had actually done some research about we, again, some sort of pre intervention and post intervention with the with providing educational intervention of physicians, the comfort and confidence they had in addressing mental health concerns that, you know, went nothing but up, you know? Mhmm.

Dr. Jonas Bromberg:

Just by providing, know, good, solid education and some availability to consultation, I mean, just made them feel much more capable. Because prior to that, you know, the patients would come into their office and they wouldn't know what to do. They wouldn't, you know, know how to even reliably utilize the system outside the office to to engage patients in care. But it it the world sort of changed for them.

Daniel Williams:

Yeah. Last question then. You I made a note during the summit conference in your presentation there. You said the biggest challenge for practices isn't whether to do it, behavioral health integration, but it's knowing how to do it. You've been covering that, but we've covered a lot of ground here today.

Daniel Williams:

So for a practice that's hearing you today, what's maybe a first step or two they should look at doing to bring that integration into the practice?

Dr. Jonas Bromberg:

So when we you know, in the work that I do when I work with a practice, I think the first thing I wanna do is, you know, not after I understand what they're doing now, you know, is help them understand what their needs are. Not not every practice, you know, given their location, the population they care for, who they are as a care team, you know, what do they need? What are the most common sorts of concerns that they're seeing? And, you know, so we, you know, would often ask practices do a bit of a a time study or, you know, use the data that they have to look at, you know, what the most prominent concerns are. And not only that only not only helps you think about how to structure the program you're gonna build, but also the types of clinicians you might wanna look for when you go to hire.

Dr. Jonas Bromberg:

The other thing I think is super important, we always approach this in a every time I work with a practice, I approach this in a ecosystem kinda way that this involves a bit of change in, you know, organization and structure in the way certain things happen in an office, and that affects a lot of different people from the person that greets a patient when they walk through the door to the person that sends out the bill on the back end. It touches a lot of people in between. So we want every member of the staff to know about what we're doing, why we're doing it, to understand the value that it provides to families and how satisfied they are so that the whole ecosystem in the office can, you know, buy into it. You know? You really want a high level of, you know, sort of buy in and engagement.

Dr. Jonas Bromberg:

Yeah. We're doing this for the right reasons. So that's a really important first step to take too to, you know, make sure everybody's on board because it it's gonna affect a lot of people in a very positive way, and that's a story you wanna tell. And I always encourage practices that are doing this to with some frequency to highlight those success stories, remind everybody, reengage everybody about why we're doing this. It certainly doesn't make life easier to take this on.

Dr. Jonas Bromberg:

But it but, you know, for all the right reasons, it it makes sense. It it empowers physicians, provides higher quality care, generates patient and provider satisfaction. So it's worth the lift.

Daniel Williams:

Well, doctor Bromberg, before we sign off, I wanna give our listeners an opportunity to connect with you if you have any additional information you would like to share. So provide, if if you would like, any kind of contact information or any other benefits they might learn from you about that health care, behavioral health integration in their practice.

Dr. Jonas Bromberg:

Yeah. I'd be happy to, you know, fill questions, follow-up with any of your listeners who would like to if they wanna, you know, sort of learn more. You know? And this is this is what I do day in, day out at Crossroads Health Consulting is, you know, support practices that wanna do this in a variety of ways. So, you know, I'd be happy to have you put my information in your your show notes and have people contact me.

Dr. Jonas Bromberg:

I'd be happy to continue the conversation, and I'm available to help practices, you know, do this kind of work if if they want an experienced guide to to help them.

Daniel Williams:

Alright. Well, doctor Jonas Bromberg, thank you again for joining us on the MGMA podcast.

Dr. Jonas Bromberg:

Thanks, Daniel. I really appreciate the opportunity, and it's always fun to talk about something I, am really passionate about. So thank you.

Daniel Williams:

It is very clear your passion shines through, and thank you for the work you're doing. And everybody, as doctor Bromberg said, we will put those resources and links in the episode show notes. I'll also provide a link to an article we're gonna develop on this conversation here. So until then, thank you all for being MGMA podcast listeners. Hi.

MGMA Insights: Transforming Patient Care Through Behavioral Health Integration
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