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Becker’s Healthcare Podcast
The Business of Care: Elevating Behavioral Health Reimbursement with Purpose
00:18:55
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- [00:00]
Erica Carbajal
Hi, everyone. Thank you so much for listening to this episode of the Becker's Healthcare podcast series. I'm Erica Carbajal, an editor with the Becker's Hospital Review news team. Today we're going to be talking about elevating behavioral health reimbursement with purpose. Joining me for today's discussion is Kevin Isaacs, founder and president of Tribunist Health. Kevin, thank you so much for being on. It's a pleasure to have you.
- [00:25]
Kevin Isaacs
Absolutely. Pleasure to meet Lefcito.
- [00:28]
Erica Carbajal
Yeah, well, to get us started here, do you mind sharing a little bit about yourself, Tribunis Health, and the scope of your work in healthcare?
- [00:36]
Kevin Isaacs
Yeah, of course. So like you said, I'm Kevin Isaacs, president of Tribunist Health and you know, we, we help providers negotiate better rates with payers. That's what we do ultimately through their contracts with those companies. So, you know, when a provider or a facility group brings us on, they can expect not only the best outcomes with those payers, but also the best client experience. And that stems really from our teams and behavioral health specifically. You know, we've got multiple leaders, two to three decades of experience conducting these negotiations, which makes a big difference both in terms of, you know, their Rolodex, just kind of the what to do next as, as different offers and counters come through. And you know, the wrinkle here for us is really that we do it in a very data informed way, which has not been the norm in our space.
- [01:25]
Erica Carbajal
Yeah, for sure. Thanks, Kevin. Well, super relevant topic. Obviously we continue to hear and report a lot about parity when it comes to reimbursement with mental health and the lack of access to care, in part because of that. I know mental health is a deeply personal issue for many, including yourself. So can you share a little bit about what motivated you to start tribunas Health? How have your personal experience really shaped the company's mission to serve mental and behavioral health providers?
- [01:57]
Kevin Isaacs
Yeah, thank you for asking. I mean, for me, like by the age of 27, I'd had three close friends who suffer from mental health issues pass away. I remember my parents at the time, you know, this happened from the ages of 17 to 27. I remember my parents not really having anything to say about it. And that made me like mad at first. But I realized they had not really had those experiences themselves. Kind of a glass shattering moment in the parent child relationship. But I think it was emblematic of, you know, a culture where you just didn't talk about it. So kind of with that simmering as a backdrop and you know, the truism in my, in my business brain that healthcare was broken, quote unquote. I set out to understand what the different problems that providers were facing and how that impacted care delivery. Payer contracting really stuck out to me. There's, you know, a lot of things that I think the sort of average provider based business could improve on. But payer contracting really stuck out. It was a near universal need that was largely going unfilled on the provider side at least. Meanwhile, you had access issues on the patient side driven in no small part by the financial barrier to care that, you know, you kind of referenced earlier. And then from a supply perspective, you know, the majority of negotiation experts out there were kind of one off without the resources to really represent providers effectively.
- [03:24]
Erica Carbajal
Yeah, Kevin, thanks, thanks for sharing that. Certainly representative of just how much has shifted to, over, over the years in terms of awareness and openness and talking and seeking help when it comes to behavioral health care as well.
- [03:40]
Kevin Isaacs
Yeah, I think, you know, all those factors contributed to like a power imbalance that was and still is threatening the independent practice of medicine. You know, you think about sort of the consolidation taking place both, you know, with hospital systems, but also, you know, payers who are buying provider groups and that dilutes the market mechanism that's supposed to be the linchpin of the US healthcare system. And so kind of understanding those macro industry dynamics is one thing. But you know, to your question, like the personal side gave me the kick I needed to sort of make my vision a reality. And you know, that vision ultimately was to bring together the best at payer contracting and to resource those individuals so effectively in terms of data training, analytics like human resources also so that they could both be more effective at what they do and also at a scale that would allow us to serve clients beyond just large health systems that have a bunch of cloud. So like a residential treatment center like your local php Iop, the goal being for us to help the cream rise, you know, and behavioral health. If you pay the best providers more, they're going to A join your network allowing more than just the 1% to access care and then B proliferate. Like filling the void that we currently face in behavioral health.
- [05:00]
Erica Carbajal
Yeah, definitely. And I can imagine the payer contracting like important across the board, but even more so I imagine for independent practices really looking to improve their reimbursement, ensure fair compensation when they're thinking, thinking about conversations with payers on the reimbursement side, what are some of the key obstacles that you're seeing Providers face in negotiating fair reimbursement rates? And how can they start to overcome such a big challenge that we really hear about so consistently?
- [05:32]
Kevin Isaacs
Sure, yeah. So I mean, they change over time. So I'll break this into two parts. In terms of the challenges that we see for clients, you know, often in the early years versus when they're more mature from a revenue cycle perspective. What I mean by that, at least in terms of early stage, is like a lot of behavioral health providers have had a historical reliance on cash pay or out of network reimbursements. And my feeling after just seeing this for a while now is that that can just be fool's gold. Revenue that's all cash pay or out of network is flightier. You probably like the margin today, but the risk that it will erode is very real. And that could come from shifts in the patient population from out of network benefit design changes, you know, basically forcing more onto the patient client. In this case, fewer barriers to entry for competitors. If you're in that cash pay world, or even over time, you know, you've got an aging facility, so more competitors can come in and compete kind of on those cosmetic elements of trying to gain patience. And you know, if your organization's cost structure gets bloated to match that out of network revenue, it's really only a matter of time until competition begins to erode your census. Not to mention payers just getting harder to collect from on an out of network basis. So that's really the first one is that reliance on cash pay and out of network reimbursements. And those risks, those experiences, as those start to happen to folks, push behavioral health providers to go and network. But often when they decide to go and network, the rates that are offered just aren't sustainable. And that's another big hurdle. It's especially frustrating because in certain markets there are just unquestionable needs from a network adequacy perspective. I mean, sometimes for clients, we'll get on the phone and make calls to everybody who says they are in the payer's network and no one's able to take somebody. And so when you get these, you know, bad rate offers, it's like they don't want you. And that kind of gets to the heart of our mission as a company. You know, it's especially important to have payers and providers make a deal, especially in behavioral health, because it lowers the financial barrier for patients and their families. And so by allowing families to use the in network benefits that they've already paid for through their premiums, more individuals in crisis can access quality care. That's going to then prevent VR visits and worse for the payer.
- [08:02]
Erica Carbajal
Yeah, certainly eye opening to hear just the anecdote you shared there on calling those providers who, they do say that they're in the networks but they aren't able to take care of you because of those other barriers that you had mentioned previously of not being able to run on the rates that payers are offering once they do actually become a network. So so many challenges that really seem to compound one another and that's the.
- [08:28]
Kevin Isaacs
Other side of our mission. So first is access to care and I just kind of touched on all the barriers that we try to get around and fulfilling that. And you know, the second is to preserve the value of the provider. And that. And that really brings us to what you just said, which is renegotiations. Once you are a network, you're still facing some hurdles. These schedules can change and even if they don't, you know, labor costs have. So beyond the first contract, we help providers we think of as climb the reimbursement ladder, often going from, you know, break even reimbursement rates when they joined. And at that level, like, you know, a blip in your business performance can cost a community a key safety. So going from those rates to something more sustainable that will allow them, you know, eventually to open a new facility where there's need, like I said, we, we try to help the cream rise. So it's not just the loudest voices in the room that are getting paid, it's those that are creating more value.
- [09:20]
Erica Carbajal
Yeah, that's certainly an important aspect of this, of this too. Kevin, when you think about data, what role does it really play when informing a contract review process in addressing all the challenges we had just mentioned of. Or when you're thinking about, you know, that reimbursement ladder, what role is data playing in helping providers secure something that is more sustainable?
- [09:45]
Kevin Isaacs
So this is kind of another two parter. On one hand you have sort of the look internally for outcomes data. So that's on one hand and on the other hand look externally at what's going on with the competition. Outcomes data can be its own hurdle. Kind of getting back to the other question because it's not ubiquitous and this gets to just sort of the broken market mechanism in health care. Quick aside, there's a good example of that. We did a first of its kind study in the fertility space where there's actually really good public outcomes data that's widely accepted comparing uhc, reimbursement rates for specific providers to the patient, outcomes for those same providers, zero relationship. I wish this wasn't just audio so I could show you the graph, but it's, it was astounding. And so in specialties, without ubiquitous or widely accepted outcomes data like behavioral health, I don't have a lot of hope that it's going to be better than even fertility. Where there are good, where there is good data. And this is a problem and an opportunity, you know, if, if you can get the right audience at the payer and bring really good data about the outcomes that your facility or group can create, you can begin to tell a winning story. And so that's, that's one side which is, is that outcomes data. And you know, there are vendors out there who specialize in this and, and also help compare to other, your outcomes to other providers. Of course, from the payer side you kind of think about that too. Like they're only seeing the folks that have good outcomes because the ones that have bad outcomes wouldn't tell them about it. So that can, it can be tough. But again, if a story can hang together, it makes a big difference. So that's one side of it. And then you know, the other side is market data. What are your competitors getting paid, what services do they offer and how well are they doing it versus you? And you know, for the longest time providers had to rely on hearsay about their competitors rates, which was far from comprehensive, you know, putting them at a big information disadvantage in their parent negotiations, in their strategy setting. And you know, what's out there now because of the Price Transparency Act. You know, it's public, but it's not usable without a subscription and some serious skills. And so that's one thing that we set out, you know, three years ago to tackle. And I mean, happy to talk a little bit more about kind of what that's made up of, if you're curious.
- [12:10]
Erica Carbajal
Yeah, Kevin, actually I would love if you could expand on that because it's one of the things we hear a lot about when we think about price transparency. Being able to put that data to use like it's out there, but to your point, actually making use of it and having it show up in these conversations in a meaningful way is, continues to be a pretty big challenge. So how are you in Tribuna's health really tackling that?
- [12:36]
Kevin Isaacs
This is another one where the insight, you know, it would really pop if I could show you something. Podcasts have limitations. So anyone listening, we'd love to do a demo, but Let me talk to you about the data a little bit and I'll try to describe the visuals. So price transparency for folks that aren't familiar, the payers had to start posting all of their rates with every in network provider publicly. And the problem here is that the size of the data is just crazy. If you can think about, you know, just one rate with one provider, you know, they could have, for one code could have multiple potential, you know, places of service, multiple potential modifiers. You know, one group could have different rates for MDs versus MID levels. The sort of, the, the variability goes on and on which compounds the size of this. And so that's sort of the fundamental problem. Our goal and what we successfully did with our tool is create something that allows you to fairly quickly control for all those different factors so that you can see exactly like within a given market. I want to see all the residential facilities, their rate for one night for this specific code, you know, within Tennessee, give me those 17 facilities. And so, you know, what we do is create a histogram where you've got rate bins. So this one's $800 to $900, there are 10 facilities, 900 to $1,000, there are eight facilities, and so on. And so you can see exactly where you stand on the codes that really matter to you and your competitors in the market and find your specific competitors that you think are look alikes. And so then you can go in a very data informed way to the payer and say, hey, I'm getting paid 800. While this facility over here, who we know does a worse job because we take a lot of their patients who are bouncing back, well, they're getting 1200. And you know, before you may have said okay, I could only possibly expect a 10 increase in my wildest dreams. Well now like you know that twelve hundred dollar number is, yeah, it's a fifty increase but it's something that's being paid right now in the market. And so it adjusts your strategy, it adjusts how you'll respond. But you know, you sort of need access, you need someone who's, who's used to building those, those visualizations in order to be able to deploy it.
- [15:09]
Erica Carbajal
Yeah, Kevin, thanks for sharing that. I think it's helpful to hear. Just, I think sometimes these conversations can, can sound, you know, inadvertently simplistic when you think about, oh, it's just about pulling the data and comparing what this payer gets for this service. And really it's much deeper than that. And being able to, to your point, have the, the know how and the technological like expertise to be able to pull that data out, create tools that actually enable providers to do that in a meaningful way.
- [15:39]
Kevin Isaacs
Yeah. And that, that's our vision in creating that tool was here we were a company that always negotiated on behalf of our clients with the payers. But a lot of times you do have folks that, you know, are never going to want to outsource that function well. They really need this data to do this well themselves. And so now we can give them a way to do that, whether it's us running a report and sort of furnishing them with the results or just giving them a subscription to the tool. And you know, either, either can happen or we can, you know, do both and negotiate for you. Right. It just depends where sort of what a provider is coming to the table with. We can sort of plug into fit and get them prepared for that negotiation.
- [16:25]
Erica Carbajal
Yeah. Thanks, Kevin. Well, earlier in the conversation we touched on your deep connection to this space. And I know you had mentioned a bit about how when you started doing some market research, saw that a lot of the payer contracting services, particularly in behavioral health, was a bit more one off. So why is it important for behavioral health providers to partner with experts who do have more focused and special in a particular realm? What are some of the short, long term benefits of that kind of relationship?
- [16:56]
Kevin Isaacs
Sure. I think the easy answer here is that you're leaving money on the table. If you hire a contracting vendor and they staff someone who thinks that the mat you keep talking about is just a really great clinician, you're not in the right place. And so you can have it all. Behavioral expertise and analytically rigorous negotiators and a great client experience. Whatever you're leaving on the table dollar wise is just too valuable. So don't settle.
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Erica Carbajal
Yeah. Thanks, Kevin. Before we wrap up, is there anything on the topic that we haven't gotten to that you think is really important to mention or leave listeners with?
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Kevin Isaacs
Yeah. So look, a lot of folks, I think if, if they're considering doing this themselves or not, if they want to outsource it, probably just want to cut to the chase and know the price. Like how do we pay for someone like us? And something unique in our space is that we're able to meet providers where they are. I talked a little bit about how our personnel model makes that possible. And you know, some are looking to align trevenous fees with the outcome we create. And we can do that and we'll offer a guarantee, you know, that a certain level of success will happen. Then again, some are more comfortable paying a, you know, a larger fixed fee. That's still a generous discount versus what you'd have to pay to hire resources like us internally. So, you know, give us a call and we can, we can help evaluate if it's a fit. You can obviously find, find us on, on our website and, you know, reach out to our team directly.
- [18:25]
Erica Carbajal
Well, Kevin, thank you so much for being on today. We appreciate your time and insights.
- [18:31]
Kevin Isaacs
Thank you. Yeah, no, it was fun to be here, fun to chat, and I was short and sweet. Happy to do it again.
- [18:37]
Erica Carbajal
Yeah, absolutely. And listeners, we also want to thank our podcast sponsor, Tribunist Health. And you can tune into additional episodes of the Becker's Healthcare podcast by visiting the podcast page on our website at beckershospitalreal. Com. Thanks, everyone.