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Management in Practice

A Whole-Person Approach to Mental Health

More than half of adults with mental illness go untreated. Christina Mainelli ’11, CEO of Quartet Health, says a value-based approach can help to expand access, standardize treatment, and create incentives for better coordination between physical and mental healthcare.

Q: What is the scale of the mental health need in the U.S.?

It’s estimated that more than one in five adults live with a mental illness. And if you add addiction—substance use disorder—that number gets much larger. It’s also pretty alarming that 55% of adults with mental illness go untreated. That’s devastating for those individuals and their families and friends. There are impacts on productivity, employment, even lifespan, and for society there’s lost economic vitality.

For adults with serious mental illness—think bipolar, schizophrenia, PTSD, major depressive disorder—there are even greater impacts. These individuals often have multiple comorbid conditions and worse health outcomes. Forty to fifty percent of this population also has a substance use disorder.

Additionally, the impact of mental illness on kids is staggering. Over half of adolescents have had a mental health issue or mental illness. Kids with a mental illness are two times more likely to drop out of school. Suicide is the second leading cause of death for adolescents as a whole and the leading cause of death for 14- and 15-year-olds.

Q: What’s keeping people from getting the care they need?

I think of three major issues that need to be addressed: access, quality, and the fragmentation of the delivery system.

This is a business opportunity because, in a value-based context, we can deliver higher quality care that lowers overall costs and provides better patient outcomes.

One way to think of access is simply getting an appointment. You hear about wait times of weeks or months for people struggling with high acuity concerns—meaning their condition may be serious and could benefit from immediate care. The average wait time to see a psychiatrist is 25 days, and it can be up to 90 days. That’s a huge issue. Generally accepted standards include speed to care within 10 days for routine needs, within 48 hours for urgent needs, and within 6 hours for those in non-life-threatening crisis.

From a business perspective, access is largely a supply and a matching issue. Almost half of the U.S. population, 164 million people, live in designated mental health professional shortage areas. To bring this to life, in Massachusetts, there’s one behavioral health clinician for every 150 people. In Alabama, there’s one behavioral health clinician for every 920 people. Essentially, in Alabama, there’s simply not enough supply, while in Massachusetts access challenges have more to do with matching the right provider to the patient.

It’s a very personal experience to obtain mental health care; we want a clinician who understands our circumstances. We may feel more comfortable with someone who “looks like us” in terms of age, race, religion, language, or gender. To fully address access, we need to support patients in getting connected or “matched” to the right behavioral healthcare clinician, and we need clinicians that reflect the complexion of our population as part of addressing health equity issues.

Q: What about quality?

Delivering high quality care that achieves the best outcomes for patients is critical, but significant variation remains in adherence to evidenced based care and in treatment outcomes across care settings, providers, and geographies. There are multiple contributing factors, including training, reimbursement models, and impact of health disparities which need to be addressed both on the healthcare delivery side as well as from a policy perspective.

Q: The third issue you noted was fragmentation.

Fragmentation between physical and behavioral healthcare is a huge problem—the more we learn about mental health care, the clearer it is that physical health can be a large determinant of mental health and vice versa.

There has been progress addressing fragmentation as demonstrated by collaborative care models and related codes, and most recently a Centers for Medicare & Medicaid Services announcement around Integrated Health Models aimed at advancing holistic care. However, there is still a huge need for a formalized structure that not just enables but also incentivizes primary care doctors to connect with behavioral health specialists.

Imagine you’re a primary care physician in a practice seeing patients every 12 to 15 minutes, and someone presents with a mental health issue. It may not be clear how acute the patient is or how serious the issue is. What’s the appropriate treatment pathway? Who should you refer the patient to? It’s not obvious—or efficient to act on—in today’s clinical world.

I often hear that physical health providers are reticent to treat individuals with serious mental illness. Why? Because patients with these conditions often have a complex combination of physical, behavioral, and social health needs.

There’s a lack of aligned incentives that would enable physical health providers to take on these patients, work with the mental health provider on a treatment plan that addresses all health needs, and engage in an ongoing exchange of information with the patient and the mental health provider about how the patient is progressing.

All of these things combined contribute to a lack of connectivity between the physical and behavioral health provider. It also creates a confusing and fragmented experience for the patient.

Q: How does Quartet Health work?

Quartet is both a technology platform and a direct provider of patient care. On our digital platform, we are connected to over 10,000 behavioral health providers that service up to 21 million patients. We also have a medical group that directly employs over 250 behavioral health clinicians who see over 500,000 patients a year.

Here’s a real-life example: a 71-year-old female patient in Michigan used her phone to access our digital platform where she answered a few questions and selected what was most important to her in her care. She requested a female provider for virtual and in-person services to help address her anxiety. Within two hours, we reached out to the patient in Michigan and matched her to a provider. The provider contacted her within the hour, and she had her first appointment three days later.

The patient in Michigan is what we’d consider a good patient experience—within three hours the patient had an appointment set for within three days. This is using technology to help solve the access problem. We triage, match, and then provide care. At every step, we’re measuring outcomes to ensure quality.

While this patient used the self-service option, primary care providers on our platform can also make a referral or have someone in the front office go through the initial matching process with a patient. Whether it’s the patient or the provider making the query, it passes right through our algorithms which help match the best behavioral health provider. That’s the connectivity between physical and behavioral health reducing fragmentation.

The name Quartet refers to what we see as the foundation of the physical health provider, the behavioral health provider, the payer, and the patient all working together.

Q: Why not just operate a digital platform to connect patients to existing providers?

Many behavioral healthcare companies were born out of the pandemic. A lot of them offer point solutions—they’re addressing one specific need. We’re starting to see consolidation in that part of the industry. We’re also seeing some of those companies fail due to lack of a robust business model. The ones that are surviving aren’t just offering point solutions, they’re taking on bigger industry-wide problems.

At Quartet, we felt that the digital platform alone wasn’t solving a big enough problem, so we made a strategic decision to deliver care ourselves. Quartet Medical Group delivers care in 30+ markets. We practice measurement-based care (MBC) to ensure our clinicians are using evidence-based medicine; we have close to 80% adherence to MBC, which is well above industry best practice. We also offer appointments within 48 hours for high acuity patients, and our outcomes are strong. Our data shows over 40% improvement in total cost of care for patients in our clinic. I don’t know of another company that connects physical health to behavioral health the way we do.

I have absolute conviction that we must address the whole person in healthcare.

Using that integrated approach, we’ve just launched a new product. For patients with serious mental illness, we’re building a behavioral health home that delivers whole-person treatment—physical health, behavioral health, and social care, which is reimbursed in a value-based model. I worked closely with two of my classmates from Yale SOM to develop this solution: Tom Dow, who leads our medical economics team, and Michael Lipp, our chief medical officer. Getting to collaborate and innovate with Michael and Tom at Quartet has been one of the greatest gifts from the program.

Q: Why did Quartet choose to focus its new offering on the seriously mentally ill population?

In the last few years, we’ve seen lots of new entrants in behavioral health—think Talkspace, Headspace, Calm. Most new entrants focus on those with mild mental illness. There are very few programs directed at the moderate to seriously mentally ill.

This is a patient population that really struggles. Their average lifespan is 15 to 17 years shorter. Often, they do not have access to physical or behavioral healthcare. And from an economic perspective, these are incredibly expensive patients because they require a lot of services and, if they don’t get those services, they end up in situations that require an emergency room or inpatient facility.

I have absolute conviction that we must address the “whole person” in healthcare. I’ve spent over two decades in the field. I’ve worked on the physical health side. I’ve seen the difficulties and complexities of delivering care to patients. I’ve also done work focused on the social determinants of health. That’s why I know Quartet’s approach is an opportunity to improve experience and outcomes for these patients. This is a business opportunity because, in a value-based context, we can deliver higher quality care that lowers overall costs and provides better patient outcomes.

Q: How does the program work?

We take total cost-of-care accountability. Our primary care and behavioral health clinicians provide care virtually and in person. We meet the patient where they are: in the hospital, in the home, in the community. We provide whatever service the patient needs, whether it’s physical health, behavioral health, or social services. We’re not saying, “Oh, this or that’s not covered.” We’re doing what we think is clinically appropriate for each patient because, at the end of the day, we are rewarded based on our clinical outcomes: Did we reduce cost of care? Did the patient’s health improve?

Value-based care is a very impactful reimbursement model for this population because it aligns incentives. This population has complex needs, with nearly three comorbid conditions on average, and thus requires a payment model that reimburses for not just mental health services but treatment for the whole person. By treating all aspects of health, we can prevent acute events such as hospital admissions by ensuring access, quality, and continuity of care, which in turn lowers overall costs. And we can do this successfully because it’s one care delivery team working together.

This isn’t a short-term program; we stay with patients for as long as they need us. That could be 12 months or 18 months or it could be three years. We see up to a 30% to 40% total cost-of-care reduction while improving quality and patient experience. It’s early, but we’re seeing very good results to start. For example, we are seeing over 25% patient engagement in a tough to reach population, and over 95% are coming back for follow on appointments and visits. That is an early indicator of success.

Q: How is mental health care usually paid for?

Today, mental health is still primarily a fee-for-service game. If you’re fortunate enough to find a provider that’s in your network, you have a co-pay, but the lion’s share of individuals are using cash pay in order to get access to the mental health provider that they want on the timeline that they want.

A lot of work has been done on mental health parity, which would ensure mental health issues are covered by insurance and that providers are available, but more work needs to be done to fully implement these programs with payers across the country.

I know people who are paying up to $450 an hour to see a therapist in New York City. I don’t think that’s sustainable. It doesn’t solve the core issues at hand with respect to equitable access, quality, or fragmentation. For example, the fee-for-service world does not reimburse for treating the whole person. Services like transportation, wellness visits, or peer support are often not reimbursed, but they are critical to improving health outcomes and lowering overall costs. That’s why we’ve made the choice to work with both commercial and government payers, so the providers we make available to individuals are largely in-network choices, and why we’ve launched our value-based products to provide alternative payment models.

Q: Who is your customer?

We have a patient-first culture and mentality. We are accountable to our patients, but often we get access to them through a payer, so at the end of the day, our customers are health plans, health systems, community mental health centers, and government payers.

Q: Where do you see the field moving in the next five years?

I think that we are going to see a lot more movement toward value-based care for behavioral health. Traditional fee-for-service does not work for whole-person care or for higher acuity populations—whether its mental health or substance use.

I also absolutely think there’s a place for AI in behavioral healthcare. There’s work being done on patient intake, routine administrative tasks, and transcribing notes from sessions, all of which can help to tackle issues of supply by freeing up staff to focus on patient care.

AI can also analyze vast datasets far more efficiently than humans. This capability can lead to earlier detection of diseases, help develop personalized treatment plans, and lead to better patient outcomes. It’s worth noting that for these efforts to be successful, they rely on high quality data, a multi-disciplinary team to develop and validate recommendations, and the protection of patient data and privacy.

Q: Has your experience at Yale SOM shaped how you approach your work?

I got a tremendous amount out of my Yale SOM experience. Because I chose the healthcare focus, my classmates all worked in healthcare, too, but they had expertise in other disciplines such as law, technology, or medicine. Their different points of view gave me a broader understanding of the many constituents in healthcare and the challenges and opportunities each faces, as well as the importance of the entire healthcare delivery system working together. This broader view and experience have made me a better problem solver, strategist, partner, and leader of people and organizations.