Mental Math: Adding Quality and Subtracting Cost through Behavioral Health Integration

A Look at Quartet Health and Landmark Health

Schuyler co-founded Oxeon Partners and currently serves as a Senior Associate. He has largely been focused on building leadership teams for high-growth Healthcare IT and Services clients like Evolent Health and Landmark Health. He is currently embedded within Oxeon client Quartet Health, a behavioral health technology company backed by Oak HC/FT, Polaris Partners, and Fidelity Biosciences, where he leads Marketing and Talent. Schuyler is deeply interested in businesses that create alignment between multiple stakeholders as well as those that accelerate the shift toward value-based care.

I grew up in a suburb of Denver, Colorado, roughly 50 miles from the Rockies. My town is known for many things: John Kerry was born here, we’re home to the brewery that took Gold at the 2006 World Beer Cup, and the Pope even visited once.

In 2012, we became known for something entirely different. Start to type “Aurora, Colorado” into Google today, and the search engine will suggest that you add “shooting” as a suffix. James Holmes forever put my town on the map in 2012 when he committed one of the worst shootings in state history, second only to the Columbine massacre.

Much of the coverage of the shooting focused on the gunman’s mental state—the psychiatrist privy to his homicidal thoughts, the clear signs of Schizophrenia exhibited in the months leading up to the shooting, the plea of not guilty by reason of insanity. Countless other news stories have focused on the same: Virginia Tech, Newtown, CT, Robin Williams’s suicide, the Lufthansa crash orchestrated by a severely depressed pilot earlier this year—the list, unfortunately, goes on. The idea here isn’t to be macabre, but rather, to point out the media’s increased focus on mental health. Many feel that the reduction of the stigma associated with mental health coupled with better access and availability of mental health resources could curtail future tragedies.

These stories I mention are easy to focus on. The impact is massive, and the cause, seemingly obvious. Often overlooked, however, are the countless instances of mental illness that impact the livelihood of millions across the U.S. In recent years, a great deal of evidence has emerged to indicate a very strong, bidirectional relationship exists between behavioral health (includes mental health and substance abuse) and chronic physical conditions. For instance, many of the health risk behaviors and psychobiological changes associated with behavioral health conditions such as depression increase the risk for chronic physical conditions, while biological changes associated with chronic physical conditions often precipitate depression as well.[1] In fact, 29% of those with a physical disorder have a comorbid mental health condition and more than 68% of adults with a mental disorder have at least one physical condition.

In the 1990s and early 2000s, the notion of a more integrated care model—where behavioral health and physical conditions are treated in concert—emerged and received a great deal of attention from the healthcare industry. One such model developed by the University of Washington called IMPACT is characterized by collaboration between a primary care physician and a depression care manager (often a nurse, social worker, or psychologist). As published in the Journal of the American Medical Association (JAMA), about half of the patients treated through IMPACT experienced a 50% reduction in depressive symptoms, compared with only 19% of those in normal care. Perhaps more impressive is the cost savings: over a four-year period, IMPACT patients had lower average costs for all medical care (which includes treatment for both behavioral and physical health conditions) by $3,300 than patients receiving care as they normally would.[2]

Health insurers and providers have started to take notice, and there has been a shift in the way the healthcare community is tackling behavioral health in recent years. Previously, the predominant method for addressing behavioral health needs was to “carve out” care to contracted organizations that specialized in treating mental illness. However it is often argued that this fails to treat the whole person. Treating behavioral health as separate from physical health, some say, is akin to having one physician treat the right side of your body and another the left.

Today, government as well as the healthcare community acknowledges the need to disrupt the traditional approach to behavioral health care delivery and many health plans have increasingly begun to “carve in” behavioral health (meaning behavioral health benefits are provided by the same organization or network of providers that addresses all other health benefits). One of the biggest drivers behind this shift is the recognition of the staggering prevalence of comorbidity between mental health and physical conditions. Studies suggest that 30-40% of the total healthcare spend is driven by members with comorbid behavioral health (mental health and/or substance use) and physical disorders.[3] Health plans have realized that the cohort of patients possessing some sort of comorbidity is a huge determinant of cost and quality and, they’re increasingly trying to figure out how to best care for this population.

Accompanying this paradigm shift has been the emergence of a number of companies that are enabling health plans to more effectively manage these comorbid populations at the delivery system level. Oxeon Partners works with, and has made investments in, two companies taking novel approaches to treating the whole patient.

One such company is Quartet Health, which allows better collaboration between behavioral health providers, primary care providers, and patients. The company has built a cloud-based platform that connects PCPs to the right behavioral health providers in a closed loop collaborative care model focused on specific comorbid sub-cohorts (i.e., diabetics with depression) as well as a comprehensive data engine that leverages healthcare claims and EMR data to generate advanced insights on utilization patterns driven by behavioral and physical health conditions, provider network quality, and at-risk members in the population. The company partners with payers and provider organizations seeking to improve quality and reduce the costs through a more connected approach to treating behavioral health conditions. “We’re using technology to scale proven models for at-risk populations,” says Dr. Juliana Ekong, Quartet’s Chief Medical Officer who is a psychiatrist. “Our goal is to optimize the existing network to help folks with behavioral health risk and comorbid physical health illness get evidence-based, quality and easily accessible behavioral interventions that achieve the triple aim.” Dr. Ekong previously led behavioral health for Anthem’s Medicare and Medicaid lines of business nationally and also held leadership roles in community psychiatry clinics. Quartet, backed by Oak HC/FT and other high-profile investors, has grown quickly over the past year and assembled a team of top clinicians and technologists committed to bridging the divide between behavioral and physical health.

Another such company is Landmark Health, a multispecialty provider group exclusively focused on delivering high quality in-home care to high-acuity, multiple-comorbid populations. One of the company’s earliest hires was a Chief Psychiatric Officer, Dr. Christopher Dennis, to develop, implement and execute a collaborative-care strategy to support the broader interdisciplinary in-home care model. “The Landmark Complexivist^TM model relies on technology and an internally developed EMR to connect the various caregivers, nurses, medical and behavioral health providers as well as other members of the interdisciplinary team who are actively managing patients wherever they reside, and whenever they need it,” says Dr. Dennis. “Because our patients have multiple co-occurring conditions, it’s important that we employ a model that can address both mental and physical health simultaneously.” The company currently partners with varied health plans and providers across the country.

Admittedly, there is still much work to be done to achieve true integration of behavioral and physical care. However, evidence-based care models and the companies like Landmark and Quartet that help them flourish are gaining significant traction. Health plans are grasping the incentives to adopt these models in order to improve quality and reduce cost, which is certainly a step in the right direction. My hope is that, as these integrated behavioral health models become more common, data will demonstrate a clear impact at a population level, and adoption will accelerate. This shift will benefit payers, providers, and most importantly patients dealing with comorbid behavioral health and physical health conditions.

[1] J. Katon W. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues in Clinical Neuroscience. 2011;13(1):7-23.

[2] Unützer J, Katon WJ, Fan M-Y, et al. Long-term Cost Effects of Collaborative Care for Late-life Depression. The American journal of managed care. 2008;14(2):95-100.

[3] Source: Quartet Health