“Hybrid” is a word that is no longer associated with just cars, and plants. The pandemic crisis has changed all of that. We couldn’t dine in our favorite restaurants, but takeout meals ordered online saved the day. My local farmer’s market has created a portal for online orders that are picked up at the market. Grocery stores and drugstores are offering home delivery and curbside pickup that can be initiated with a telephone call or email. But as we move into the post-crisis period, hybrid will take on a new meaning in the delivery of health and human services. The models that will likely win the race for competitive advantage are not the traditional face-to-face models or the all-telehealth-all-the time models. The winning service model is one that blends the best of both for maximum convenience and value for both consumers and payers.
We got a close look at what these new hybrid models look like in the addiction treatment field last week in our exclusive OPEN MINDS Circle web briefing, Blended Virtual & Onsite Services For Continuity Of Care, led by my colleague and OPEN MINDS Senior Associate Deb Adler. Executives from two addiction treatment provider organizations—Lakeview Health and Hazelden Betty Ford Foundation, and from two health insurance organizations—Cigna and Optum, discussed the promising practices for blended addiction treatment models that combine the onsite and the online for intensive outpatient (IOP) and partial hospitalization programs (PHP). Both provider organizations are providing addiction treatment services using proprietary hybrid service models. Their executives stressed two important factors in program design—balancing consumer convenience and safety with the solid value proposition.
The Emerging Models
Lakeview Health runs multi-site adult addiction treatment programs in Florida and Texas, and treats consumers with alcohol and substance use disorders simultaneously with any co-occurring mental health or physical health issues. The organization has a value-based contract with Aetna and is the preferred provider organization for NFL Trust, Mayo Clinic, and Cleveland Clinic. Lakeview switched to virtual services for consumers in IOP and PHP programs where feasible and permitted by state regulations. Family workshops and visitations went entirely virtual.
However, the organization kept its facilities open for those who needed in-person care, especially for consumers with co-occurring disorders and complex medical conditions. To do this, Lakeview sanitized all facilities and practiced social distancing according to guidelines from the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). Consumers who came in and exhibited symptoms were sent home to quarantine but received daily check-ins through telehealth. As an integrated care facility with physicians and nurses onsite, Lakeview was able to offer nursing assessments seven days a week for all consumers—those with a temperature were isolated, tested, and sent to the emergency room. Screening and two levels of testing (point of contact testing for antibodies and nasopharyngeal swabs) were instituted—at first for staff and symptomatic consumers but eventually for all. As Lakeview has a 3-building campus, one of the buildings was designated as a quarantine facility through which all new residential consumers were admitted before being transitioned to other facilities. This facility also allowed for isolation of residential consumers who tested positive for COVID-19. With the blended care model, they saw readmission rates for IOP and PHP consumers drop to an all-time low of 2.3% while PHQ-9 and GAD-7 scores between admission and discharge dropped significantly.
The Hazelden Betty Ford Foundation provides comprehensive inpatient and outpatient treatment for adults and youth affected by alcohol and drug addiction, as well as co-occurring mental health conditions. The organization has 17 locations nationwide and collaborates with an expansive network throughout health care. Hazelden’s Butler Center for Research advances knowledge about addiction treatment and recovery and helps to integrate addiction treatment research into practice. Hazelden Betty Ford started to offer telehealth about a year before the COVID-19 crisis started and learned many lessons on the go about how to improve virtual service delivery. This was valuable as they ramped up telehealth during the crisis. But they also modified programs to work better virtually—for example, family groups that were done over three days in-person transitioned to one-day virtual events.
Starting May 1, 2020, Hazelden is following more than 1,000 IOP consumers and monitoring how they are doing one, three, six, nine, and 12 months after discharge. They’ve had continuous interaction with payers to determine what performance measures they want to see. “Why do some patients do better?” asked Quyen Ngo, Ph.D., executive director of the Butler Center for Research at Hazelden Betty Ford Foundation. The Butler Center is tracking data for four groups of consumers—those in in-person IOP for the three months prior to the virtual transition, those who stepped in to virtual IOP following the virtual transition, those who started in in-person and transitioned to virtual, and those who started in virtual treatment and transitioned to in-person treatment.
The Payer Perspective
Ms. Adler pointed out that pre-COVID-19 key performance indicators have not changed—length of stay in IOP and PHP; readmission rates within 30, 90, and 180 days; 90-day episode costs; medical costs (emergency room, labs, or pharmacy); outpatient follow-up within seven days; consumer-reported outcomes; migration to lower levels of care; Consumer Assessment of Healthcare Providers and Systems surveys; and net promoter score.
Deb Nussbaum, senior director of behavioral product at Optum, and Erin Boyd, solutions and program director at Cigna, both emphasized that payers want to know what provider organizations are measuring and want to have a dialogue to ensure better outcomes with virtual and hybrid care. They want to monitor treatment outcomes over time to understand who needs to be seen in person and who needs to be seen virtually. Cigna is working with Hazelden Betty Ford to help shape what is measured in their longer-term research but in the meantime, the payer will compare the standard performance indicators for in-person vs. telehealth visits to gauge variations in efficacy.
Payers are pleased to see a significant uptick in the use of virtual services. Pre-COVID, Optum mainly offered reimbursement for virtual therapy sessions and medication management visits while Cigna also offered virtual IOP reimbursement. But few provider organizations used any of these options before the crisis. However, payers added reimbursement of virtual services for more complex IOP, PHP, and medication assisted treatment (MAT) during the pandemic crisis to respond to consumer needs and maintain continuity of care.
While the number of consumers seeking PHP and IOP services dropped by nearly 30% during the crisis, those who did get services largely opted for telehealth. Cigna contracted with digital provider organizations (such as Talkspace, Meru Health, and nocd) to expand virtual services. Optum also noted a 125% increase in registrations for its free wellness app, Sanvello, during the crisis.
Business Model Considerations
In the future, Cigna intends to contract with virtual-only IOP provider organization platforms that embed peer support. “There’s no turning back,” said Ms. Boyd, but treatment efficacy must continue to be monitored closely to determine the long-term viability of blended care, beyond the crisis. Ms. Boyd also suggests embedding virtual services into discharge plans for consumers who receive IOP and PHP services, to demonstrate continuity of care to payers.
“A hybrid model is a win-win for all,” said Ms. Adler. Consumers like the advantages of virtual and can stay engaged. Provider organizations can meet consumer preferences with a smaller footprint and have fewer no-shows to contend with. And payers appreciate the increased utilization and increased efficiency, with regulatory compliance.
So what does this mean for traditional provider organizations with addiction treatment programs? From the comments of our panel, it appears that the payers think they will get the addiction treatment outcomes they are looking for in treatment services that are largely virtual. A return to pre-crisis levels of residential or even facility-based outpatient addiction treatment is unlikely. For crisis recovery planning, executive teams of addiction treatment provider organizations need to plan on the majority of services remaining virtual. This means creating treatment program packages that are funded with a business model that is sustainable—at a price point that is set largely by virtual behavioral health organizations. And it means looking at how to get payers to contract with traditional provider organizations for expanded virtual care, in preference to digital-only provider organizations (see The Amazons Of Health Care). In short, how can provider organizations become the virtual platform of choice for health plans?
Any level of onsite and residential services can likely be sustained only if integrated care for co-occurring medical and behavioral health disorders is a key element of the model (see Getting To Whole Person Addiction Treatment). So think about which integrated model (see Ten Integration Models Reshaping Specialty Service Delivery) is feasible for rapid implementation.
And, referral generation and marketing planning must change as well. The traditional models for addiction treatment referral generation will need to be enhanced with a stronger virtual marketing plan. (For more on this topic, listen to the web briefing, Increasing Your Service Volume – Creating A Referral Development Crisis Plan by my colleague and OPEN MINDS Vice President Richard Louis, III, and the briefing Going ‘Virtual’ For Revenue Generation: Assuring Consumers & Referral Sources Can Find You by my colleague and OPEN MINDS Executive Vice President Tim Snyder.)
It appears that the hybrid model is the future of addiction treatment. Finding the business model for that future is the challenge.
For more on innovative service models, check out these resources in The OPEN MINDS Circle Library:
- Hazelden Betty Ford Foundation’s RecoveryGo Program
- Virtual Care Expands Consumer Access At Centerstone
- Mental Health Center Of Denver’s Innovation Lab For Virtual Care
- Making ‘Virtual’ Work – Two Case Studies
- Cedars-Sinai Pilots Aiva Virtual Assistant In Patient Rooms
- Crossover Health Expands Virtual Care Through Sherpaa Health Acquisition
- At UMass Memorial, Clinical Professionals Bring Virtual Care To Infants
- Boston Children’s Hospital & 2nd.MD Form Virtual Care Partnership
- The Future Of Residential Treatment: How Technology & Innovative Program Models Are Redefining Service Delivery Models
And don’t miss our August 13 web briefing, Opportunistic Business Development – Responding To New Market Needs, Quickly, led by OPEN MINDS Vice President Richard Louis, III.