You know things are weird when behavioral health visits are outpacing primary care visits (at least as far as percentage increases) at many health centers. This is one of several paradoxes of the COVID-19 era along with the finding that many (if not most?) patients are preferring phone visits to video consults – which is causing many administrators consternation since many payers do not reimburse well for phone visits. So as Arsenio Hall used to say, these are things that make you go, “Hmm?” So let’s dive in to these and see if the data going forward bears our assumptions out.

Why Behavioral Health Is So Busy All Of A Sudden

First, it is not true that all integrated behavioral health personnel are busier. I have certainly heard of clinics, especially clinics serving underserved populations, like the homeless, who have had trouble staying busy in large part because of poor phone access. However in the era of the smartphone many clinics are finding that even poor patients have smartphones or at least a cell phone. And while we might assume that anxiety about the COVID-19 pandemic is the cause of the increase in behavioral health visits, my guess is actually that it is a sequelae of COVID-19, namely patients staying home, that is the main driver behind the productivity increase. In other words, patients have the time (at home), means (phone) and motivation (lots of things including stress) to engage behavioral health and are far less likely to no show. Basically, what many in the world of integrated care have been harping on for decades, that behavioral health places too many barriers to access, is bearing out once again. Reduce the barriers and the patients will come.

The productivity on the primary care side will come back eventually, but since talk therapy is so amenable to telehealth I suspect that behavioral health visits will continue to outpace primary care for a bit. The irony is that it used to be primary care providers who were too busy to reach out to their behavioral health consultants – now it’s often the other way around.

And if you are thinking about what’s on the horizon here is my bullet point list of things to ponder with regard to your integrated care teams:

• How can we transition patients seamlessly from provider to provider in a visit? If we coordinate the underlying work strategies it should actually be easier in a telehealth world.
• How about huddles? Getting team members together should be easier in this environment, but I’m still not hearing much of this other than general staff meetings.
• Are we building a backlog of demand in primary care? I’m concerned about all the patients not reaching out for care right now. At some point will we have a lot of patients trying to access the system at the same time and can we do something about that now through proactive panel management?

Why Many Patients Prefer The Phone

I have long suspected this since a lot of my work has been on the phone with patients. Patients like phone conversations for the convenience. It’s providers who don’t like the phone because of the lack of visual cues and the feeling that it is not a “real” visit. The truth is, I feel just as effective on the phone as in person given the amount of practice I have had. But what was surprising to me was that patients seem to prefer it to video consults. Then my middle-school daughter clued me in as to why.

We all have a little middle-schooler in us.”

An insight gleaned from observing my middle school-aged daughter.

She was on a school zoom call recently where the poor teacher was the only one sharing his video. Every one of the students had their video turned off. Now likely some of that is a desire to be less accountable to paying attention, but some of it I realized is that middle schoolers are notoriously self-conscious. I suspect that patients don’t necessarily like seeing themselves in a video chat and that the video format creates a level of self-consciousness that is uncomfortable enough to push some to use the phone. In other words, we all have a little middle-schooler in us. That said, as video chatting becomes ever more ubiquitous I suspect that will change as well. We already have become less self-conscious on business video calls that show are messy rooms or kids in the background.

Where this will all settle out is anyone’s guess. This blog is likely to be outdated by next week. Such are the times we live in. My guess is that telehealth is here to stay and that primary care will adapt its services to provide routine care that can be handled well via telehealth while providing more complex care in house (eg. diabetes management). Because we are integrated, the same will occur with behavioral health. Why make someone come to the clinic if we can reach them at home and avoid no-shows (and get paid)? At the same time, we will still need to have those in-person visits, particularly for complicated medication management or perhaps certain types of family visits (although has anyone tried couples work with each partner on a different device?). For now, what I am sensing from our members is that we are dealing with today today. Survive and advance and hopefully at some point soon we can pick our heads up and see the horizon in the upside down world of COVID-19.