D Healthcare Daily

Arlington psychiatrist Ken Hopper is on a mission. He wants to reinvent how psychiatric services are delivered, and he wants to carve out a prominent role for mental-health providers in healthcare delivery reform models.

Of the 10 largest physician specialties, psychiatry represents the most severe provider shortage in Texas. There are fewer than seven psychiatrists for every 100,000 Texas residents. That rate is less than 60 percent of the national average.

About one out of four U.S. adults suffers from a diagnosable mental disorder in a given year, according to the National Institute of Mental Health. About half of those suffer from two or more disorders. Mental health is the leading cause of disability in the United States.

Difficult economic times definitely take a toll on mental health. About 40 percent of employees report increased stress and anxiety. The Occupational Safety and Health Administration has declared stress a workplace hazard. An American Psychological Association survey showed that the top three causes of stress from 2007 to 2010 were money, work and the economy. Yet demand for psychiatric services slackens during recessions.

Why are there so few psychiatrists despite so much mental illness?

Hopper said a major contributor is the fact that psychiatrists cannot charge patients based on the complexity of their conditions. The cost of a visit by a patient with mild depression is the same as that of a person with several mental and physical conditions.

To combat this, Hopper screens his patients for three criteria.

• Ability to pay. He only accepts Blue Cross Blue Shield, Aetna, and Value Options. He said major carriers such as UnitedHealthcare and Cigna do not reimburse psychiatrists adequately. Otherwise, his patients are self-pay.
• Complexity. Hopper said accepting complex cases requires more office overhead and treatment time.
• Patient engagement. They must commit to adhere to treatment guidelines, committing to what he calls a “behavior contract.” Likewise, the patients need to believe the treatment guidelines make sense.

Hopper said many psychiatrists get into trouble because they only do financial screening. Because of his thorough upfront screening, Hopper said he has terminated fewer than 10 percent of his patients for noncompliance. He said malpractice insurers especially like the behavior contract because it limits practice liability.

Before he started screening for complexity, Hopper said his office was handling 1,200 patient visits a month, using three providers and seven support staff. He has since reduced that to 500 monthly visits, with only three support staff.

Hopper pointed out that primary-care physicians are treating an increasing number of behavioral health disorders. That, he said, has resulted in more complex cases being referred to his practice.

Hopper runs his practice not unlike a patient-centered medical home. He has two nurse practitioners who he estimates can do about 85 percent of what he can do on treatment complexity. He said he sees patients earlier in their course of treatment before handing off less complex cases,  and spends more time creating treatment plans.

He said other psychiatrists have difficulty using mid-level clinicians if they only accept self-pay patients. He estimates about 40 percent of psychiatrists no longer accept insurance.

Hopper said his practice model is evolving into one like a cardiologist. He said he “tunes up” patients so they can return to their primary-care physician for maintenance. That now comprises about 25 percent of his practice.

Hopper  is pushing the integration of medical and behavioral treatment. As a former executive with Humana, he said he successfully used the model to save $2 for every $1 invested in combined case management of behavioral and medical treatment. He envisions working either by referral or providing “a behavioral overlay” onto an accountable care organization or patient-centered medical home. He cited Kaiser Permanente’s success as a model for integration.

“We live in a divided world. But you can get a tremendous (medical) yield with patient adherence,” he said.

Hopper is also attempting to work with employers to lower their healthcare costs.

Much like solo primary-care practitioners, psychiatrists are folding their practices to work for the government or changing careers. Hopper believes there is a path to success for psychiatrists willing to recast their roles in the healthcare.

“You must have a strategic mindset,” he said.

Steve Jacob is editor of D Healthcare Daily and author of the new book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at steve.jacob@dmagazine.com.