Like many successful behavioral health organizations, Idaho Behavioral Health, founded by Tami Jones, LCSW, started small, as an outpatient mental health clinic in 2008, and has since had to confront the challenges of incremental growth. With a staff that now includes a physician, a psychologist, 11 clinicians and some 31 community-based specialists, IBH provides medication management, psychotherapy, and community-based services that include psychosocial rehabilitation and service coordination for children and adults.
In 2010, the organization grew significantly, adding a new location in Caldwell, about 26 miles west of its headquarters in Boise, and acquiring a mental health outpatient clinic in Mountain Home just over 40 miles east. While IBH welcomed the growth opportunity, Chris Culp, its director of business operations, quickly recognized that serving hundreds of individuals located away from Boise was creating immediate and costly service challenges.
“When we took over operations for the outpatient clinic in Mountain Home, we had to ensure that the folks being served there could get to Boise for their appointments,” says Culp. Two types of appointments were of greatest concern: medical necessity and medication management.
Culp explains that in Idaho, people on Medicaid have to have an in-person medical necessity visit annually so that IBH's Boise-based physician, Thomas Young, MD, can validate their needs and determine whether they qualify for basic (outpatient visits only) or enhanced (visits, plus community-based and psychosocial rehab services) Medicaid programs. Those receiving prescribed psychiatric medications also require periodic medication management visits.
For the first couple of months in late summer 2010, Culp and his colleagues struggled to accommodate the new service consumers from Mountain Home. For those consumers who were unable to travel to Boise on their own, “we had our community specialists and workers driving them up,” says Culp, adding that, “from a cost standpoint, we were running an expensive cab service” that required “paying hourly wages, plus mileage because specialists were using their own vehicles.”
The drive, some 43 miles each way, proved costly. And, while IBH realized internal savings when consumers arranged their own transportation-buses or cabs paid for by Medicaid-Culp notes that this option, available only to “basic” Medicaid participants, generated additional costs for taxpayers. No such transportation benefit was available to those with access to enhanced (community-based) Medicaid services.
The downstream impact of transportation costs also hit IBH's Boise-based staff because, even with the resources being offered, no-show rates for these important physician visits topped 30 percent. Noting that Idaho Medicaid reimburses $52.91 for an office-based medication management appointment, Culp determined that “if you have paid staff hauling a consumer around, it's a money-losing proposition.”
While Culp was aware that telehealth options might help to address his problem, he discovered that unlike a growing number of states that reimburse for telehealth-based counseling and therapy appointments, Idaho did not. That meant he would have to finance a telehealth solution based solely on a relatively low number of reimbursable physician services-the 50 or so medication management visits that Dr. Young provided in a typical month. (Note: Idaho's Medicaid program requires all initial medication management visits to be made “in person”).
Given his concern about the cost of higher-end videoconferencing products, Culp sought alternative solutions. At Dr. Young's suggestion, Culp contacted Secure TeleHealth, a Pittsburgh-based company whose secure video product was already used by a Boise-based organization. After finding that this product's overall costs would be considerably lower than the videoconferencing options he had considered earlier, Culp invited Secure TeleHealth in for a live demonstration.
He saw in the product a secure, web-based, platform backed up with real-time user support for telepsychiatry over the internet. Secure TeleHealth partners with Nefsis, a cloud-based HD video conferencing service.
“We liked the product,” states Culp, noting that its capital cost was minimal (a webcam and microphone were added to available computers at two locations. Its recurring costs-about $300 per month based on IBH's needs-were modest enough that he says “we can make that cost back in a week or so” of telehealth-related physician visits and reimbursements.
“For telehealth, we get $40 in reimbursement per appointment-$20 for the originating point and $20 for the remote point, in lieu of the transportation cost.” When the telehealth and physician reimbursements are combined and the telehealth appointments are properly scheduled, Culp says that the math works. Even after paying a contract physician and staff, “there's still a margin there,” he jokes.