AHLA's Speaking of Health Law
The American Health Law Association (AHLA) is the largest nonprofit, nonpartisan educational organization devoted to legal issues in the health care field with nearly 14,000 members. As part of its educational mission, AHLA's Speaking of Health Law podcasts offer thoughtful analysis and insightful commentary on the legal and policy issues affecting the health care system. AHLA is committed to ensuring equitable access to our educational content. We are continually improving the user experience for everyone and applying the relevant accessibility standards. If you experience accessibility issues, please contact accessibility@americanhealthlaw.org.
AHLA's Speaking of Health Law
Behavioral Health Strategies for Rural Hospitals to Meet COVID-19 Challenges
Katie Culver, PYA, P.C., talks with Jeanna Gunville, Polsinelli PC, William Teague, VMG Health, and Anna Whites, Anna Whites Law Office, about their session “Behavioral Health Strategies for Rural Hospitals: Engaging Investor and Community Partners to Increase Access to Care and Meet the COVID-19 Challenges” from AHLA’s 2020 virtual Annual Meeting. The podcast discusses specific issues in delivery of behavioral health services in rural settings, creative and innovative affiliations that address rural care, and exceptions or safe harbors that can be used to protect relationships that address behavioral health needs. The speakers also talk about business and valuation considerations related to inpatient psychiatry services. Sponsored by PYA.
New Health Law Daily Podcast Coming in January 2025
Coming in January 2025, AHLA’s popular Health Law Daily email newsletter will also be available as a daily podcast, exclusively for AHLA Premium members. Listen to all the current health law news from the major media outlets on this new podcast! Subscribe Now
Support for A H L A comes from p y a for nearly 40 years, p y a has helped clients find value in the complex challenges related to mergers and acquisitions, clinical integrations, regulatory compliance, business valuations, and fair market value assessments and tax and assurance. P y A is recognized by Modern Healthcare as one of the nation's top 20 healthcare consulting firms, and by inside public accounting as a top 100 accounting firm. Learn more at p y a pc.com.
Speaker 2:Hello, listeners. My name is Katie Culver, a consulting senior manager with p y a pc, an accounting and consulting services firm, headquartered outta Knoxville, Tennessee. Go Balls. I'm sorry, I just couldn't resist. Hopefully we have some UT fans listening today, or at least not quite as many Alabama fans. So today I'm joined by two healthcare attorneys as well as a healthcare consultant who presented a very valuable topic at this year's HLA annual meeting, which was of course virtual. We'll be diving into their presentation in just a little bit, but before we dive in, I'd love for the listeners to get to know Gina, William and Anna A. Little bit more. Gina, can you kick us off with a brief introduction and please tell me you're non-lab Alabama fan,<laugh>
Speaker 3:<laugh>, uh, Notre Dame. So I don't know if that<laugh> where that puts me,<laugh>. Um, but hi everyone. Uh, I'm Gina Gunville and I'm a healthcare attorney with postelli PC based in Chicago. I work with clients nationally on a variety of transactional and regulatory matters and work with a lot of providers all along their care continuum, including hospitals, health systems, academic medical centers, ACOs, clinically integrated networks, as well as behavioral healthcare providers. Lately I'm spending a lot of time advising clients and strategic partnerships and affiliations, provider alignment issues and different kinds of cost savings initiatives. And I also serve as a member of the HLA Behavioral Health Task Force.
Speaker 2:Perfect. Thank you Gina. William, how about you?
Speaker 4:Hey, my name's William Teague. I'm a director, uh, with MG Health based in our national office. Um, I specialize in providing valuation, transaction advisory and, you know, just general financial operational consulting services to our healthcare clients. Um, I'm a member of vmg, uh, behavioral Health Affinity Group, and I have over 10 years experience working with all types of behavioral health providers on transactions, joint ventures, um, and just, and just general planning. I'm excited to be here today and I'm also a Tennessee fan, so, so go ball.
Speaker 2:There we go. So we're up one so far,<laugh> Anna, what about yourself?
Speaker 5:And good to talk to everybody and, uh, let me emphasize, I'm from Kentucky, so we had very little love for Tennessee, but, um, I am a healthcare attorney focusing on rural behavioral health and substance abuse care. Um, I also do, uh, some work with the state autism services providers. I do a lot of pro bono and autism because that's, um, in our extended family. So that one is near and dear to my heart. I own Anna White's law office, which is in the middle of our teeny weeny state capital in Kentucky. Great location because in five minutes I can walk to the Capitol and engage with legislators, or even if I'm lucky, the governor's office and, uh, 10 minutes the other way. And I'm at the Cabinet for Health and Family Services and Department of Medicaid. So, um, anytime something goes wrong, I can just jump into somebody's office and address it, um, in real time. So that's a huge advantage, particularly dealing with, uh, how quickly changes are occurring these days in telehealth and in behavioral, uh, care. I represent clinics, rural hospitals, and a toxicology lab. So I can bore anyone on urine drug screening. Hit me up if you really want to get into the weeds there, but primarily I am a huge telehealth nerd. I'm a member of the state's telehealth steering committee, which was just made a formal division of, uh, state government. So we're looking for a director, um, and really moving telehealth forward. Five years ago, Kentucky was lagging far behind much of the nation in telehealth, and now we are very close to the forefront and I'm very excited about what our state has done and been able to share with other states in the that arena. Um, I'm also on the A H L A Behavioral Health Task force and I'm education chair and I'm on a state bar association committee dealing with youth and behavioral health services provision, um, particularly via telehealth, but uh, also in schools.
Speaker 2:Thank you so much, Anna. And before I continue, we will be discussing telehealth later on, so we're excited to to hear Anna's insight on that. And she did give me permission to call her a telehealth nerd for the rest of the podcast. So, um, with that being said, I did wanna take, um, thank the three of you for taking the time to join me for this podcast. Um, today we'll be asking these three individuals several questions related to their presentation provided at the annual meeting. And just to level set the title of their presentation was Behavioral Health Strategies for Rural Hospitals Engaging Investor and Community Partners to increase Access to care and Meet the COVID 19 Challenges. So I'd like to start off with a question that I think will build a foundation for the conversation to follow in this podcast, which is why this particular topic was chosen for the ALA annual meeting. So Gina, why was this topic so important for you to present on?
Speaker 3:So likely all that are tuning in to this podcast are aware of the opioid crisis national emergency, and now added to that we have the latest information from surveys of the American public as we are dealing with the COVID 19 pandemic, and that that is really greatly increasing individual levels of stress and anxiety. And so while the three of us chose to highlight the importance of delivery of behavioral healthcare in rural areas as a topic due to shared and collective client experiences since the time we submitted the topic, the pandemic has really exacerbated the need to look at delivery models as well. And we think, um, you know, talking at, in our session about potential strategic partnerships and ways to collaborate and coordinate can offer a lot of support, um, and ideas to our rural healthcare clients. And some of those areas, um, of potential benefit are, um, you know, a few that I'll cover here. One area of potential benefit really is improving their financial viability and overall picture. Public payers have historically, um, accounted for a large share of overall payer maximum rural areas and also have historically relatively low reimbursement. Um, and that combined with a limited private insurance base often puts a financial strain on rural providers, um, to begin with. So pursuing collaboration or coordination can help strengthen their financial position by allowing them to participate in different types of innovative care models, which I'll talk a little bit more about later, like value-based care payment models. Um, a second carry of benefit that we think we, you know, really wanted to highlight in the course of our talk, um, is that potential impact that collaboration can have to the health workforce and shortages of mental healthcare providers in rural areas, um, over half of primary care, medical health professional shortage areas or are located in rural areas. And so looking at ways to collaborate can help our clients think of, um, better and more efficient ways to deliver, um, services as well as assist them with, um, ways to strengthen their position to recruit and retain professionals in this area. Um, also a potential area of benefit is just increasing healthcare access points generally through collaboration. And finally, we see a potential benefit in the way collaboration, um, and seeking out effective community partners can help address social determinants of health. Um, we're seeing greater attention now paid to treatment of the whole person. And so by addressing, um, those determinants of health, like education level, income and equality, um, housing quality and stability, um, and food availability, all of this can influence how patients access healthcare and how they manage their own health. And so we really think that looking at addressing delivery of behavioral health issues is a timely and important topic, and that's why we were excited to present at the annual meeting on it.
Speaker 2:Perfect. Yeah, I agree. Everything you guys covered was, was super important and also really eye-opening. Um, so moving, moving on, Anna. One of the things, um, that I know you spoke about was driving forces behind rural hospital affiliations and partnerships to better deliver behavioral healthcare services. And specifically, I remember you mentioned that you can't treat the behavioral health patient in a silo and that record sharing and fact sharing is a huge benefit that rural hospitals bring to the table. Can you speak a little bit more about this, um, what this is and why it's so important?
Speaker 5:Absolutely, and like Gina emphasized, collaboration and treating the whole person is one of the primary focuses in behavioral healthcare. You can't treat a person with addiction or a person with a mental health issue as just that subject, that symptom, that issue. You need to look at every aspect and every health need and even social needs that patient has. Many, many providers when they're working with somebody with a behavioral health issue, express how much they wish they knew what had gone on in the patient's life before and what the rest of the patient's life is like, and you can't get that in a 30 minute or even an hour long visit. And so, um, bringing that information to the table is a key role that rural hospitals can provide in a county or a small town. The hospital may be the only provider who literally sees you from birth to death. The hospitals also, uh, has employs the provider who maybe staffs the ED and sees the patient in crisis, or the counselor who sat with the patient through hospice when his parent or or significant other was in care or the pediatrician who treated the patient when she was younger. And so if you can bring all that information together with patient consent, the providers can work together to weave that, um, healthcare home type, uh, treatment. They can have the solid basis for treating the whole person and not just looking at the behavioral health issue as something that we don't know why it happened or how it happened, but we'll just treat that specific symptom. Also in the small town or or rural hospital is your education provider, that's frequently where the doctors and other medical professionals in the region go to get care, go to get cme, go to sit and talk and learn about, um, improvements in practice areas. So the hospital is a hub of information sharing and can bring best practices to the table that otherwise might not, uh, be available to providers in that community. And the hospital has an awful lot of data as well. And so if we can get the hospitals to de-identify that data and share it with providers, it would really help everyone in that local community to know X number of people, people here are struggling with these particular issues. Not only can the providers already in that region use that data to better treat their patients, but sometimes you're lucky enough that you can entice a provider from a different area to come in to treat if you know that there's a huge occurrence of autism in this community and caregivers don't know how to deal with these individuals as they're reaching adulthood, you can bring in a specialist from someone else somewhere else and they can help the providers, um, help inform the care for the patients in that community.
Speaker 2:Perfect. That's, that's really great context. Thank you Anna, since you, since you brought it up in, I'd also like to dive a little bit deeper and focus on the specific delivery of behavioral health services in rural settings. Gina, during the presentation you indicated that when your clients and specifically those clients that are located in more rural areas have evaluated their total cost of care for patients with a comorbidity that involves a behavioral health condition, they found that those costs hugely increase. I think I even heard you say that sometimes the costs increase as much as three times those without the behavioral health condition. Can you talk a little bit about what's, why that might be the case?
Speaker 3:Sure. So there are a lot of factors that potentially drive up the cost of care for patients with, uh, mental health or substance abuse disorder need that is not being efficiently and effectively cared for and supported when they also present for another medical condition. And I think our, our clients have started to analyze that patient population more closely to look at how their access, um, you know, of the system is often sometimes, um, at the highest cost, the most expensive care site by, for example, frequent visits to the ed. Um, versus if they run the analysis of looking at how they can coordinate care better, um, in lower cost settings or like, for example, through an effective partnership with a community mental health provider over time, that really can change the cost trajectory for them in caring for the patient population and avoid those more expensive ED visits. Also, they've found that just slowness in their ability to identify the comorbidity, um, can increase general inefficiencies and increase costs. Um, for example, continuing to address obesity with a patient that also has the comorbidity of depression, um, can kind of lead to inefficiencies and increase costs as well. And so all of that feeds into those total cost of care statistics when they're looking at kind of overlapping patient populations and trying to isolate opportunities, um, for cost management, not only to control the cost for their system, but also improve support of the patient and the overall patient experience and also look at whether or not they can begin to improve quality of care as well. So that's, those are just some of the factors I think that they look at, um, when trying to isolate like the, their overall spend for not effectively addressing patients with comorbidities that include behavioral health conditions.
Speaker 2:Got it. And staying on the same topic, Jenna, you had said that one option for rural healthcare providers to increase the support network was to attract potentially a commercial payer to be able to provide them with a bundled way of covering costs for this particular patient population. Can can you expand on this topic?
Speaker 3:Sure. So I, I mentioned earlier that, uh, there's often a higher public payer population for mental healthcare and there's historically been more limited private insurance, um, coverage or EVA of coverage. Even private payer contracts have specifically had carve outs, um, in the past where, um, you know, they're, they're not gonna offer, um, the, the main contract care for behavioral health services. Um, what's interesting now, and I think what's um, hopeful is seeing how that has only contributed to more problems with access to care in a more fragmented care system, especially in rural areas. And so, um, that, and that's really been straining, uh, providers financially in the process and also contributing to, um, the healthcare provider shortage. So what we're seeing that we're excited about is a recognition by payers, um, that, uh, treatment of the whole person is very important. That if, um, they're incentivizing providers appropriately with the reimbursement model, um, that they can kind of drive down the overall cost of care. And we look at it, um, you know, from a representing most often, at least in my practice, the healthcare provider side ways to, um, encourage providers to consider those partnerships and collaborations that can help them adopt a new model that shows, um, their ability to effectively manage care for a population and perhaps, um, them be able to effectively negotiate with a pair that has determined to offer this, these types of incentives and models. Um, for example, in North Carolina, blue Cross Blue Shield has just come out, um, with a specific initiative related to, um, rewarding providers for effective treatment of behavioral healthcare. And so I think that, um, we're gonna see more of that over time. And then it becomes kind of a, do you develop it as you go along and seek providers to develop something great and take that to a payer, or do you look at what a pair is offering as, as an initiative and see if what you're already doing can plug into that model. Um, these are conversations that, um, that we think can happen over time, but we wanna kind of add that to the discussion around, um, strategic planning for, for our clients to think about, um, once you've shown that you're effectively managing this pa patient population, think about, um, you additional ways to capitalize on that once you've built that infrastructure
Speaker 2:That makes sense. And either way, they're moving in a, in a positive direction, whether they're bringing that to the, the table themselves or falling in, in line with the commercial payer. I think that reducing the cost overall is, is the end goal. And it sounds like both of those ways can, can accomplish that. I'd like to switch gears now and, and speak about some of the models that are being implemented to address care in rural areas. William, you specifically mentioned that some of your clients have come up with creative and innovative affiliations and partnerships to try to address the needs of, of their specific market. I I heard a lot of great ideas from you and your presentation, but I was most interested about the, the rural health providers reaching out to their schools and fire departments to become the provider of choice for behavioral health for their communities. Can you expand on this approach and what maybe made it so successful?
Speaker 4:Yeah, sure. Um, so I mean, when we talk to our clients, really the two big problems we see when they're trying to establish behavioral health service lines or, or service those needs in their communities is can they get provider coverage and can they get enough volume to make a service line, you know, financially viable? And honestly, you know, if you've got enough volume there in the market, it usually makes attracting providers easier, right? It makes a, the proposition, um, to, to recruit a provider more straightforward if you have an established patient base so they can kind of step into and, and, and not have to build from the ground up. So, um, when we've seen our clients, and I thought Anna did a great job in our presentation talking about this, I mean, at the end of the day, you've gotta be creative and you've got to work with your community stakeholders. So for example, when, when you mentioned the schools and the fire departments and police departments, I mean, those entities direct a lot of behavioral health patients, you know, whether you're in school and they have behavioral issues or autism, et cetera, or fire departments or police, uh, departments getting called to scenes, uh, where there might be a, an acute issue, um, a suicide or, or something along those lines that might require an inpatient, um, stay. You know, if the, if a rural hospital goes ahead and tries to establish relationships with those type of entities, they can keep those patients in the community in many cases instead of, Hey, you know, this child has special needs, we, we'll send them to the, the more urban location to get care from, from the bigger facility of the academic medical center. If you go into the school and help them establish procedures and protocols and establish relationships with their, you know, administration and et cetera, um, you know, you may, you, you have a good chance to keep that volume in the community. Um, you know, if, if a police officer picks up a, um, a person at a scene, you know, instead of them driving somewhere else, you know, they'll, they'll take the patient to you versus having all of your volume just driven through the er, for example. So at the end of the day, you know, it's about being creative, just, um, reaching out to stakeholders, making sure everybody's on the same page and educating them on, you know, what you can bring to the table. And, and hopefully that enables you to kind of build that patient base that can also help you, you know, attract providers. Um, you know, I also mentioned trying to coordinate a little bit with other community health systems. I, I will say I'm not a lawyer, um, to do that. You know, you wanna make sure you're not going up against any competitive factors. And I don't know, Gina, if you wanted to talk about some legal structures, if you will, you've seen some, some folks use to help, uh, coordinate on the clinical side with other clinical providers.
Speaker 3:Sure. I know, um, in mentioning that we would say if you're, because if you're in a rural area, there, there are competitive concerns, especially if you're in a two hospital town. And so as you're evaluating your options to collaborate really to just, um, you know, consultant, attorney, and also potentially utilize a third party consultant to the extent that you're working through issues around competition and analyzing the risks. Um, but there are really a variety of options from, you know, a single hospital driven community collaboration to formation of a rural health network with that fellow hospital. Um, you know, to where you recognize together that your combined efforts to address behavioral health are gonna be stronger than on your own, um, to other potential affiliations and partnership opportunities.
Speaker 2:That's helpful. Thank you William. And thank you Gina. Um, William, another strategy you mentioned was to reach out to more urban providers given their natural tendency to, to wanna drive volume at their facilities. Because of this, a lot of these providers are willing to provide outreach for rural health providers such as outpatient behavioral healthcare. So can you give one or two examples of this approach and how to best operationalize it?
Speaker 4:This, this approach really works in urban communities where there're where there's numerous providers of, uh, behavioral health, um, healthcare, you know, maybe there's a couple hospitals with psychiatric units and there's even maybe some freestanding facilities in the market. So as with any healthcare organization, it's, it's, and many aspects of volume driven game, right? So, um, and plus when you look at behavioral health in general, a lot of those issues are happening in your rural communities and you see out migration from those rural communities into to more urban markets. So we've seen rural clients able to go to providers in more urban, urban settings and kind of formalize relationships to try to, you know, align their interests. So whether that be, you know, they come into town a couple days a week and do kind of a timeshare to provide outpatient care. So if there is an inpatient stay required, you know, they've already got that relationship so they can drive that, that admission to their associated inpatient facility, um, is kind of one thing. We've seen facilities even provide coverage on, um, an inpatient unit, for example, in rural communities. It just depends on what their capacity is, what their ability is. Um, you know, unfortunately we do see many institutions today in urban settings that are already full. So they don't necess they're not necessarily as interested in, in driving additional volume. Um, but you know, everything from a timeshare to, you know, some sort of PSA arrangement to provide coverage or telehealth, um, we've definitely seen seen folks, um, do that for sure. So.
Speaker 2:Perfect. And the third strategy that was mentioned in the presentation was Telepsychiatry and Anna, again, your words, not mine, but you said you were a huge telehealth nerd. So can you talk briefly about two or three reasons why this might work and conversely, when it may not work?
Speaker 5:Absolutely. Um, I want to share my husband's favorite story. He's not in healthcare, but he says he loves to listen to me talk about telehealth. He said, I don't understand a word you're saying, but you sound so happy. It's like watching the creek run<laugh>. So I guess there's a compliment there. Um, there are three big barriers in behavioral healthcare that we all face. Stigma, cost, and access and telehealth is a really good way to solve or remove those barriers as a society. We're only a few years out from the era where persons with behavioral health issues were locked away or not talked about still in many communities. Addiction in particular is a, is a stigma. People think there's something wrong with you if you are a person with addiction. And so, uh, the telehealth format allows a patient, particularly in a rural community, to access care without being seen. Nobody sees you going into the psychiatrist's office. Um, and for teens in particular, this is a, uh, a format they're used to. Lots of our young people are very savvy on their phones, and they may even be more comfortable discussing their mental health or behavioral health issues with a counselor or psychiatrist via the phone than they would be if they were sitting in your office. So, um, stigma is a big factor. It resolves in another, uh, arena. The access issue was huge. And so if you are in a rural area, you may be 20 minutes as the crow flies from your provider, but if you have to drive rural roads, you may be two hours away. And it is much easier for somebody to, um, pick up a phone or dial in on a laptop and reach the provider than it is to hire a sitter, buy some gas, take time off work and drive. Um, not to mention the wait times in providers offices. So with telehealth, we suddenly enabled people who couldn't afford the time or, um, the money to go see a provider. Uh, an easy way of doing that. In Kentucky, our, uh, community mental health centers were seeing about 2% of their patients, um, in some areas. Uh, and now with telehealth being more available to them, more suddenly available to them for the first time, their population and their ability to access those first time folks in need in particular has gone up. Um, not to a hundred percent, but much, much closer. And so we see the immediate effect of the telehealth being available to everyone in, in our state, and I think we're seeing that nationwide. And the last factor, cost is a big driver for a smaller provider. Every missed appointment is a lot of money that you're losing that would've gone towards overhead to employing your staff. And cost is also a big factor for, um, federal payers in particular. Medicaid really can't pay for lost visits, but providers who suffer a lot of that can't continue to work for Medicaid patients. And many rural communities have a high percentage of those patients. And lastly, we're learning from the, some of the private payers who, as Gina pointed out, are not always willing to pay for care and have figured out the best and most economical way to do it. And many of these private payers were already using telehealth or telephone visits for patients. And so it's a chance for the rest of the world, Medicare and Medicaid in particular, to see that huge cost savings and, uh, adopt best practices. We did see, and this was a huge surprise to me in Kentucky, when we suddenly went to telehealth boom this year with Covid, everyone could provide any service from art therapy to counseling via telehealth. Um, we saw two big issues, and one was provider fatigue. Uh, providers reported it's much more exhausting to sit and look at that screen and do appointment after appointment after appointment because they didn't have the downtime of an in-person in your office visit where you socialize, you have a little small talk, you sit the person down, you walk around. Um, and so providers expressed fatigue, uh, with a solid telehealth only schedule. And so as a state, we're, we're working on that to make sure providers schedule appropriately. And we did see in Kentucky and in other states, some concerns about licensure types. And not every licensure had used telehealth prior to Covid. And when it was open season, everyone had to use it. We had providers whose, um, governing bodies hadn't ever trained them how. And so there was a lot of, uh, what we called etiquette issues with folks trying to figure out how to use this effectively and patience trying to figure out how even to log on to their computer. So, uh, there were some early glitches, but we, I think we've resolved it and, uh, Kentucky's leading the way.
Speaker 2:Thank you, Anna. I thought your perspective on the provider fatigue was, was, was insightful. I had not heard that before, but it does make perfect sense that that would be something they're experiencing as a result of this increased use of usage of, uh, of telehealth. So I appreciate your thoughts on that. Um, Gina, you also discussed some common legal issues related to evaluating different models for addressing behavioral healthcare. Specifically, you've mentioned that it is likely you can find an applicable exception or safe harbor to protect the relationship you're gonna set up to address the behavioral health needs. Can you give an example of this?
Speaker 3:Sure. Um, and staying with our discussion of tele behavioral health, I think we can show her that kind of an opportunity and arrangement could also raise the potential for the need to comply with the federal anti-kickback statute. Uh, as many on the call likely already know, the federal anti-kickback statute prohibits the exchange of anything of value in an effort to induce referral business in federal healthcare programs. So in the tele behavioral health example, for example, if a large hospital system were to purchase or lease telemedicine equipment at a discounted rate to a rural practice, um, to help build that ability to link rural patients with, um, providers with a relevant expertise, the hospital or health system could be accused of providing that equipment at less than fair market value in order to secure referrals into a larger health system. Um, but when that kind of an arrangement is presented to you as an attorney, the key is to really understand all the facts and circumstances around that. Understand, um, if there's a shortage of care and the needs, um, that are prompting the, the situation that's, and the potential arrangement that's being brought. Um, and then analyze the applicable guidance that's available to you via oig uh, guidance and advisory opinions and others in order to analyze and calculate that overall level of risk, um, that's presented by the arrangement in the lease of equipment. Example, you would be looking to try to fit within the equipment rental safe harbor to the federal anti kickback statute. And provided that you were able to show that the rental charge was consistent with fair market value and not determined in the manner taking into account volume or value of referrals, you likely could tick through the whole of the elements in that safe harbor, um, to, to deem the potential structure low risk and, and move forward. Um, however, oftentimes in our rural health settings, um, it might not be a fair market value, um, presentation. There might be a, a lower discounted rate made available. Um, there, there might be a variety of reasons prompting that. And so I, I would say yes, always seek to sit, um, as best you can squarely within a safe harbor, and especially if you're talking about Stark law compliance, um, squarely within an exception of the Stark Law. But keep in mind, um, that based on the facts and circumstances, um, and overall analysis of, um, potential safeguards and corporate in the arrangement, like, uh, preventing inappropriate patient steering or avoiding increased costs to the federal healthcare programs or improving access to care, that these are all legitimate benefits that the federal government wants to encourage. So I think I would say yes, in many situations you're able to fit within a safe harbor or exception, and, um, hopefully you will. But even if you don't, um, you know, considered throughout your analysis, all those potential safeguards that can be incorporated into a strategic partnership, um, to kind of alleviate concerns that are, you know, are enforced, the agencies find, uh, are very valuable to encourage in, in partnerships and can kind of mitigate the potential risk of non-compliance with fraud and abuse, uh, regulations and laws.
Speaker 2:Thank you, Tina. And staying on the same theme of, of legal issues, Anna, back to you. Telehealth is an amazing advantage to today's healthcare as we've demonstrated on this call. What are some of the most prominent areas you see providers not paying close enough attention to from a regulatory perspective?
Speaker 5:Well, these days, most of us are very, very casual and comfortable on our phone or our devices, and this can bleed over into HIPAA and privacy concerns. That's always an issue in telehealth. And typically we see recommendations that only HIPAA compliant software be used for patient care, but during covid, those restrictions were removed. And so I think we're going to see a big concern as those restrictions come back in place that providers and patients who've been used to just FaceTiming one another, um, will struggle with remembering to be HIPAA compliant. And particularly in, in psychiatry, we need to remember how sensitive these topics are, and providers need to think about not only where am I as I'm providing this care, but where's my patient? Is my patient in McDonald's? Can other people hear me? Will this have a negative impact on long-term care or prognosis? So, um, HIPAA and privacy is huge with telehealth. Another problem that is occurring already is that state law on telehealth differs. And so in Kentucky you can do one thing, and Tennessee it's not necessarily as broad. And, uh, if you go up to West Virginia, it's, it's, you know, more restrictive. And so providers need to make, uh, a point to look at where they are treating this patient. It's very easy in telepsych to cross state lines. You know, it, it, that patient is not in your office in the state you live in. They may be two or three states away if you're licensed to provide services there. So you need to pay attention to the differences between law and regulation from state to state. Um, a lot of my clients are finding that documentation is more of a challenge. They get so focused on that screen and making sure they do this right, that they forget. You still have to take notes, you still have to document the visit and build that patient care record. And so a lot of the training I do, I focus on don't forget to document. And, uh, lastly, everyone's favorite billing and coding and modifiers and use of, uh, documentation as to the place of service of care. You have to make sure as you're billing and coding for these services that you're doing it in a way that will let you get paid. And as importantly that you're not miscoding. We saw some providers early on say, well, it's a little difficult to get paid when I put that oh two modifier on there, they ask me a lot of questions, so it's the same care. I'll just leave off the modifier. And so a huge caution is please bill and code correctly and use the modifiers that the, uh, payer is asking you to use, or you won't get paid and you might get in trouble.
Speaker 2:That seems like straightforward advice. So I, I think everyone should take that<laugh>. Um, I'd like to spend the last few minutes of today's podcast to talk about business evaluation considerations. Obviously a favorite topic of mine. Uh, William, can you give two or three trends you're seeing commonly with regards to inpatient psychiatry services?
Speaker 4:Yeah, absolutely. So, um, you know, and this has been over the last couple years, you know, we've really seen a trend where, um, not-for-profit health systems or even for-profit health systems in some cases have joint ventured. Their behavioral health psychiatry service lines, you know, historically it was a unit of their hospital, um, and they're gonna enter into a joint venture play, uh, into a joint venture arrangement with a, usually a for profit operator to build kind of a freestanding psychiatry hospital. So I think that was, especially before covid, the, the trend we were seeing. Um, I think there's a couple factors driving that trend. Um, number one was access. Um, a lot of these not-for-profit hospitals, psychiatric units were full and they were seeing more demand than what they had beds for. So they were, you know, putting psychiatry patients in your normal med surg beds. You could, you would even see providers, boarding patients in the er, um, et cetera. So they needed to increase capacity. Um, a joint venture, you know, with a for-profit operator enables them to provide the capital to do that. And, you know, know, obviously the hospitals have lots of demands on their capital. Um, you know, they, they get a lot of volume from the er they wanted to, to kind of redirect out of their system. So, you know, with covid, um, I think just like everything, everybody kind of pressed pause on that for the last few months, but we have seen that continue and I've, I feel that a few phone calls even in the last couple weeks around interest in that, in that model, you know, usually the model is, is they build much bigger facilities, you know, usually a unit and a psychia, uh, a psychiatric unit, uh, not-profit hospitals, 20, 30 beds, something like that. You know, most of the freestanding facilities we see the Acadias or the UHS is, and I believe even Kindred now is, is pursuing this model or usually, you know, 80 plus beds. Um, and those arrangements we, we can see that the hospitals contribute things like their brands. Obviously they have a C O N or their, their existing service line. So that in terms of inpatient psychiatry is definitely the trend we're seeing. Um, you know, from evaluation perspective, you know, COVID I think definitely slowed, um, the behavioral health volumes down, number one. I do think it was less severe than we've seen in other verticals, um, like outpatient surgery or, um, imaging or, or one of those type of, you know, healthcare modalities if you will. I do, they did see an impact cuz a lot of that volume is driven outta the er and with just the collapse of ER visits, I think, um, that impact was still felt. It's just not as severe. However, based on my conversations with clients, I, I get the sense that a lot of that volume softness we've seen, things are beginning to come back to normal and, you know, with a longer term view, there might even be more behavioral issues down the line with the stress of the pandemic. You know, um, people, I've seen studies where people are abusing substances more now, um, their stress, you know, maybe people lost their jobs and had marital issues during quarantine and um, you know, cause that might cause depression or some other related issues. So I think long term the fundamentals are pretty still pretty strong. Um, from evaluation perspective, I, I would treat the covid volume impact as almost a one-time item. Um, and I will say, you know, the other thing about covid from evaluation perspective we hear about is, oh, what about long-term unemployment? You know, what if we have elevated unemployment levels for a long time or there's significant changes to payer mix, et cetera. I think a mitigating factor for that on the behavioral health side of business is that it's heavy government paying, right? So they're a little bit more shielded from payer mix issues because they've already got a, a fairly government heavy mix to begin with. Um, so I think that's, that's the main trend we're seeing, um, is just that shift from smaller units within a hospital to more specialized, freestanding, you know,
Speaker 6:Hospital providers.
Speaker 2:Perfect. This is really great information. Thank you William. Unfortunately, I think this wraps up our time today. All the information provided from Gina, Anna, and William was incredibly helpful. I'm sure we could talk for days on in about these issues. So thank you to the three of you for your thoughtful feedback as it relates to this topic. If you have any additional questions for Gina, William, or Anna, other contact information is available in the details within the podcast. Thank you. Thank you. Thanks.