Why Behavioral Health Institutions Are Closing Despite Skyrocketing Demand: Lessons in Leadership and Workforce Strategy from Elwyn’s CMO

<p>hello everyone this is Cole from the American Journal of healthc care strategy joined by a special guest fellow Pennsylvanian uh Dr Meli uh Dr melli please introduce yourself into your role sure I'm Kurt melli I'm the chief medical officer at elwin I've been at elwin for about six years now and I really oversee the health services and quality for lwin [Music] thank you so much for coming on it's a big honor to be able to talk with you you have so much experience looks like you started your residency or finished your residency rather back in 2008 so you've been practicing uh for a long time now I want to ask here what got you into the field of of Psychiatry why did you originally want to go into medicine well certainly first off thanks for having me really appreciate being on the podcast here um so my parents envisioned that I would be an ear nose and throat doctor and I would take over my uncle's practice um granted my uncle had a wonderful practice and really inspired me to be a physician but I I would say it was that thirdy year Medical School rotation oddly enough at the eastern Pennsylvania psychiatric Institute which is no longer open Epi right next to mCP which also unfortunately closed but um but nonetheless just being on the unit seeing adolescent girls uh really receiving psychotropic medication to help make them better uh it really sort of struck me in a very powerful way that wow I wonder if I can do something to really help these young people and and help really anybody with psychiatric illness and and then certainly as I did other rotations in family medicine and internal medicine and even in surgery and such the theme was clear that behavioral health issues were through it all and uh especially in Family Medicine I mean a third of the folks that were coming in were really coming for Behavioral Health needs and so um it interested me and as I looked at opportunities was very fortunate to find a combined program with medicine and Psychiatry I always thought internal medicine was also fascinating and UVA had a combination program in Charlottesville Virginia and I was fortunate to to be part of that program uh it was a great experience it really taught a lot on both the medicine and the Psychiatry aspects and was very fortunate to be with some really great mentors uh and peers I didn't realize it wasn't combined and and I see that of course in in the resume now that you mention it but uh that is pretty unique and and I think uh that is very interesting I I have to ask as well you were a resident I believe when you started your MBA is that right I was just finishing residency and um you know as I mentioned with EPI and with mCP that unfortunately those hospitals both closed and so the other thing that was also peing my interest at the same time of Psychiatry was just the fact that wow if you really don't run a hospital or hospitals can go out of business and that was something that that really struck me very powerfully and and it made me wonder that is it possible for me to help continue the role of healthc care as a physician leader as a physician executive to offer that expertise uh as opposed to a a purely non-clinical point of view or expertise and and granted I think one of the things I've realized is that it's tough uh running a hospital or running an outpatient practice or or running any piece of the Health Care System it's a challenge and certainly I I like to always wear that clinical hat to remind myself as to why we what we do in terms of caring for patients and really aiming to make their lives better so yeah it was uh the business school aspect was a was a fortunate part as I was just finishing residency I had applied to Darden at University of Virginia and um they uh let me in and and it was a great experience I was one of the few Physicians that were there I think over time mbas are becoming more and more popular with Physicians uh but it was a phenomenal experience to to be with folks in finance and other Industries especially in the 20 8 to 2010 period where we had the financial crisis so it it it augmented the the the experience and and I had the opportunity to to work a little bit at UVA as an attending physician and also at Western State Hospital which uh was the state hospital out um just some miles west of of Charlottesville in Stanton Virginia because you you also were a summer associate at McKenzie right that is correct so during that year that I I oh I guess the two-year experience that I was with Darden um I thought that perhaps I would want to do Consulting and the the opportunity availed itself that that I could do the 10-week summer period of time uh at McKenzie which was just a tremendous experience I mean it's amazing to see the the individuals that work there the the um professional degrees that many individuals had uh it it made me think that um it humbled my own education I'll say that and it was just again another great piece of the The View into Healthcare being a consultant helping in that case again it was only 10 weeks but it was primarily pharmaceutical companies uh providing Consulting on some drugs and such in terms of marketing and there was also a piece of the uh the stint that went into some policy formulation uh so it was again a phenomenal experience with phenomenal folks and um you know again I've been very fortunate and blessed to have been part of some really great teams throughout my career and so you you have a lot of experience you know right coming out of this and then in about seven years you become the chief medical officer of bankr um a little bit before that you start teaching at Villanova Healthcare economics right during in their MBA program but what got you into leadership like you said you you looked at Consulting you know you were a well-trained physician you you know you chief resident of your residency program so you know you probably had a lot of options of different things you could have done right you've you'd been very successful what made you want to go into leadership as as a chief medical officer for branc crft what was the the cause of that yeah so again um you know as a clinician there's the physician patient relationship is is something that is definitely sacred and I value with my own physician and likewise I I hope that many folks have that same opportunity with with their physician I I thought I could perhaps do more and that was perhaps the the biggest driver that it's great to be helping folks on an individual basis and granted in my time in crisis ecosure or um whether it was at fair amount behavioral health or various situations it was phenomenal to be able to help folks on that localized individual level however I thought there could be something greater maybe from a population point of view and how could we really Drive care to a better degree and you know frankly I I wondered about administrators and thought and questioned well is that really the right decision that doesn't really make sense to me the clinician that isn't helping me the clinician in the context of supporting the patient um and granted being on the other side of the aisle I I think I see some of those decisions perhaps a little bit differently than I did initially as you again with experience gain some different perspective but at the same time my focus really has always been how do I make things easier for the clinician so that the clinician can do what we ask them to do and that's provide exceptional patient care client care you know whatever the relationship is with the individual that we're supporting and that's really been the primary focus of of my mission is wanting to make life better make life easier supporting those folks that are um you know the employees of the organization so they can be successful because if they're successful with the individuals that we support the individuals will be successful and we'll be getting great results and so then you know as as the quality leader uh really sort of seeing those results will come to pass and materialize so it's um you know it's it's been quite a journey and likewise I me frankly seeing mCP Hospital go under and and Epi close uh it's it's it's very real and it's been very real in Philadelphia There's Been tremendous movement in the industry here whether it is through closures or or consolidation and it always makes me you really go back to uh could something be done better to have preserved saved those institutions those those pieces of the Health Care System U or or maybe not you know maybe maybe maybe the outcomes are what they are and we can do something better I I don't know uh but it it does make me wonder and has made me wonder and driven me to be more administratively involved and again it's it's been um it's been a phenomenal experience I think one of the the questions that I have right is we have p demand we have a lot of demand for Psychiatry Services Behavioral Health Services um at large right because it seems like we do because the wait times are really long um but you know thinking back to my you know freshman year macroeconomics class it feels like if there's this demand and this opportunity then why are institutions closing why are the present institutions having a hard time you know paying staff or getting enough doctors I mean not to overgeneralize but what is kind of the issue because it it doesn't really make rational sense right you would certainly think that in a a free market system and reality is we don't have a free market system we we've got a a system again not necessarily good bad or indifferent but the system that we have is is very much um a system that's oftentimes based and indexed on the prices that CMS has believed to to be those that are set and truth be told we go over this and much in the Villanova course that I teach when you look at those relative value units those units that are assigned to the degrees of care that we provide whether you get three points for something or five points or whatever those units are and then you multiply it by a dollar amount that's actually set by Congress the conversion factor you you can actually figure out the Medicare rate and and oftentimes many of our our private insurances will mimic that rate or or multiply it by a factor of whatever another 20% 30% whatever it might be the challenge has has greatly come to pass that um perhaps those rates for the cognitive Sciences really aren't enough per se and I I know that oftentimes there's a conversation in the medical community that the proceduralists tend to do better in terms of the number of points they get for the rvus and no fault to them I mean heck I'm not a neurosurgeon and and that's not what I'm doing and I totally understand that that's highly skilled highly um you know dedicated piece of the workforce in healthcare um however on the behavioral health side we have our our degrees of cost but we um or or our the revenue that we can potentially generate but we also have significant costs just in the fixed costs uh and really those are oftentimes the labor units and and even at an organization like Ellen you know where I look at that labor is 70% of really our expenses so it is the driving force and um and there are a lot of impacting factors there making sure that clients are showing up for their appointments tella Health has been great in allowing and improving the access to care and it do also help to improve the the um the number of folks who are showing up because perhaps if you can't make it in the office tell health is easier you can just turn your computer on or get somebody on the phone so so that has definitely definitely helped with our organization uh but the the demand for um you know for clinicians and the and the workforce has um has changed and and Co has been a significant contributor to that change in the sense that we move very much to a lot of te practice and um and frankly there are a lot of tele practices that have spun up whether those are public traded companies or whether those are you know local to the the area and such and so there's a tremendous Demand on the labor part of this as well and so I think we've seen significant expenses rise there which is again great for clinicians who can then earn more money and that sort of thing um however for you know an organization and an organization that perhaps deals with mostly Medicaid or managed Medicaid services which tend to be lower than that Baseline Medicare rate in their payment that could be a challenge and it's especially when we're competing against other organizations that perhaps have more access to commercial clients where again the rate is greater than the Medicare rate um that puts pressure on again a nonprofit like Ellen or bankof or such um where whereby we are potentially getting less Revenue per client that we're seeing but in the same labor market competing for the same labor units um you know I I'd love to um to to think that if um if Healthcare System were maybe structured differently you know perhaps we would see different results again they might not be better they they they could be worse or perhaps they they could be better um but um but no doubt that the the access issue that you point to would certainly make one think that why isn't there more being done but when you start getting into the weeds of it and you start looking at the revenue versus the expenses that one has um the equation turns out to be a little bit different for the practice and so one of the things I want to touch on too though here you have the payer mix problem right but then you also elwin what does that look like in terms of the percent of people who can use Ted versus those who require in-person appointments when we look at a Medicaid population at least our Medicaid population they require usually more in-person appointments and so it's kind of a double right you know a doubly big problem right because not only are we dealing with a more resource you know intent intensive situation but you're also you know having individuals who struggle to really access the care that is resource intensive what does that look like at L this episode of the strategy of Health was sponsored by modality Global advisors modality Global advisors optimizes Hospital Revenue enhances patient experience and delivers proven results visit modality global advisors.com to learn more yeah no doubt and at times during the pandemic or the really when we were in the thick of the pandemic there was money thrown at us in terms of hey if you need money to buy iPads for people or such like that fair enough you can use that again certain areas in certain States as to uh looking at different types of dollars that were federally available and that was certainly very helpful whether it's for our clinicians to allow them to work from home or potentially some of our clients to stay connected many of those we're in a different world now we're back to the pre-co world of of financing of Health Care and such and so I I think the the challenges that you bring up or or are the challenges that we do see and um and again I mean there can be technical limitations whether it's a Medicaid population or maybe it's um you know older individuals folks who aren't as familiar with technology so whether folks have access to the technology or I'm familiar with the technology those are barriers potentially and un fortunately from a regulatory standpoint there's been some allowance for using the good oldfashioned telephone um those allowances will probably go away as time moves on because you know there's there is something that you get again you get the most from an in-person visit you can see if someone completely and and such and feel them touch them and that sort of thing you get more obviously from a video than you do just from the audio only so we certainly really want to help encourage folks to do that but we do recognize that there is a segment of the population where the telephone is the way that we're communicating with them and certainly you know our argument and our advocacy is very much for the fact that we want to support individuals um where they are and um this is one way to do that and so you know that's the conversation that we have with the payers and such in terms of making sure that these these allowances continue um again we're one voice in the in the sea of voices and so there there other voices as well and I I would suspect that they're they're saying the same thing but um but no doubt there there are limiting factors there are challenges however I would say that being in the world where we are today with the allowance for telea health we are in a much better situation than we were before Co and in a very weird Way co again was has been awful with all the people that you know lost their lives as a result of it but in terms of what it did in accelerating the acceptance of tele medicine and particularly tele Psychiatry I suppose that that that's a positive outcome I mean again that's it's a bizarre way I wouldn't really want to say much as positive from covid but but at least it has forced us to look differently and I don't know if we would be where we are today had it not been for a pandemic that really forced us to think differently whether that's because of the slowness of bureaucracy on the government side or the slowness of organizations uh on just developing technology or the slowness of of clients and patients to accept it as a legitimate modality um so I do think we are in a better place I mean no doubt our our no-show rates are significantly improved I mean we were an organization that would have almost 50% um noow which certainly is a death nail for any practice um and you know also really makes you worry and want to figure out ways of connecting with with people to make sure they're getting the treatment you know for whatever reasons could be a very innocent reason that they can't make the visit I mean heck maybe they don't have the bus fair to to get to the the office there could be other reasons maybe they're just terribly depressed and and that's you know we want to obviously address that and such from the the medical perspective yeah no and and I think I I do get concerned as well at the potential of of tele medicine kind of exacerbating the issue because we've seen where sometimes we can kind of just throw tele medicine at a problem and then we don't always address some of the underlying public health concerns and what I like kind of about your approach is you guys have been trying to address these concerns all along and then tele medicine is just giving you a boost I do worry though and I want to ask a lot of it comes down to focusing on the patient focusing on the client you know which you throughout your career have been very clear that that's something that you know is your focus a lot of the administrators who listen to this podcast like myself are not clinicians we don't have that patient care direct patient care experience is there anything that administrators who are not clinicians should be aware of or should do to try to enable that relationship that you were talking about earlier to enable that member experience or patient experience yeah yeah one of the things that I've seen administrators do who aren't clinicians is literally walk the beat go to the homes go to the offices see the encounters I mean granted not necessarily sitting in the room with the with the patient and such but but being there to at least maybe see the waiting room or or to again see other areas where one can meet clients meet clinicians certainly other avenues obviously talking to the clinicians and and again I mean I think there are many administrators who who do that and do it very well and do it very effectively in terms of keeping the the lines of communication open I suppose I thought I needed to get the MBA in order to have the sheep's clothing so that the business folks would would listen to me or at least invite me to the table um so I I suspect that the the opposite can well be true for someone who has the NBA and is is looking to partner with the clinicians I I think clinicians are always interested in chatting about whether it's their research their their clients their the experience that they have of providing the care and ultimately you know the the the um suppose the beautiful thing about it is that we're all patients we're all clients at some point in time right and and so we all know what it's like to be on the other side and I think that can be a means of connecting with the clinicians to to help understand and to help bridge some of those divides U but you know we're we're only as good as as our Clinic and the folks Who deliver the service and so being part of their hearing their voice and responding to it and likewise if there things that the clinicians think and perhaps things that I thought when I was a resident that that you know I would think well this is so silly how could anyone ad you know from administrative level allow this and now I sort of like oh now I can understand it I I think having it having that conversation having the open dialogue building the relationships I suppose it's um in some sense my own version of Psychiatry 101 it's all about the relationship that you have with people and nurturing them developing them so that you can have honest conversations and you can give honest feedback to the clinicians not that it's a yes to everything because yeah there are going to be times where maybe it doesn't make sense from a different point of view an advantage point for how we're we're moving the organization forward so um I think again we're embracing good people with kindness and and compassion and treating each other as we want to have our clients treated that will set a great tone and I think build a great relationship between any person in administration as well as those folks in the front lines very important advice and and I completely agree with it I've seen that firsthand where you know we have the administrators in the hospital who are shadowing the Physicians who are talking to the patients about their problems uh and it makes a huge impact um like you said there you know the most important part of the organization you know it's the people it's it's so important but yet we struggle to recruit and retain still even organizations you know like yourself I mean there are struggles because the market just simply seems to not have enough Physicians where do we go from here what do you think is going to happen right because a lot of people do not know what the solution is yeah that's a it's a real challenge we see in human services 40% or so turnover that has a huge cost associated with it as well right millions of dollars because you onboard someone that costs money and then they leave in six months it's a problem that that we really are looking to confront and and have been aiming to confront head on with how do we how do we turn the faucet um how do we turn the faucet on so so we get great employees coming in and then obviously plug the drain so that we don't have them leaving and um and so you know we're we're approaching that really from from both angles from one from the experience of the interview to make sure we have the right people in the door you're absolutely right I mean folks can can work and again in an entry-level position um and when I think of entry level at a place like elen or a human services organization I'm thinking of a direct support professional so this could be a relatively a high school educated person or even a college person you know who maybe has um a degree in Psychology or something or could have a degree in anything but wants to work in the behavioral health space yeah for those folks looking at a salary of$ 15 to $20 an hour is kind of where it's at and yeah there might be some that are a little bit higher and some that are a little bit lower but heck you can make that same amount of money or maybe even more possibly working for Target or Big Box store or whoever it might be uh that is not in the health care space and your your job not to say it's going to be necessarily any easier or harder it's going to be different but I I certainly would argue that um direct support side where you're caring for individuals where Anything could happen I mean someone could have a seizure someone could have whatever medical episode or any other episode uh behavioral episode in the middle of the day or the middle of the night that's different than what you would necessar see making that potentially same amount of money at a Target or a big box store or whatnot so so yeah there's a real pressure there and what we see is we need ways of of showing folks even before they're interviewing what it means to work in the group home what it means to work in the outpatient setting what it means to work in the residential treatment facility let's have them walk through the unit on any given day perhaps it's the Perhaps it is that sort of showand tell type modality so folks can see what they do it's one of the pieces of information that we've got in many exit interviews that we've done when folks have left the organization is that it this wasn't the job I signed up for so I think it's on us to show them what the job is that they're signing up for I mean obviously you can't show everything in the sense of you're not there 247 but if you can at least hey show a a clip of it real time I think it gives folks a sense of of what they are signing up for what they are interviewing for and truly we want those folks who are motivated who are aligned to really see us as the organization they want to work for because they want to help people they want to do the right thing whatever those you know those additional reasons are um that is a great sense that you can get from an organization like an elwin where a sense of Missi driven purpose and such and so if that helps facilitate a better hiring process we certainly believe it will contribute to the retention side because people will be add in the organization for more reasons than just the paycheck likewise when folks do get to the to us and are our unit we've got to make sure that they're well trained and we've got to make sure that we're doing everything to support them and so you know we we've seen that with um with high turnover you do lose managers and such and we are very much focused on the management team to really help teach them how to be a better supervisor how to coach better how to be a mentor how to do those things so that when I join the unit and yeah you know things start happening on the unit I've got someone that I can go to we can have all the policies in the world and all the procedures in the world but if if we're not teaching them in clear coherent fashion if we're not modeling them if we're not really pointing to them when the occurrence happens I think we're losing out and so we do see the supervisors really being a key Link in that chain and the last thing I'll say is that folks come to elwin or any Human Services organization or any Healthcare Organization for different reasons but we do know that there is a segment of the population that this might be their first job out of high school or out of college and it might be a way for them to to get a taste for Behavioral Health and it might be a way for them to maybe become a the next clinician that's there and you know we've we've seen some really great development from folks uh whereby we even um have relationships with universities where they come as an intern and they might be working for us unpaid or maybe some of them are working for us paid but at a pretty nominal amount of money and they're seeing things firsthand they're seeing the group homes they're seeing the outpatient they get to know who we are we get to know who they are and I think many of them find that we're the best kept secret they they find things out about us that they wouldn't have known otherwise and and we really have um a great time then um we know who they are hiring them and then continuing to Foster that relationship perhaps use education dollars that they can get through through our program um you know different types of um typically I think it's like 5,000 or so dollars um to be able to provide folks with such stiens so they can pursue their career so maybe they want to pursue that Masters or go for that PhD or s or whatever it is we want to support them in that growth we want to again really help make this a home for for ideally you know the rest of their career again that's not for everybody but I think we need to think about those Pathways very deliberately and consciously because we also need the next generation of clinicians and of leaders and of managers and of and so we we've got to really invest that in our folks and frankly I mean those Investments end up being cheap if you're able to turn down the turnover needle um you know millions of dollars much rather have it spent in investing in people keeping them there and again it's all about relationship so when you're working with folks with intellectual developmental disabilities it is even more about relationships um than um than those who might not have those you know those same um challenges and such so so um yeah I think that's a it's a multi-prong strategy it's it's not easy uh but it's it's the one that we need to take because it is it is competitive out there and we're all competing for many of the same folks and you know we want to really show them um the best of us and give them the best so that they can be successful and they can drive great quality care for the folks they're supporting I I really think that's something that we need to adopt in the United States as a whole but I I think especially in health care in business school my last course that I was taking last semester there was an article about how in India the turnover rate throughout the country is very high right so it's 60 to 40 to 60 % and so they do long-term strategies of implementing education training uh benefits um you know a lot of the competitive companies and and that Echoes a lot of what you're saying that the environment is so competitive and when somebody leaves we're kind of just throwing the money away right we're not actually investing like the money is gone and it's gone in both scenarios but at least in one we could retain some Roi on it absolutely AB hard like we don't always you know I think we don't always see that onless spreadsheet right it tell you have to look further than the spreadsheet to get the story well and I think um was it the CEO of Boeing attributed much of the troubles that Boeing has had to the loss of really I guess institutional Knowledge from the pandemic uh I think that's true of any organization right and certainly again when you have that high turnover you're going to lose institutional knowledge you're going to lose um many of the the things that you do and and so you're absolutely right investing in in those folks that you have hire well and and train well Mentor well retain well it it goes a long way and again I don't think it's um you know it's it's it doesn't need a rocket scientist so to speak to to to produce that but hey at least we do need to be clear on the map so that we can follow it and and and go towards it so um so yeah that's that's our aim and and it really is the calling for for certainly um last fiscal year and this fiscal year as as we we look to to build upon the investment in our employees thank you so much for sharing all of this uh with us Dr melli and thank you for coming on uh during your evening after probably a long day and and sitting with us for this time so I really do appreciate it and I hope we can have you on again in the future love to do it and appreciate you taking the time with me thank you so much</p>