Psychiatric services aren’t the consistent boost to the bottom line that Health Alliance hoped
An April financial report brought good financial news to trustees of Cambridge Health Alliance about the system’s mental health clinics. The number of visits from patients – usually below expectations in recent years – had shot up to 11,558 in March, 19.2 percent higher than anticipated and the highest monthly total in 10 years.
Members of the board’s finance committee applauded. But the elation may not last. Visits the next month were back to their normal level – below the target.
Mental health treatment is a major focus of the Alliance and an important part of the system’s expansion into western and northern suburbs. Its budgets in the past few years have relied on outpatient services and psychiatry in particular to attract more patients and produce a surplus, but the numbers have not materialized to the extent that was expected – though CHA finances have benefited from unexpected revenues, so the system has not suffered financially.
One big reason for the improvement, chief financial officer Jill Batty said when it was reported, was that “we have redesigned how referrals to psychology work. It was broken before.” Dr. Edgardo Trejo, interim chief of the department of psychiatry, also credited the new system at a meeting of the CHA Committee on Population Health.
In an interview later, Trejo said the health care system had created a “central intake group” that assessed and handled all referrals for outpatient psychiatric services, from inside and outside the Alliance. The system began operating for some patients in March 2018 and began dealing with all referrals throughout the organization in January, a presentation to the Population Health Committee said.
Trejo didn’t agree the intake system had ever been “broken,” but he acknowledged that before the central intake process, “we didn’t know where the patients would come from. They would come from all different directions.” Referral sources inside CHA included the patient’s primary care doctor, the emergency room and the Alliance’s inpatient psychiatric units at Cambridge and at Everett Hospitals. Patients could also come from outside community behavioral health agencies, or admissions from patients themselves.
“We were able to simplify the process to one universal referral form that is used by everybody including people in the community,” he said. The central intake unit is trained to use the form “to send patients to the appropriate clinic within outpatient psychiatry,” Trejo said. Patients may also be sent to “community partners” such as Eliot Community Human Services in Lexington, Riverside Community Care in Dedham or North Suffolk Mental Health Association in Chelsea, he said.
“Now we see an increase in access to our patients,” Trejo said. He couldn’t provide figures comparing the average time patients wait for an appointment before and after the new system, saying CHA didn’t keep those statistics before implementation.
Trejo said if clinicians think that a patient needs to be seen “sooner,” the person may go to an available clinician quickly and get “handed off to the next provider” for a more permanent placement. Patients who need a quick appointment may also go to a clinician at one of the community agencies while awaiting an appointment with a CHA provider, he said.
Alliance spokesman David Cecere said the first aim of the new system was to shorten the time between a referral and the initial call to the patient to schedule an appointment. That “outreach turnaround” now occurs within 48 hours, he said. Previously it could take “anywhere from two weeks to six months,” Cecere said.
That doesn’t mean the patient answered the phone, so that statistic doesn’t reflect the wait time for an appointment. One-quarter of patients referred by a primary care doctor hadn’t been reached in the first two months to arrange a time for an appointment, the report to the population health committee said.
Many patients referred for psychiatric treatment are unreachable or turn down the offer. For example, almost half of emergency room patients referred to outpatient psychiatry in the first two months after the new system took effect declined treatment or couldn’t be reached, the report said. The same figure ranged from 36 percent of patients referred by their primary care doctor to 25 percent coming from CHA inpatient units. Trejo said the level of rejections is similar for other mental health providers.
Meanwhile, the number of visits to outpatient psychiatry fell to 10,264 in April, 11.5 percent below projections. Despite the spike in visits in March, volume for the 10 months since July 1, 2018, when the health care system’s 2019 fiscal year began, lagged expectations by 3 percent. Cecere said the year-to-date total of 91,827 visits was higher than the figure for the same period last year: 86,377.
Cecere was asked why volume had dropped below projections despite the new system. “Volume figures against budget vary monthly based on a range of factors, including inclement weather, the number of business days in the month, the number of clinicians taking vacation in a given month, etc. We have seen steady improvement in actual outpatient volume year-over-year, with current year-to-date visits about 7 percent higher than last year, “ he said in an email.
Staff vacancies can also reduce visits. “While we have been very successful at hiring and retaining new providers in the past 18 months, provider turnover, staff retirements and the nationwide shortage of psychiatrists do affect our volume. As we continue the process of hiring new providers, we work with our preferred providers in the community to handle some of our patient volume,” Cecere said.