A startup delivers mental health care to those missed by the unicorns

The explosion of investor interest in behavioral health startups has minted an expanding list of unicorns focused on helping people access care through employer benefits or commercial insurance.

Concert Health has its eye on the other part of the market.

“I love what all those people are doing, but they’re all solving for probably 30 or 40% of the need among those people that are [privately] insured versus the 60% of the spend in behavioral health that happens in Medicare and Medicaid,” CEO and co-founder Spencer Hutchins told STAT.

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While there are well-documented challenges in getting mental health care for everyone who needs it, Hutchins says that many of the people targeted by the largest startups in the space could eventually find their way to an out-of-network provider and navigate the “thicket” of challenges in getting reimbursement. Those providers are out of reach of many people on Medicare and Medicaid.

Founded in 2016, Concert helps health systems and independent practices deliver what’s called collaborative care — a method for treating behavioral health alongside primary care. Patients are screened for depression and anxiety during routine appointments, and those who may need behavioral health treatment are introduced to Concert’s providers, who follow up within about a day over phone or video.

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The evidence base for collaborative care has been developed over decades, but Concert’s founders say the business is only possible now because Medicare started covering it in 2018. Many states have followed with support through Medicaid as have commercial insurers.

“Collaborative care was meant to be telephonic long before Covid,” said co-founder and chief operating officer Virna Little. “Covid didn’t actually change how collaborative care was delivered. The only thing that changed is people were a little more used to getting care telephonically or through video.”

Little is a psychologist and social worker who has been involved in collaborative care since shortly after the original research supporting its efficacy. She has spent decades delivering care, supporting research, and training providers.

Concert boasts that it’s seen some 18,000 patients in eight states at 54 medical groups and health systems. Over half of those patients are enrolled in Medicaid or other government programs that cover the cost of their care. At one of its health system partners, 75% of patients hadn’t ever received behavioral health treatment.

The company announced an $8 million investment plus a $6 million credit line at the beginning of 2021. Hutchins said he’s not in a hurry to raise more. “We’re trying to be a little old-fashioned and, you know, make more money than we spend.”

Adelphi University in partnership with Concert was recently awarded a $1.92 million grant from the Health Resources and Services Administration to train students in its social work and nursing schools in collaborative care.

STAT spoke with Hutchins and Little in several interviews. Their comments have been edited for length and clarity.

Why treat behavioral health alongside primary care?

Hutchins: A whole part of it is really recognizing that we just fundamentally mis-built the mental health system a long time ago by thinking about it as something separate, and we all know that’s not true. Our depression and our obesity and diabetes, they’re not separate. They are influencing and driving each other. And the other reality is, no matter how you sort of move around the deck chairs, we don’t have enough specialists to manage everyone with mental health conditions. You need to use the primary care workforce to be the driver.

How does Concert Health help providers initiate collaborative care?

Little: Through my years of doing the implementations, I had come across a lot of organizations that were not able to get collaborative care up and running for some good reasons and some not so good reasons. They didn’t have space. They couldn’t find providers. They didn’t know how to do it. They didn’t want to take on a separate business line. They weren’t sure what to do about the registry. And so oftentimes, I would see it not get adopted or not work. And it was really frustrating because I knew that people in those communities really needed care and access.

Concert Health’s ability to come in and essentially be a turnkey approach for those organizations to bring them, not only the staff — the behavioral health clinicians and the psychiatric consultants — but also the expertise around the implementation. How do you build that into your electronic medical record? [We] give them very specific technical assistance around the billing, which allows them to actually implement collaborative care and to bring the model to their patients who are in need.

How does collaborative care help expand access to mental health treatment?

Little: Often the only choice people have is therapy. So you can go to therapy once a week. And if you don’t do that, then you sort of get nothing. And we know that 50% of the people that get sent to specialty mental health or therapy by primary care providers don’t actually get there or stay in treatment. And so what collaborative care does is it really allows you to pick what would be helpful. “Would it be helpful if I gave you a call every day to see how well you’re doing and we practice some of your deep breathing around your anxiety. What’s something you could do today or tomorrow to help you feel less bad” — and then give someone a follow-up call.

I often tell people to think about it like meditation. If you went to see your doctor, they wouldn’t give you a big pill to take once a week. Most of the time what they would do is give you a dose every day. And so this is really like therapy or behavioral health treatment in doses based on what the patients think will be helpful for them. And that not only increases access, but it allows more people to be engaged.

How are you using technology?

Hutchins: I think most importantly, it’s embracing the fact that you don’t have a clean division between tech and clinical services. It’s 2021, everybody needs to be a technology company. And so, it’s all about ease and automation for the patient and for our team — our clinicians.

A few things would just be, hey, make it easy for the patient to connect with us. That can be a video visit or a phone call. Making that simple … The other is helping so that they can tell us how they’re feeling through structured surveys, so we can track their symptom severity over time using tools. But that can just be done with secure messaging.

Another huge part of the technology integration is invisible to patients in a direct sense … And that’s a real deep integration into primary care physicians’ medical records so that we know what’s going on. We know if they were just in to see the PCP last week and we know how their diabetes is doing. That’s not directly visible for the patient, but they see it and they feel it in a way that, “Oh, my God, you’re actually talking to one another. You know what’s happening with my whole self and my whole care and you’re planning the intervention around my sadness or my nerves in a way that is consistent and reinforces what we’re trying to do with my weight or my diabetes or my COPD.” And that really happens on the back end of having data flow between our systems and the medical records of our partners.

Also, I’d say a major piece of the model and something that is, again, patients don’t see it directly, but I think they can feel it, is real fidelity to outcome measurement. Are your symptoms getting better or not? Are we measuring those? And that can trigger more time and attention being paid by our supervisors and our clinical leaders, as well as our psychiatric consultants.

What’s the future for Concert Health?

Hutchins: There’s just been an enormous amount of good we can do in the world and enormous amount of scale just by perfecting, operationalizing and improving those core processes [of collaborative care]. And so I think that’ll stay our raison d’être for a while.

Certainly the evidence base is strongest around specifically depression and anxiety. When you do structured research, you look at specific indications. I think, smartly, Medicare and the health plans have allowed collaborative care to support patients with a broader set of diagnoses. But we’re really focused on taking the same mindset, and eventually being part of that literature. As an example, we’re now seeing a lot of the ADHD needs out of our pediatricians and that they feel like they need to diagnose that better, understand it, understand the interventions and track whether or not they’re working.