#003: Striking a Balance: How Regulatory Lag and Fragmentation Impacts Care Delivery

Explore a healthcare landscape reimagined by a thoughtful balance of regulation and innovation. In an interview with Ryan Estes, a Licensed Clinical Social Worker and Chief Operations Officer of Coastal Horizons, we tackle pressing issues like rate-setting challenges, innovation in regulated markets, and the delicate balance between regulation and a more agile healthcare system. '

Ryan unravels the complexities that shape behavioral health and integrative care delivery in Eastern North Carolina. In a world where quality care is paramount, discover why challenging the status quo is not just an option but a necessity for transformative change.

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Transcript

00;00;00;00 - 00;00;32;02
Ryan Estes
It's been over 12 years since we've had rate reimbursement increases on the Medicaid side. Commercial insurances are also not keeping up with hyperinflation. What that's costing systems is we see increases in the opioid epidemic. We see increases in suicidality when those things happen. Now who's taking the brunt of it? It becomes hospital systems, prison systems. And then in turn, the taxpayers.

00;00;32;04 - 00;01;04;00
Liz Church
Welcome to the Atrómitos Way Podcast, where we have meaningful discussions on the challenges in healthcare and the solutions behind them. I am your host, Liz Church. Each episode, we dive into the complexities of our health and social system, gaining the experiences and insights of the guests that shape our lives and our communities.   Have you ever wondered what our health care system would look like if there were a more thoughtful balance between regulation and innovation, where unnecessary friction and redundancies were reduced and a nimbler adoption of effective innovations is allowed.

00;01;04;03 - 00;01;43;13
Liz Church
Licensed clinical social worker Ryan Estés has, and his thoughts on why it's necessary. We challenge the status quo. This question takes center stage in today's rapidly evolving landscape, where access to quality care is paramount and we cannot talk about the rapidly evolving landscape without someone in particular who you met a few episodes ago. In this collaborative interview, I am joined by Tina Simpson to delve into the challenges of rate setting and health care, addressing innovation constraints and regulated markets, navigating monopoly environments and their impact of quality of care, and the crucial art of balancing regulation within the context of a nimbler health care system.

00;01;43;20 - 00;01;55;09
Liz Church
Without further ado, ladies and gentlemen, let us begin. First question. And Ryan, what is your big idea or vision for an improved health care system?

00;01;55;11 - 00;02;19;22
Ryan Estes
Yeah. Thanks, Liz. I think that there is a place right now we're at an inflection point to be able to balance innovation and regulation in a different capacity. I think if we can move the needle from this being a pendulum of sometimes we really push down on to regulation, and then sometimes we're put in a position where we really are focused on innovation, but rather look at a different way.

00;02;19;22 - 00;02;49;08
Ryan Estes
The third way, that's a polarity where we're able to say like, what's the best part of innovation and what's the best part of regulation and push forward in a way that has a different prioritizing of both of the best parts? I think we could have a health care system that becomes more sustainable. It's more nimble to the changing environments, whether that's a pandemic or a workforce shortage crisis, that we have a way that really centers the best of both innovation and regulation concurrently.

00;02;49;13 - 00;02;50;16
Tina Simpson
I love that answer.

00;02;50;23 - 00;02;52;07
Liz Church
This is Tina here.

00;02;52;10 - 00;03;09;16
Tina Simpson
I particularly love your example of the duality or Polaris of innovation. I think as Americans, we tend to think that we can have all things all at once, at the same time and without spending a penny more. And we're uncomfortable with the idea of rationing and recognizing that, you know, there's a trade off between one good and another.

00;03;09;16 - 00;03;36;16
Tina Simpson
And there's a fundamental trade off between regulation, which favors consistency, sort of conservatives, conservative conformity, compliance and then innovation, which is creative, offers new horizons but also includes risk. So my follow up question I know I took a long time getting to it is this knowing that regulation is important. Speaking as a compliance attorney, what would more effective regulation of care delivery and care billing practices look like?

00;03;36;23 - 00;03;43;20
Tina Simpson
Are there any primary principles that that you would want regulators and policymakers to follow when it comes to this?

00;03;43;25 - 00;04;08;22
Ryan Estes
You know, I think that Covid put us in this place. It was a portal to re-envision things. And so it really cut out of lag that our regulations follow through, what, ten years ago and not what we need today. So I think about, you know, Intel therapy when Covid was at the height of the that we needed to be able to see people and balance public safety and access.

00;04;08;22 - 00;04;44;13
Ryan Estes
And so we we cut through at both a federal level, a state level on said. And we allowed different voices to come to create those systems, you know, providers voices, members that were being served had a different place at the table, a different arrangement. And so ideas came forth that otherwise wouldn't. So I think that's one of the pieces with regulation is how have we gotten so locked into what we think is the right thing versus being able to say, if we have an idea and we believe that that arrangement can be done differently, will we get a different effect?

00;04;44;14 - 00;05;08;19
Ryan Estes
And so I think that that is one piece. Also, we have redundancies in our system with the regulation side. And it often creates fragmentation and drives up cost. And so an example of that would be if we look at an opioid treatment program. You've got the DEA that has a say in it. Then you would also have a state authority that's going to say how things are going to be done.

00;05;08;20 - 00;05;38;19
Ryan Estes
Then you have the individuals who licensed the facility. And then, you know, there's probably other 2 or 3 regulatory bodies that aren't even coming to mind. And so they all are requiring like check these boxes. And sometimes the boxes overlap. Sometimes they contradict each other. And it's like, well, how do I manage all of these things? And you're spending so much time on the back end as a provider, having to justify that you've done everything to protect your payment as a member.

00;05;38;19 - 00;05;59;03
Ryan Estes
It's creating a lag. It's like, hey, I didn't get this, or you're coming in and we're going to spend three hours to make sure that we've done every single checking of the box to ensure that this is the most appropriate service, and it delays access to care. So I think that those are sometimes where we see this regulation that holds us up.

00;05;59;05 - 00;06;18;24
Ryan Estes
Now let's think on the other side, the innovation can get so far ahead of itself that I've talked with people that are like, I can do anything for health therapy or this. And it's like, you know, I was looking at flexibilities that were keeping substance use just came out where the federal government said, we're going to allow these flexibilities stay in longer so that we can better research them.

00;06;18;24 - 00;06;39;01
Ryan Estes
And interesting I am like the Ryan Haight Act, which protected being able to prescribe without having done a face to face so that we're not just pushing out really the substances that should be controlled to the mass market through your mail. It was like, hey, you need at least see them in person. And now we're saying, well, we're going to allow that flexibility to continue for another year.

00;06;39;01 - 00;06;54;27
Ryan Estes
And I'm like, that's innovation. That might be too far out ahead of itself. We're not in that public health crisis anymore. People can get to an office. And so is that where innovation is out of balance to the regulation. So I think there's a middle ground.

00;06;55;00 - 00;07;13;19
Tina Simpson
Another quick follow up. I mean, I guess also we have this segmented system, but also it just keeps building on itself there. Maybe your call to rethink how many agencies are governing so many different things. So I think that there's sort of an intentionality or maybe a reset in a certain way.

00;07;13;21 - 00;07;35;15
Ryan Estes
Yeah. You know, I agree, the analogy that I often use is that it feels like picking up a game of Jenga. The tower is about to topple over, but it's now your tower. It's like you weren't the one who set it up that way. And rather than building forward onto it, do we need to move backwards? You know, I think Isabel Wilkerson does a really nice job of talking about, like, the house analogy.

00;07;35;15 - 00;07;53;12
Ryan Estes
It's like, you know, I moved into this house and I didn't set it up this way, but it's still my responsibility now to take care of it. Obviously, she's talking about different things and health care regulation with that analogy, but I think it does crosswalk really nicely that like you and I didn't create the regulations that we're in, and yet we still have to function within them.

00;07;53;12 - 00;07;59;08
Ryan Estes
And it's also our responsibility if we see that they're not balancing innovation, that we have to push to make those changes.

00;07;59;10 - 00;08;05;11
Tina Simpson
How has your clinical experience in behavioral health informed your perspective of the health care system as a whole?

00;08;05;18 - 00;08;29;15
Ryan Estes
You know, I think behavioral health is often left on the cutting room floor. We've had to fight for parity for years, and that parity still isn't really seen. There's this idea of like, could it be managed better if we carve it out? Can it be better if we bring it in? Treat holistic care within a funding the same way that our body treats like we don't separate mind and body, yet somehow oftentimes our funding streams do.

00;08;29;15 - 00;08;58;08
Ryan Estes
So I think as a behavioral health provider, I've seen where there's inequities that occur because of stigmatization, because of a lack of understanding it. And it's also a relatively new field. You know, we are still developing the methodologies to treat a lot of disorders. We're still trying to really fine tune. That's why you see the diagnostic manual that we function form continues to have new additions because we continue to emerge as a practice around how we diagnose, how we do prognosis, how we treat.

00;08;58;09 - 00;09;29;29
Ryan Estes
So I think that that's allowed me to see what it looks like in a carved out specialized space. But then there's also a lot of lessons that I think do transfer back over to the full system. You know, there's the same way that we have lags and our inefficiencies, the same way that we're overly regulated take place on primary care side, as well as having done integrated care for, you know, the last ten years and having primary care providers that are co-located into our space, getting to see like there's some things that are going really well in their system that we need to quickly adopt.

00;09;30;01 - 00;09;50;21
Ryan Estes
from a regulatory standpoint and from a funding practice that are included from us, because we need the system to transform and to be able to do that. Population health is a great example. You know, being able to do value based contracting. These are concepts that have been in the federal framework for primary care, for quite some time, that we're just now starting to see spill into the behavioral health world.

00;09;50;27 - 00;10;22;10
Liz Church
I do have an interjection on this one. And I went back and forth a little bit whether or not this was appropriate to ask. And I don't know if the stigma is the right word to use for this, but mental health care was not seen as something to take seriously for a while from from my viewpoint as a patient, and it seems like now we are adopting this new phase where, yes, it is catching up to physical health, but maybe the stigma is the reason that we're having a slower adoption to all these different things, having these services available.

00;10;22;12 - 00;10;44;13
Ryan Estes
And do I think that people that look like the three of us are now asking for mental health, and that hasn't always been the case? I think that we have weaponized mental health in a lot of ways, that it is then pushed on to people who are in the child welfare system, that are in the carceral systems. It's individuals that dominant society gets to determine what normal looks like.

00;10;44;13 - 00;11;01;16
Ryan Estes
And as there's been this shift and we've seen more people have said, well, I want a mental health therapist the same way. I want a dentist or a doctor. It's created this transition to where more people are asking for it and they're accessing it. And part of it is that there's been a breaking down or whittling away of that stigma.

00;11;01;16 - 00;11;19;08
Ryan Estes
Part of it is that going back to tell a therapist, you can access a therapist from your home, and you may not have to have everybody know in the public because you're not going to a community center. So I think there's been a huge transition the same way that we treat the opioid epidemic. We arrested the crack epidemic.

00;11;19;08 - 00;11;31;06
Ryan Estes
So we now are treating mental health, and we're putting more funding into it because more people that again, look like us are accessing it. And so there's a different value base being assigned to it.

00;11;31;08 - 00;11;54;25
Liz Church
So a follow up to I was talking about mental health access and services and such. so earlier this year, 2023, earlier this year in 2023 that the state was going to invest in behavioral health and resilience investments. That way, North Carolinians are able to get the essential mental health care and support services that they need. And this announcement feels like it's coming off the heels of the pandemic.

00;11;54;28 - 00;12;16;08
Liz Church
Transitioning into a way of recognizing a lot of things happened during the pandemic. There was a lot of substance misuse. There were a ton of people just plummeting into a mental health crisis. They didn't have the ease of access that they were normally used to because, you know, we had to use telehealth, couldn't see people, so the socialization was taken away.

00;12;16;11 - 00;12;35;11
Liz Church
I see that there's it's like it's being finally taken seriously. I don't know if that's the right word for it, because I'm seeing this from a patient level. It's like, wow, this is really great. There's there's a lot of things that can come out of this. So what does this mean, though? This is the only reason I ask this because, you know, a lot of money means potentially great things.

00;12;35;11 - 00;12;46;04
Liz Church
But what do we do in order to create the meaningful change for things to happen? You know, money doesn't automatically fix it. And sometimes more money means more problems.

00;12;46;06 - 00;13;06;04
Ryan Estes
Yeah. So there's a lot to unpack in that statement. And so, and you know, sparked that today is mental Health Awareness Day. there's been a lot of communication coming out. North Carolina spent $830 million reinvesting into our behavioral health. and I think that it's a bit disingenuous. We expanded Medicaid, which came with new federal dollars.

00;13;06;04 - 00;13;23;18
Ryan Estes
So, yes, we're giving ourselves a lot of credit that we we did finally expand Medicaid, which is huge for the state. Do I think we would have spent $830 million otherwise if it wasn't coming in from the federal government as a bonus program? No. Do I think that we would have spent more money on it because we've recognized that it's an issue?

00;13;23;19 - 00;13;52;03
Ryan Estes
Yes. But North Carolina has a historically underfunded our mental health system or behavioral health services, I think Covid, but in our face that, yes, this is something that is more pronounced it. A lot of people who are experiencing anxiety, depression that were exacerbated by the pandemic, we also then we're in the process of creating a lot of access increase, whether that was through talk therapy, breaking down stigma to where more people are going into private practice.

00;13;52;03 - 00;14;14;06
Ryan Estes
So more people start accessing therapy, and all of a sudden our state funded and our Medicaid funded programs, our safety net programs, became so threadbare that I think that there was a fear that we were setting ourselves up for class action lawsuits around access to care, because you cannot find a therapist that takes Medicaid and really even commercial insurance at this point.

00;14;14;06 - 00;14;37;19
Ryan Estes
It's all private practice. And so we had to infuse our system with money. I would like to be optimistic and think that it's a round, that we realize the value of it. But I think it's also the fact that we didn't want to be in a class action lawsuit or spend money by not treating mental health, and instead of not paying for it, they're you're paying for it and increasing prisons or institutions.

00;14;37;19 - 00;14;40;02
Ryan Estes
So I think that that's why we've seen this increase of funding.

00;14;40;04 - 00;14;41;26
Tina Simpson
And I can also interject here.

00;14;41;26 - 00;14;43;15
Liz Church
And this is Tina here.

00;14;43;20 - 00;15;02;02
Tina Simpson
You know, I just wanted to sort of harken back to you were talking about, you know, regulations, you know, trying and rethinking about it in the context of, you know, more of a polarity as opposed to this pendulum that Swift goes back and forth and as you're describing the you know, what it has taken for us to reinvest after chronic underfunding of behavioral health.

00;15;02;02 - 00;15;23;09
Tina Simpson
It just strikes me that that just seems to be the way we operate when it comes to spending as well. Do you have any guidance on how, as a political system, we might have a more stable basis for these sort of policy and spending decisions where we don't go so many decades with sort of starving programs like this, and then that it needs that big influx.

00;15;23;09 - 00;15;25;15
Tina Simpson
Do you have any insight on that?

00;15;25;17 - 00;15;56;14
Ryan Estes
We've got to quit politicizing things that don't have to be political. Mental health shouldn't have to be political. But once it gets in the crosshairs of things like Medicaid expansion versus it being, hey, we all know somebody that's suffering from depression and we can treat, I think that when we have big ideas and political environments, it causes us not to fund things, because then you have PACs and other things that put down how much funding you're going to get or what your scorecard is.

00;15;56;14 - 00;16;15;17
Ryan Estes
And when we start to have to have these things that get a scorecard rating, and you're going to get voted out of office and put in with somebody else that has an R, a D behind their name. Then all of a sudden we see systems grind to a halt. I also think there's a lot of money that comes into who's getting their voice heard.

00;16;15;17 - 00;16;41;03
Ryan Estes
You know, if I am wanting to build prisons or I'm wanting to build casinos and I can invest money into it, and those become priorities over something else, then all of a sudden, I think that gets in the way of us investing where we need to. I think, Tina, to that answer, I think it's just having the conversations, finding the unlikely allies in the room so that we can be able to advance things.

00;16;41;03 - 00;17;03;15
Ryan Estes
You know, I had an opportunity to sit with U.S. Senator Tom Tillis at a roundtable about a month ago, and he did put forth bipartisan, spending into behavioral health at the federal level. And so, again, it's who are the unlikely allies that are going to advance things so that we can get money and that we can quit saying that mental health is a Partizan issue.

00;17;03;15 - 00;17;27;16
Ryan Estes
Medicaid expansion is a Partizan issue. It doesn't have to be. We've seen, you know, 40 states, red and blue that have invested. I also would like to see us take a more of a data driven approach. You know, I think it's concerning and this is a bit dated, but I remember after the parkland crisis and there was information that came out around who has funded their mental health system since Columbine.

00;17;27;18 - 00;17;55;29
Ryan Estes
And like most states, had increased funding since Columbine, North Carolina was one of the few that hadn't. And so, in fact, we were one of like the only I want to say it was like three, 4 or 5 states that had actually cut funding since, since Columbine. And so it's when we see data like that that we have to sit there and questions like, do we really understand the complexities, why we're funding these types of programs and systems?

00;17;56;01 - 00;18;10;22
Liz Church
So to pivot back, let's talk about reimbursement rates inadequate or reimbursement rates under Medicaid create challenges for maintaining an adequate and competitive marketplace. Ryan, can you elaborate? And how will these set rates impact both health care providers and patients?

00;18;10;28 - 00;18;43;03
Ryan Estes
Absolutely. So when we saw a fundamental shift of what fair market value was for therapy because there was an increased demand, you know, I look at my local marketplace and it's 150 an hour to 200 an hour, but we have locked in rates with commercial insurances, Medicaid that are grossly inadequate compared to that fair market value. What we've created is a system that some people can get access and some people can't.

00;18;43;05 - 00;19;08;22
Ryan Estes
So if you're relying on your health insurance and that could be Blue Cross Blue Shield, could be Medicaid to pay for services. And you don't have the ability to say, don't worry about taking my insurance. I'll pay for it out of pocket. If you're not in that position, then you're less likely to get services. You're also more likely to have really brain therapists, therapists that are just entering the market.

00;19;08;22 - 00;19;31;11
Ryan Estes
They got their graduation degree, they're freshly minted, and they're now doing your services because, again, goes back to supply and demand and basic economics of who can command a higher price point. That's been one of the issues that I have seen with the lag. It's been over 12 years since we've had rate reimbursement, increases on the Medicaid side.

00;19;31;17 - 00;20;06;02
Ryan Estes
Commercial insurances are also not keeping up with hyperinflation. And what that's in costing systems is we see increases in the opioid epidemic. We see increases in suicidality and when those things happen now, who's taking the brunt of it? It becomes hospital systems, prison systems. And then in turn, the the taxpayers. So we're all suffering because we haven't recalculated what that, value of therapy is and how it spills into these other systems.

00;20;06;05 - 00;20;22;13
Liz Church
Ryan, I have a little interjection here that I wanted. I wasn't sure if I could bring it to the table. Do you think people are more complacent to be like, well, we don't really want to fix this problem because fixing it is a little scary. Change is too scary. We've been doing this for a really long time. Why do all of this?

00;20;22;13 - 00;20;38;26
Liz Church
We can just kind of keep it afloat. I really would be appalled if people really think that, but what do you think it will take for people to see that it's necessary because we're not adequate in these rates and all these other elements. People are suffering, like you say, and, you know, going to prisons and so on and so forth.

00;20;38;26 - 00;20;51;14
Liz Church
So what will it take to make people realize these, you know, what's being effected, even though it's not physically in front of you? What would you say it makes people actually respond to change in what is necessary?

00;20;51;17 - 00;21;15;03
Ryan Estes
I think the issue has to become salient and personal. You know, it's what happened with the opioid epidemic, which was then all of a sudden it was this is not, you know, somebody that's living on the street. This is my son. I've seen them or my daughter go from being a productive citizens to not. It's been the you know, I was talking with a very well-to-do individual.

00;21;15;03 - 00;21;37;13
Ryan Estes
His 13 year old daughter ended up in a hospital bed on involuntary commitment. And he didn't understand the system and the challenges, like mental health. We don't think about it until we need it, you know, we all know how to access, like if you wanted to go buy groceries, you know where to go if you need to buy gas, even if you're in a different town, you know where to find a gas station.

00;21;37;17 - 00;21;55;12
Ryan Estes
We don't have that same understanding of our mental health system because it's not something we think about until we need it. And so, you know, I look at my own, like, bank account. I'm not spending money aside for things that I don't realize that I need. And so that's been our larger system as well. Why do I need to have money for mental health?

00;21;55;15 - 00;22;16;29
Ryan Estes
We don't need it. We only need it for a subset of the population. And now it's the whole population that needs it. So it's like, oh, well, I need money for that. Yeah. And so I think that that's been the problem is that that lag of recognizing that we had anxiety, depression and people couldn't more kids weren't going to school, kids were coming back to school.

00;22;16;29 - 00;22;28;21
Ryan Estes
And the behavioral issues, there was a spike in child welfare reports that came after the pandemic. All of these things that required us to have attention as a system. We weren't prepared for it.

00;22;28;23 - 00;22;43;28
Liz Church
It's really hard to prepare for something on such a large scale like the pandemic, and nobody was really prepared for the after effects either. I think a lot of us just thought we were going to go back to normal, and when that happened, it was hard to go on, to go back to normal. Like, what is our normal?

00;22;44;01 - 00;23;00;17
Liz Church
This is our new normal of problems. You know what's good, what needs to change. And whenever we were preparing for this interview, one of the things that I was thinking of is, how can we make it so people take this seriously? What do we do? I mean, where do we begin is a very daunting question.

00;23;00;19 - 00;23;37;04
Ryan Estes
You know, it's really interesting. Was I, I think of it this way and all those great apocalyptic movies, they all start with the scientists running around saying that we're in a bad place with the mental health crisis. Mental health professionals knew we were in a bad place prior to Covid. We knew we had a underfunded workforce. We knew that we had a shortage and we would talk to, you know, legislators, regulators, politicians and say we're in a bad place.

00;23;37;06 - 00;23;55;17
Ryan Estes
But we were that scientists from the the movie running around where everyone just says, this person doesn't know what they're talking about there. and exciting danger that's not really there. And then all of a sudden we're on the other side of it and it's like, well, how did we get here? It's like we knew how we got here.

00;23;55;17 - 00;24;18;19
Ryan Estes
This shouldn't come as a surprise to anybody that was in the mental health profession. Mental health professionals knew the same way that I'm sure that those dealing with like bad drinking water in certain communities are like, oh yeah, we knew that there would be cancer that came from this because we were dumping coal ash into our water, or we knew this other crisis was coming.

00;24;18;19 - 00;24;28;05
Ryan Estes
So these things really aren't as a surprise. We just tend, as a society, to dismiss experts until it's actually a problem in our face.

00;24;28;07 - 00;24;41;12
Liz Church
To be honest, as a person who is, you know, tired of seeing it because it's in my face and it's been in my face for a while. And as a patient of mental health support services, it's like, I'd like to see something happen here, guys, and you get a little impatient. You know.

00;24;41;14 - 00;25;04;17
Ryan Estes
It's, you know, the way that you said it too. It's like the the check engine light was on. Yeah, but we did. We waited until the car was broken down and now it's so much more expensive because we waited. And I think that that's part of what we had to walk back is to say prevention or early intervention is way more affordable than waiting till we're in a crisis.

00;25;04;19 - 00;25;31;27
Ryan Estes
And I think that like as a population, we would have seen the turning of a lot of these, whether it's the suicide epidemic or and now it's the opioid epidemic, any of these other aspects of our system, if we had put money in earlier, we wouldn't be at this point. And we would actually see these the numbers changing and in a favorable direction, rather than appearing stagnant or taking or still increasing.

00;25;32;00 - 00;25;50;08
Liz Church
Goodness gracious, we could go off topic so quickly, and I need us to pivot back. I'm going to pivot back just a little bit. And I apologize for the segue, because this is a very interesting topic. There are so many things, and when you are passionate to see change, you have a tendency to be like, oh, there are more people that believe the same things that I do.

00;25;50;10 - 00;26;09;27
Liz Church
Let us talk about. So to kind of pivot back, let's flip it back a little bit. Like I said, with the regulatory system, I need some clarification because I am so not the expert I am not familiar with or understanding of regulatory lag. Is this tied to policy decisions and is the political legislative system a part of it as well?

00;26;09;29 - 00;26;25;19
Liz Church
Because I wanted to kind of clarify, talking about concerning health services and the payments, and then we're talking about the inadequacies and will inadequacies being paid. Do you believe that there's failure in setting the budget for how care is paid for?

00;26;25;21 - 00;26;47;18
Ryan Estes
So I guess I heard two questions there. I think that some of the regulatory regulation is administrative. Some of it's legislative, and I think it determines who has the authority. So there's certain things that we can change. And the administrative level that's left in charge with those that are part of like the department or the division, depending on which setting we're talking about.

00;26;47;20 - 00;27;18;26
Ryan Estes
And then there's other things that require approval at a legislative level, and that could be state or federal. And so I think we have to always exercise to the ceiling of our power to make these innovations and changes. And I think that that doesn't always happen. And I think sometimes it comes to seeing how things are prioritized. So, you know, for instance, I look at Washington just funded all undocumented citizens within their system for Medicaid, and that was done through state funding at a state level.

00;27;18;26 - 00;27;44;01
Ryan Estes
That's not going to happen at a federal level. So that's a great example of innovation that is going to then improve everybody's health, because hospitals now can get reimbursed for things that they would otherwise be writing off or passing cost over. So that is one example of how we can do innovation in a in a policy level. Then I also look at the right question, the piece of that.

00;27;44;04 - 00;28;12;04
Ryan Estes
And I think what that was, what what comes to mind is that rates are always going to be insufficient to really ever meet the demand. And I and maybe that feels jaded. I think that we are in a medical model. So we oftentimes are paying for things in a reactive manner than a proactive manner. And so we don't pay for a lot of services to keep someone from ever developing depression.

00;28;12;06 - 00;28;35;25
Ryan Estes
We pay for treating depression. And so I would love to see us invest more on the preventative or early intervention side, because I think that that is a more affordable approach. But in a medical model where we pay for reimbursement diagnosis, then we're oftentimes dealing with individuals who come into systems or needing services after they're already really sick, not just in that class.

00;28;35;25 - 00;28;45;14
Liz Church
More so moving from that, achieving the right balance between regulatory controls and flexibility can be challenging. Are there any places you see or have seen balance in action?

00;28;45;16 - 00;29;10;18
Ryan Estes
Yes. So when we had the height of the Covid pandemic, I talked about the fact that we were in a very different space. The system had been thrust into chaos and in chaos. There's a lot of new ideas that emerge. And so things that we were doing differently, we allowed technology that was previously not fully leveraged. We said, how do we increase access?

00;29;10;19 - 00;29;37;02
Ryan Estes
And so things that we were trying to do was to keep people safe, that they weren't spreading the virus. But what we actually saw was that people who didn't have transportation, people who had childcare issues, were now getting into services. So in North Carolina and all the talk therapy policies are different across different states, but ours was specific to you had to be Medicaid, registered site to a medicaid registered site.

00;29;37;04 - 00;30;02;15
Ryan Estes
That policy was so dated that meant that if you wanted to do a therapy from an office to a school, you weren't within the bounds to really be reimbursed. There's no reason that a child at school couldn't meet a therapist at home putting do therapy to someone else's home. So there was all of these things that made no sense from a regulatory team or an innovation standpoint, or really even regulatory.

00;30;02;18 - 00;30;25;26
Ryan Estes
And we were thrust into a different position. I said, throw it all out. We are going to work under the greatest ceiling of flexibility. During that time, we codified what we thought was going really well and so it advanced. I mean, you would hear politicians and people at the department say our health care policy went from ten years behind to ten years ahead.

00;30;25;28 - 00;30;40;17
Ryan Estes
So almost within a year, which doesn't happen because we reimagined. But it's like, why do we have to wait for a system to be in chaos, to advance ourselves 20 years within a policy framework?

00;30;40;20 - 00;30;42;26
Tina Simpson
I love that example.

00;30;42;28 - 00;30;44;09
Liz Church
This is Tina here.

00;30;44;11 - 00;30;55;23
Tina Simpson
I think that giving an example of how sometimes the best solution is not. We always look for the additive solution. What do we add on to something? Sometimes it's it's taking something away that's impeding progress.

00;30;55;25 - 00;31;22;04
Ryan Estes
Yeah, absolutely. I think there's a lot of additions by subtractions. You know, I talk a lot about like the administrative barriers. So it's the prior authorizations for a service that isn't that doesn't come up a lot of waste or abuse. And so when you don't have a prior authorization, you're able to expedite someone getting into services. You're we're cutting out provider time and payer time to have to look at an authorization.

00;31;22;06 - 00;31;43;11
Ryan Estes
And certain services come with an increased abuse potential or fraud potential. And so yes, highly regulate those. But most services don't. And there's not as many bad actors in the system as we think that there are. And so those allow for us to take that cost and to reinvest it where we need it to be versus saying, hey, we need to increase rates.

00;31;43;13 - 00;31;48;01
Ryan Estes
Do we need to increase rates, or do we need to look at red tape that can go?

00;31;48;04 - 00;32;12;17
Tina Simpson
And it's interesting, I, speaking as a former administrative lawyer, you know, engage in writing regulations, I'll confess that I you know, I think sometimes the problem is, you know, in writing those, not knowing what it is that we should be measuring, what are the things that should be that are the indicators of, you know, fraud, waste and abuse or quality of care, you know, not being very always very intentional and consistent with our policy making.

00;32;12;19 - 00;32;35;15
Tina Simpson
But I think narrowing in on knowing what it is that we should be measuring and are the indicators for whatever, whatever good we're trying to achieve through regulation is, is pretty critical. Is there anything that you can speak to in your experience? Does that just I had wanted to get to you had such a good comment about the, you know, we just add more staff and it's like, that's where I was going.

00;32;35;17 - 00;32;36;08
Tina Simpson
okay.

00;32;36;10 - 00;32;36;28
Ryan Estes
Yeah.

00;32;37;00 - 00;32;37;23
Tina Simpson
Well, once.

00;32;38;00 - 00;33;02;13
Ryan Estes
I think about like that right now, we have like, you know, a patient enrollment person that's having to check, you know, it's the inefficiencies of technology. Someone comes in and they say, I've got to show what they do, and then they also have Tricare, or they also have some other secondary insurance. And so we're spending, you know, we have to create positions that all they do is check people's insurance.

00;33;02;16 - 00;33;25;23
Ryan Estes
And then, that's expensive. You know, that's a full time position with benefits. And then all of a sudden that gets put back into these rates where we start to say, and it's like, and then you've got someone on the payer side saying, hey, before I pay this claim, I need to make sure this person doesn't have some other form of insurance that we really should be the pair of last resort or first payer.

00;33;25;25 - 00;33;51;03
Ryan Estes
And so there's duplications on both sides. and I just, I feel like those examples play out so often within our systems of submitting. I'm a clinician. I'm writing up my my report that justifies that service. I'm a now a clinician on the payer side, reading this report to make sure and then we're going to submit a claim every single time.

00;33;51;10 - 00;34;14;09
Ryan Estes
So probably one of the best advancements I've seen, it's not just the waiving a prior approvals or extending out those prior approvals. So for instance, that like I know the prognosis is someone's not going to be better for 3 to 6 months, then I don't need to review it every month. Let me review it at three months at the earliest point that we might see improvement.

00;34;14;10 - 00;34;40;12
Ryan Estes
So I'm not asking for a reauthorization. And then instead of asking you to submit a paid claim after every visit, let me just bundle for the month and give you a, a monthly rate. So that like, yes, you're still doing documentation after every visit, but we're not having to pay for a bill or to make sure that it's a clean claim going out the door 12 times in a month versus just one time.

00;34;40;14 - 00;35;07;16
Ryan Estes
And so those are things that don't really cost, they save a lot of money in the system, and they allow people to center the work, which is taking care of people. And when we're not centering the work or taking care of people or centering the work of bureaucracy and people to check paperwork, that's where I think the regulation has taken away from the innovation.

00;35;07;18 - 00;35;29;20
Liz Church
You've given us a lot to think of here, Ryan. You always you always do. So, to close out the conversation, summarize and have a call to action. So in the grand scope of the health care industry and the challenges that we face, what's one piece of advice or a call to action you would like to leave the listeners with.

00;35;29;22 - 00;35;33;17
Ryan Estes
Challenged the status quo?

00;35;33;19 - 00;35;34;04
Tina Simpson
I like that.

00;35;34;05 - 00;36;07;23
Ryan Estes
As as those doing the work, you're going to see innovation and what's working. You're going to have this researched, inform practice and practice and form research circle that we as practitioners are able to advance systems faster than payers, faster than politicians. But our voice has to be at that table and we have to be loud so that we can push forth the innovation that we're saying.

00;36;07;25 - 00;36;18;15
Liz Church
Went for the mic drop, you. Know, thank you for. That's perfect. Closer. Thank you both for joining me this this morning Tina this evening for you.

00;36;18;17 - 00;36;21;08
Ryan Estes
Thanks. Close. Thanks, Tina.

00;36;21;10 - 00;37;18;26
Liz Church
The Atrómitos Way is produced by me, Liz Church. Editorial assistance for this episode was by my fantastic team at Atrómitos. I would like to express our heartfelt appreciation to our guests who shared their expertise, stories, and insights with us on the podcast—finally, a big thank you to our listeners. Your support and engagement have meant the world to us at Atrómitos.  

We are a boutique consulting firm with the imperative mission of creating healthier, more resilient, more equitable communities. I encourage you to connect with us. Let’s continue these conversations and work together towards positive change. 

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