April Razo, a Leader in Integrated Care
July 17, 2017
April Razo is a force to be reckoned with. Each team she is part of, she changes for the better. She is constantly optimizing, looking for more efficient and effective ways to take care of her clients. As CEO of Spectrum, Ms. Razo uses her business savvy to optimize the integration of physical and behavioral health, which is no easy task.
The Valant team had the chance to sit with April to talk about how Spectrum made the transition from behavioral health to integrated care, how they measure success, and the role of technology in her strategy for care. Before we get started on how Spectrum successfully integrated two completely different types of agencies and reports on all their data, let’s look at some quick facts about Spectrum:
- Founded in: 1965
- Added Primary Care: 2009
- Annual revenue: $15,000,000
- Clients served annually: 7000
- Approximate encounters per year: 85,000
- Primary care visits per year: Approx 10,000
- Staff of 200 comprised of MDs, FNPs, PNPs, RNs, licensed mental health counselors, licensed social workers, BA and MA certified addiction professionals, BA and MA level counselors, care managers, peer specialists, and administration staff
Inspiration for Integrated Care
VALANT: When did you get started in integrated care? What inspired Spectrum to make such a dramatic change?
April Razo: It all started with a report that came out in 2009 that showed a connection between mental and physical health. It stated that people with mental illness were, on average, dying 25 years earlier. After reading this report, our priority became to manage some of the comorbidities that were arising because of mental illness treatment. For example, to treat schizophrenia, you have several different medications, which cause physical health conditions like weight gain. But that weight gain may lead to hypertension, to hyperlipidemia, to heart problems. Those byproducts of mental illness treatment were causing health issues that weren’t getting treated due to a lot of different factors. Some in particular were people felt a stigma when they went into their primary care physician, primary care physicians didn’t feel comfortable treating people with mental illness, or they didn’t have enough time.
When that study came out, part of our major population consisted of people living with a serious mental illness so we felt like not only are we well positioned to manage the care of these people, their physical health care, but we’re really kind of responsible. We should be managing that. We can’t have this happening; we’re not going to have that occur.
The Pathway to Integrated Care
VALANT: How did you go about making such a dramatic change to the way you served your clients?
AR: We set out to bring that physical health care service delivery onsite for our SMI individuals to access, but at that time, as you can imagine, not many people were doing that. There were no other agencies doing that, and there was a reason they weren’t doing it: the reimbursement rates are not sustainable.
Medicaid rates for reimbursement for primary care are set up so that if a primary care physician spent five minutes with a patient, they would get about $50 for that time. If the patient spent 15 minutes, the physician would receive that same $50. If a patient has a serious mental illness and a physician is trying to talk with them about their medical history, and the patient is responding to internal stimuli because they’re actively psychotic, you can imagine that takes a little bit longer.
On the behavioral health side we are reimbursed differently so if I spent sixty minutes with you, I would be paid for sixty minutes. I get paid for units of care so it’s a much higher rate, but physical health reimbursement supports quantity over quality so it’s like a churn and burn kind of scenario. You have to get as many patients as possible into an hour. And I’m sure you’ve experienced that in your own primary care. You wait to be seen, you are called back, you spend two minutes with the doctor, and then you’re out the door.
We actually contracted a physical health provider to come co-locate onsite with us and provide primary care services to about 99 seriously mentally ill clients. For licensing, we had to establish separate entrances, separate lobbies, separate workflows for physical and mental health, which presented its own set of challenges.
We quickly found that there weren’t economies of scale to sustain what we were trying to do, and the contracted primary care provider that came onsite didn’t want to have anything to do with it. They weren’t making any money and they were paying a lot of money to be there, so they left. That’s when we decided we’ll pursue medical licensure on our own. Rather than having two separate entities working out of the same building, we’ll just employ the staff. That’s when we hired our family nurse practitioner that first started seeing people.
From Transition to Stability
VALANT: Was the transition from contracting primary care to bringing it in-house a big change for Spectrum?
AR: Yes, that was revolutionary at the time. People weren’t doing that in behavioral health and in community mental health, at least in Arizona. We got medical licensure and employed a couple of providers. We expanded our service delivery to include 400 SMI clients rather than the 99 that we were focusing on. Again, it just wasn’t enough scale to sustain.
Around that time, we became aware of a practice in our area that was retiring, and it was a well known, well liked, well established, full service community primary care practice. The owner approached us and wanted to know if we’d be interested in buying his practice because he knew that we were trying to launch into providing physical health. In 2012 we acquired that practice, which came with five providers and a patient count of about 6,000 people that served the entire community; not just focused on Medicaid. We felt that would give us the scale that we needed to continue to be able to do what we were doing.
With any merger and acquisition, companies tend to have the financial process and the due diligence down pat. It’s a tried-and-true process, but what’s largely ignored and neglected time and time again is the attention and sensitivity that needs to be paid to merging two cultures, and that’s what was lacking when we acquired the primary care practice. I think the mentality was, we’ve been successfully running a behavioral health company for all these years, why will primary care be any different? We’ll just acquire this practice, wall all these providers in together into this fully integrated facility, and we’ll call it good and they’ll all get along. And because they’re doctors, of course they want to do the best for clients, but it turns out that wasn’t necessarily the case. I don’t think we really explored the providers’ comfort level with seeing most of our clients, what they think about treating people living with serious mental illness, or what they think about what the behavioral health side is trying to do. When I took over there was a joint vision, but beyond the vision there was a chasm between teams. Despite the fact that we were structurally integrated, there was not really integration occurring in the way that we intended as a company. They coexisted in the same building but they weren’t getting along.
VALANT: Was this reflected in any way in your data that you collected?
AR: Well, that was another problem. We didn’t have any data. There was no data. We had these two EMRs that didn’t talk to each other. We were basically providing two different services under the same roof without any sort of bridge between the two and we didn’t have any way to measure that from a data standpoint. We were data poor on the management team.
We knew anecdotally that we were having an impact because we offer both things under the same roof but we couldn’t really demonstrate that. So, we just had to do a lot of regrouping. We had to hire a lot of new people. We had to figure out what data we wanted to collect and why and how we were going to use it, how we’re going to educate everybody on what it meant, and how to structure things so that we could get this back under control.
VALANT: This was all happening when you transitioned into your role as CEO?
AR: When I became CEO, there was a lot of change happening: all of our regional behavioral health authorities were up for bid, and we didn’t know if the incumbent RBHA was going to get the contract. At the state level they were doing administrative simplification, eliminating some of the behavioral health oriented agencies that managed and governed what we did. And my management team turned over almost completely. A couple of those were some very tough terminations that I had to make and decisions that I had to make not knowing what the fallout was going to be, but I felt like it was the best thing, especially in our IT department. I felt that technology was going to be crucial, having the right people in the IT department and having the right infrastructure was going to be critical going forward, so we needed to make those changes.
As it turned out, the incumbent RBHA did get the contract, which helped. However, they were now not just the legacy behavioral health RBHA; they had joined forces with a corporate health plan and were now in a for-profit behavioral health authority. It changed everything. We experienced a $1.5 million funding decrease on my first day as the official CEO. We were at an operational shortfall month one of the new fiscal year under my leadership. We were dealing with this disconnect in our integrated clinic at the same time that the entire state was turning to us for guidance on how to do integrated care, and then we were entering into value-based purchasing. We had our very first contract for Value-Based Purchasing that I had to look at and sign and decide, how we were going to meet these measures and generate these outcomes.
VALANT: Wow, and you started out with a decrease of $1.5 in funding?
AR: Yes. All in our SMI program. That was probably the biggest thing. We made the decision that we weren’t going to pare back any of the great services we had put in place. I could have done what most companies would do, which would be lay off staff, cut things back to the right size so that we could net an income or we could double down on our services that we had developed with integration and work adjustment training, and then hope that we would be made whole after some time.
That was a tough decision, but we held the line and it worked out for us. And now we’re doing all these other things. I’m about to start our first major renovation. We just completed our first million dollar commercial property purchase. We’re in the middle of an acquisition that will bring us into a new market, and we’re expanding whole health care to all of our sites.
All of us, community mental health providers, agencies, we’re all like Blockbuster: Netflix is knocking on our door and we can all decide whether to double down in what we have and what’s been working all of these years and hold true to that or to invest in new markets and new strategies, and new technologies because it’s going to happen either way. What we’ve decided to do is invest and develop and break into new markets, and try to diversify our funding and break out of this community mental health mold because it’s just not going to be around.
Reporting on Integrated Care
VALANT: You were saying that your data didn’t speak to each other from physical health and mental health. Have you remedied that?
AR: Oh, yeah. We’re now measuring all of our integrated population. The RBHA in our area, the behavioral health authority, requires that we report on our population of people living with serious mental illness so we don’t just report on what’s required, we report internally on all of it. How are all of our populations doing? How is integrated care making a difference? How it is affecting our outcomes of obesity, with smoking? We’re now looking at that data. We never had that data before but every time I look at it I think this could be better or how could we be doing this differently or how can we drill down even further and people have to remind me we’re still looking at things that nobody else is looking at.
The problem is is that a lot of it has to be hand-mined out of our EMRs because they will not speak to each other. They’re difficult. You can’t just get in there and dig up whatever you want. Whatever they have is what you get. There’s an option for getting whatever you want out of it but you have to be a rocket scientist to do it, and we don’t employ any rocket scientists.
We just hired a population health manager, because we decided that we’re not going to be beholden to the health plans’ population health managers. We want to have our own because we want to dig into our health care populations, those managed by mobile crisis, and populations in the work adjustment training program. We want to demonstrate how those programs are making a difference from a hard data standpoint.
VALANT: What are the outcomes that you’ve seen so far?
AR: The entire time I’ve been in my role has been spent getting the information out of the EMRs, putting it together into a baseline because we didn’t have the data at all. All we’ve done over the past two years is establish who the people are that we want to look at, how many people are enrolled in services, how many are getting integrated care, what their health outcomes are, and what their top issues are. For our populations, those tend to be obesity, smoking, and hypertension. Then we have to figure out what they are for those who aren’t in our integrated care program.
Now we have to employ an intervention for these things and measure how that intervention has an impact going forward. There are HEDIS measures and value-based purchasing measures that the RHBA requires us to manage. I could tell you what our outcomes are with those, but what we’re trying to do is drive what the outcomes should be. Just because that’s what they want to measure doesn’t mean that’s where we feel we can make the biggest difference with our population. We want to be able to go to the payor and say, “We know that you want to measure hospital readmissions because that’s what everybody is measuring but we feel like we can make a better difference here or here”. That’s where we’re at.
Technology as a Driving Force
VALANT: Given all Spectrum has done and is planning to do, how do you see technology playing a role in your integrated care strategy?
AR: All around us there’s the latest greatest technology. You can talk to a device in your home and tell it to turn on your lights and your music and whatever. If you want to go get your haircut, you can log onto an app, schedule an appointment, you set up a profile, you walk in, they know who you are, they greet you by name, they pretend like they know you even though you’ve never been there before, and it’s the same everywhere you go. There are huge companies like Uber who have completely disrupted the market and don’t own a single vehicle.
Yet in health care, and particularly behavioral health care, it’s like technology doesn’t exist. It’s like we’re in the dinosaur ages, you can’t do anything with it and so what I want to see is… well, first of all, I want to expand Spectrum at least, Spectrum’s whole health care brand to as many markets as it makes sense for our immediate area. I think there’s a limit to the kind of growth that makes sense. I don’t want to take over the nation just for the sake of taking over the nation. It needs to make sense for the population so I want to bring that whole health care brand to our other areas. Like, why is it that we have full integration but it’s only in this one location? If we’re all about access to care and giving people what they need then we’re not doing that if they have to come into one location. It needs to expand from there.
The latest thing that we’re working on is ensuring that patients could come to our website and do a mini-health screening. If there are certain triggers that indicate that they’re of high needs, whether it’s physically or mentally, then they can elect to submit that result right then and there, which would then alert a person to contact them in that moment, no matter when it is and get them into care.
That’s one thing that we want to use technology for, but also we’re still grappling with the basics, such as being able to login in the field and document in the EMR so that our mobile staff can go into people’s homes and provide care where people need it, or mobile crisis on the scene with police officers and do hospitalizations on their laptop. There are so many barriers to doing that because of the technology that we’re constricted by.
Spectrum should have a mobile app. People should be able to go onto our mobile app and consult with a doctor right then and there. The technology exists. People are using it so we want to use that. We want to provide access to care to people when they need it, where they need it so that they’re not having to utilize expensive ineffective traditional settings, like hospitals and crisis stabilization units. That’s how you bend the cost curve and provide better care.
I see Valant as representative of that next level of technology. I see the Valant platform as capable of giving us the kind of technology capabilities that we need. It’s configurable and operated off of the same technology that’s operating a lot of the things that I’m talking about, so I feel like that’s our best hope for being able to be in this field providing care without being weighed down by the fact that we can’t login.
It doesn’t make any sense not to go with a company like Valant. The technology is so obvious to me. It’s not obvious to everybody but it’s obvious to me that it’s different and I think it will be the future, for sure. The things that Valant have are disruptive in their own right and it’s going to be. That’s what I see.
Thank you for reading our exclusive interview with April Razo, CEO of Spectrum! We hope you enjoyed her perspective and learned as much from her strategy as we did. For more interviews with behavioral health influencers, click here. And don’t forget to subscribe to our blog!