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Org or email them partnerships at. Thank you life. Org thank you life healing through accessibility. This is the practice of the Practice podcast with Joe Sarna, accession number 1044. Joe Sanok 00:01:26 I’m Joe Cenac, your host, and welcome to the practice of the Practice podcast. I am so excited that you are here with me today. we have a great episode ahead of us talking about access to psychiatric, services, all sorts of things. We have Doctor Tamir Eldad, who is the founder of Mindful Care. He founded that in 2018 with the mission to bring the urgent care model to mental health. Under his leadership, the company has created the first ever chain of psychiatric urgent care clinics offering same day in-network medication management therapy and substance use counseling. Mindful care operates via telehealth in 14 different states, and also Doctor Aldred holds an MBA from the University of Chicago Booth School of Business and an MD from American University of Antigua College of Medicine. Welcome to the practice of the Practice Podcast. Tamir, how are you doing today? Dr. Tamir Aldad 00:02:25 I’m doing well. Thanks. And thank you for having me. Joe Sanok 00:02:28 Yeah. well, I love that we’re talking about access to psychiatric care, because I know that when I worked at Community Mental Health, when I had my private practice, that was always in Northern Michigan. Joe Sanok 00:02:40 One of the hardest things to to figure out. So take me through kind of the problems you see. And then I really want to hear more about this psychiatric urgent care model. but yet talk about the typical problems in the psychiatric world first. Dr. Tamir Aldad 00:02:55 Yeah. So by training, I’m an addiction psychiatrist. And then during residency and fellowship, found that access to care was a major issue. We had patients coming to the emergency room at the time, trying to find an appointment with a psychiatrist. Everyone that accepts their insurance either had a 6 to 8 week wait or wasn’t accepting new patients, and their symptoms worsened because they had no access to care. And then they would come to us and either they would meet criteria for inpatient hospitalization, or we would have to send them back out to the community and have them continue waiting. And I found that to be really frustrating, unacceptable. And I was disappointed that I had patients that we could have prevented their mental health from deteriorating, but instead, due to a lack of resources, this was the best we could do. Dr. Tamir Aldad 00:03:49 And after I, finished residency and fellowship, I was committed to finding a solution where the same way we triage patients in the emergency room, patients could be triaged elsewhere, connected with resources, and given a chance to intervene when they think is the right time and when they’re reaching out, rather than waiting weeks and taking the chance of doing worse. Joe Sanok 00:04:16 Yeah. So I know that it seems like when there’s limited psychiatrists, obviously, like there’s big waitlists. So as you see, things get worse. what were some of the things that, you know, like, for example, you said people maybe needed longer inpatient than they would have had they been seen. What were other ramifications you saw of people not getting access to psychiatric, care? Dr. Tamir Aldad 00:04:38 So the biggest story that I usually tell was of a patient that, came to us after she came home from college. She found that her mom and her younger sister were in the bathroom. The mom had overdosed on heroin. the sister was trying to call for help when she came home. Dr. Tamir Aldad 00:04:58 They were all rushed to our hospital at the time. The mom was pronounced dead and the older sister was pretty traumatized, but didn’t meet criteria for hospitalization. So we we sent her home with resources and told her to come back if she feels worse. And we found out three days later she died by suicide herself. And it is a real risk that if we don’t have resources and people can’t speak to a mental health professional and understand how to get care, where to get care, it could end with them being a danger to themselves, a danger to others. They can. If they have a history of substance use, they could relapse. They could pick up substances and self-medicate. So there are very serious consequences. And what we’re doing as clinicians, you know, before we created mindful care, is just trying our best because we’re working within a pretty broken system with reimbursement rates that are definitely challenging. We’re not properly incentivized. and the demand is extraordinary. So it doesn’t make sense to to lose money when patients are willing to pay cash. Dr. Tamir Aldad 00:06:17 So if anything, the system encourages us to focus on the patients that can afford care. But what happens? There is a huge portion of the population is neglected, and that’s who we sought to target, you know, where is the if anything, it’s more of this kind of bimodal distribution where you have, access to people who, let’s say, have straight Medicaid and have resources there, and they can go to different social services. And then you have people who can afford cash, but the hard working middle class then is supposed to go where? And that was the question we wanted to answer. Joe Sanok 00:06:59 Yeah. And I feel like the people that this is true in the counseling world to where those that you know are good and get full oftentimes then start to think to themselves, well the hardest insurance is to work with the ones that pay the least. I’m going to start to move off of, then they end up on just the higher paying ones, and then they move into private pay, and then the access, oftentimes isn’t there, for when you started to brainstorm how to address this, doing psychiatric urgent care clinics that offer same day in-network medication management to me. Joe Sanok 00:07:36 I would just think that you would be full all the time. So, like, how did you structure this out? And, like, take me through what that looks like. for the average, patient that’s seeking help. Dr. Tamir Aldad 00:07:49 Yeah. So the model required a lot of engineering in terms of because we accept Medicare, Medicaid and commercial, how are we able to get these patients through in a way that’s compliant? and we’re giving them access to care, and we’re providing best in class service in terms of evidence based medicine, that’s clinically sound. while not becoming just another practice that’s fully saturated. Right. That’s you have, so many components there that you have to navigate to to build the model, which is what we spent so much time doing, I would say, without getting into into too many details, because logistically there’s there’s a lot that goes into it. the goal. The primary focus is triage. another component is the length of the visit. Another component is, the clinician licensure depending on the acuity and complexity of the case. Dr. Tamir Aldad 00:08:48 so we the primary thing first is getting the person in to be triage, right. And assessing the acuity of the case so we could get someone to see a mental health professional. Same day next. They were very committed to that. We don’t want anyone to wait 6 to 8 weeks like they would otherwise. And then from there we assess, depending on the acuity of the case, where do they best belong, with what type of licensure level, with what level of frequency? With what length of visits, right. A lot of times if you go to private practice, they’ll just do 45 minute sessions or one hour sessions or 20 minute follow ups. We don’t do that. We have different types of sessions with different types of clinicians of various lengths. So it is a game of chess. You know, I would say that it’s it’s challenging, but we’ve been playing it for five and a half years now. And last month we had 30,000 visits. And it’s pretty, pretty incredible to to know that these people could have, you know, perhaps not, but could have deteriorated, and could have had to go to the emergency room when they didn’t really have to or might have been admitted to the hospital when they really didn’t need to be hospitalized. Dr. Tamir Aldad 00:10:00 So preventing all that is certainly something we’re committed to. And if you look at the health care system, we’re decreasing the total cost of care. So if you’re familiar with like shared savings model and value based care, which is a hot topic now, and in assessing what is the value add to the health care system, we’re significantly decreasing the total cost of care, preventing an unnecessary psychiatric hospitalization, preventing an unnecessary psych er visit. that’s huge. So there’s there’s upside across the board. Joe Sanok 00:10:36 Now for these kind of models. you know our primary audience is therapists, psychologists, counselors in private practice. if they’re thinking about this, what what could they do from either just a mental health access or bringing something like this to their community? Like, what would you say is, is applicable for private practitioners that want to advocate for different models of psychiatric services in their communities. Dr. Tamir Aldad 00:11:04 So we work very closely with therapists, mindful care, even though we do, we have a product called micro therapy, which is 20 minutes, solution focused therapy as needed. Dr. Tamir Aldad 00:11:17 we have group therapy. We have med management. What you’ll notice is we don’t do one on one long term individual therapy. And the reason we don’t do that is out of respect to our referral sources. A great portion of our patients come to us from therapist who provide individual therapy. and we thought it would be really poor sportsmanship if we start offering the same product that they offer. So, as a thank you to our referral sources and our partners, we We will never provide that. so as long as we continue to, to work kind of symbiotically in that sense. so what I think to answer your question is, in these communities, having a resource like ours is huge because therapists can focus more on doing what they do best, which is providing therapy. and they have the security of knowing that in the event that a patient decompensated relapses, signs and symptoms worsen, they have a resource where they can send the patient to see, a psychiatric professional to evaluate if a higher level of care is needed, if detox or rehab is needed, if med management is needed. Dr. Tamir Aldad 00:12:30 so having a resource like ours in in all communities, which is at the end, our goal is to have a positive impact on the mental health crisis. It would go a very long way because I know many therapists, in the back of their mind, navigate their patient’s care through the lens of intervening early. and there’s almost this, focus that that distracts you from providing good care and. Well, should I reach out to a psychiatrist now? Because in four weeks or six weeks or eight weeks, this individual might need to see a psychiatrist. That probably is not the best way to to see a patient. Right? If you’re if you’re seeing a patient, you’re thinking about planning for 6 to 8 weeks from now versus knowing that if we get there, we’ll cross that bridge when we get there? the quality of the care is very different. Joe Sanok 00:13:26 Yeah. As a therapist, I can tell you from experience that having the right EHR is an absolute lifeline. I recommend using therapy notes. 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When you think about what you’ve seen change as a result of offering this. are there any things that have surprised you in that process? Dr. Tamir Aldad 00:14:51 In what sense? Joe Sanok 00:14:53 just in regards to, you know, I mean, kind of the the old model of, you know, people just having a private practice and people are on a waitlist for 6 to 8 weeks to get in. Joe Sanok 00:15:04 and then, you know, offering this psychiatric urgent care model, are there just unexpected things that in creating a new approach to psychiatric care, that have surprised you, whether that be outcomes, reactions? just anything that surprised you? Yeah. Dr. Tamir Aldad 00:15:20 Yeah, yeah. Anything in general that surprised me? I would say it’s been refreshing to see patients come, proactively. Right. Meaning I just lost my job. My girlfriend broke up with me. I’m going through a divorce. Not really sure if I should go to therapy or see a psychiatrist. it’s nice to have somebody come and proactively look into it, and then you tell them, hey, you know, your reaction is actually really appropriate and see how you feel in a couple of weeks. But you seem to have good coping skills, strong protective factors, a lot of social support. You probably don’t need anything right now. See how you do in a few weeks and come back to us. Or, you know, it sounds like you really are going through some sort of adjustment disorder or really are in crisis. Dr. Tamir Aldad 00:16:10 We would love to help you, but I think I’ve been pleasantly surprised to see people use our services proactively, because I feel like that’s how it should be, right? It shouldn’t be when, almost when it’s too late or about to become too late. That’s when you start worrying about your mental health. The same way if you go for routine, visits at your doctor, or you have some aches and pains and you go look into it. subtle. We’re starting to see people with even subtle symptoms come to us, and it’s refreshing. You know, it’s it’s nice to be able to tell someone kudos for taking your prioritizing your mental health and happy to tell you that you’re actually responding. You’re responding appropriately to the situation you’re in, and And I don’t see an issue here versus I do see an issue here or let’s intervene. You know, it’s it’s nice to be able to have that conversation versus what has historically been very reactive with like hysteria. You know, that’s kind of been the what we’re trying to deal with in the hospital. Joe Sanok 00:17:17 Yeah, yeah. And then you’re not really kind of making your way upstream to look at what’s causing these things. Instead, you’re just putting out the fires. You’re helping people that are in such a tough situation. and then giving, you know, 15, 20 minute follow ups once in a while. I imagine that it seems like it’s more comprehensive care overall when you’ve done this, when you have the psychiatric urgent care clinic, is that so? Do people then follow up with you after that, or is it really kind of meant to be in between sort of er and a general psychiatrist? Dr. Tamir Aldad 00:17:54 No, no, we provide the ongoing care as well. So you’ll have the, urgent care mental health assessment, which is a basically a triage visit. And then based on that, the acuity, the severity of your symptoms, the type of care that you need, we will provide ongoing follow up care, but all of it is a lot easier because people are coming to us sooner, more informed with less pressure. Dr. Tamir Aldad 00:18:20 So it from the beginning feels a lot more holistic and comprehensive versus, like you said, you when you’re in the emergency room, you just try to find the biggest fire, the biggest problem and address that And maybe some maybe, maybe someone else down the line will. We’ll figure out if there are any underlying causes. Joe Sanok 00:18:42 Now I’m just thinking about how if I knew that I could, you know, see someone that quickly and then get in. I feel like that practice would just be so full all the time. And then the very thing that you’re trying to stop and that’s like having a giant waiting list, would then be created. are you finding that? And like, what do you think you’re doing? I guess my real question is like, what are you doing that is removing that barrier? Is it that you just have enough psychiatrists, that you have enough openings? You’ve automated it through like online? Like what? Like what are some of the things that like. Dr. Tamir Aldad 00:19:21 Yeah, it’s all it’s all the above. Dr. Tamir Aldad 00:19:23 It’s having constantly hiring to to remove any bottleneck issues and maintain throughput. It is having various levels of licensure. So, you know, you don’t always need sed or FD to provide therapy. So using various forms of therapists, even on the med management side, not just using an MD or a Do, but introducing psychiatric nurse practitioners, physician assistants to help with prescribing, depending on the acuity and complexity of the case. so various types of licensure, various appointment lengths, various appointment types, various appointment cadences. So it is it’s basically modeled around a making sure you constantly have staff. Right? So we’re constantly hiring as we grow and as we scale and there is extraordinary demand and then optimizing, not not treating every case and every patient and every appointment, as cookie cutter. And then, it’s like a game of chess that you’re constantly trying to move a bunch of parts and or Tetris. Let’s say that you’re trying to move a bunch of parts and making sure they’re constantly fit. So if someone does need to be seen same day next day for an evaluation, you can get them in. Joe Sanok 00:20:42 I want to pose a hypothetical. Imagine a bunch of in. This probably would never happen, but imagine a bunch of big insurance companies came together and said, Tamara, we want your help in sorting out this psychiatric mental health crisis and access in America. Help us restructure how things are done. Barriers that are unnecessary other than just saying like kind of what you’re doing, let’s do more of that. You know, through mindful care. what other systemic things do you think need to happen to improve access to psychiatric care? Dr. Tamir Aldad 00:21:14 I think you just got to open a lot more mindful care centers. No. I’m kidding. that that is that isn’t really the solution. because mindful care effectively had to. We came up with the idea, we had to navigate what I felt was a very broken system. So even even if as a joke, we say just open a ton of mindful cares, that doesn’t solve the problem at the at the root, I think at the root, the reimbursement structure is very, very discouraging. Dr. Tamir Aldad 00:21:50 you know, I work with residents and new grads. They’re not incentivized to pursue in, in network care. and the fee schedules and the fee for service reimbursement structure, in and of itself, doesn’t prioritize mental health. So I would say if we really wanted to move the needle. And I wrote an op ed about this, I think last year we really need insurance companies and Medicare Medicaid to acknowledge that these fee schedules are a priority and acknowledge that if people, you know, take their mental health seriously and we want doctors to to take the patient’s mental health seriously. Reimbursement needs to be competitive. And then from there, I think we’ll see a lot of physicians accepting more in-network patients. and then giving these patients the care that they deserve. I’ll give you an example. We had a fee schedule in Florida that we were negotiating. And for 40 minutes of therapy, the the fee schedule had $14 as the reimbursement. So for $14 for 40 minutes of therapy, that means if you, correct that to an hour, right, you’re looking at $21 for an hour of therapy. Dr. Tamir Aldad 00:23:21 Now, keep in mind you’ll have to you have to cover your overhead, your EHR system, your rent, your electricity. So that means we need to hire a PhD or side psychologist at the 16 to $18 an hour range. And I think that’s that might even be illegal. I don’t know what minimum wage is in Florida, but that could even be below minimum wage. So whoever’s doing the math, right, where am I supposed to find psychologists in Florida willing to work for $16 an hour? And these people have SIDs and they’re in debt, or they have PhDs. And the math just doesn’t make sense. So I would say, if you’re asking me systemically, what do we fix? It’s making in-network reimbursement competitive. So people are properly incentivized. Joe Sanok 00:24:07 Yeah. Joe Sanok 00:24:09 Yeah. It’s like you look at, you know, different aspects, all sorts of different aspects of medicine or medical and, you’re looking at all the different ways that things are billed, you know, like I was in the hospital and there’s every little thing gets to be billed, and in the counseling world that that’s often really difficult to, to figure out. Joe Sanok 00:24:26 And in the psychiatric world, and to even negotiate with these companies. So I’m glad that you’re at the forefront of all of this. my next question is the last question I always ask if every private practitioner in the world were listening right now, what would you want them to know? Dr. Tamir Aldad 00:24:41 I think the most important thing for a clinician, and I try to remind myself of this every day, is to go back to your admission essay to grad school and remember why you went to grad school in in the first place. And what was the reason that you wrote there? what inspired you to become a clinician? You know, a lot of times, I think the system really, impacts our perspective. And I think we need to stay true to. If we took an oath. What was that oath? And and remember why we’re doing this, and why we went into the into the world of patient care and clinical care to begin with. Joe Sanok 00:25:27 Well, it’s amazing what you’re doing serving over 30,000 patients a month, in, you know, 14 different states. Joe Sanok 00:25:36 to me, or if people want to connect with you, if they want to connect with mindful care, where should we send them? Dr. Tamir Aldad 00:25:42 Yeah. We’d love we’d love to connect with, clinicians. Feel free to visit us online at Mindful Daycare, or reach out to me or anyone on my team and we’d love to work with you. Joe Sanok 00:25:55 So awesome! Thank you so much for being on the practice of the Practice podcast. Dr. Tamir Aldad 00:25:59 Absolutely. Thanks for having me. Joe Sanok 00:26:10 Well, we have covered a ton of different series, throughout this summer. we kicked this summer off back in May with our psychedelic assisted therapy series that we did, interviewing ten different practitioners, legal analysts, people that were talking about access to services. So if you missed that, that kicked off back in episode 989, then we had our summer series on Movers and Shakers, really kind of big name people that were doing things, people that were working on, you know, different ways to, to think, different ways to grow. we talked to Goop Lab founder Elisa Lohan, and we talked to a few different other people that were during that series. Joe Sanok 00:26:52 then we had, you know, our Level Up Week series that was going just right before, these couple of episodes. So all those episodes, all those trainings we did back in the spring of 2024, a lot of you weren’t able to attend those live, but we we talked about starting a group practice. We talked about staying motivated. We talked about how to transition between your tasks day to day. what kind of things should you be using for your marketing, your networking? all sorts of different things. So make sure you check out those series if you’ve missed it. We’re doing again, right now, looking at the calendar looks like seven days a week. We’re kicking this thing. So doing lots of interviews and so excited that you’re hanging out with us. And we couldn’t do the show without our amazing sponsors. Therapy notes has been one of our sponsors since, near the very beginning. They are the best electronic health records out there. they have all of your telemedicine in there. You can have credit cards on file. Joe Sanok 00:27:44 they they’ll have people that help you transition from wherever your EHR is right now. and it’s real live people that are helping you. It’s not just chat bots. It’s not just, you know, texting with people. It’s an actual person. It’ll jump on the phone and help you out. so love therapy notes? Head on over to therapy notes.com. to read more about them, use promo code Joe at checkout so that they know that their podcast money is working, but also to get that discount that they offer you. Thanks so much for letting me into your ears and into your brain. Have a great day. I’ll talk to you soon. Special thanks to the band. Silence is sexy for that intro music, and this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither the host, the producers, the publishers or guests are rendering legal, accounting, clinical or other professional information. If you want a professional, you should find one.