Issue 7, August 2021

Behavioral Healthcare Roundtable

What Needs to Change and How to Make It Happen

Intro: In this latest issue of Leverage Insights, Richard Lungen leads a kinetic discussion with four industry movers and shakers about the state of behavioral healthcare. At our virtual roundtable are psychotherapist Marjorie Morrison, CEO and Co-founder of Psych Hub; Patrick Kennedy, former U.S. Representative from Rhode Island, Co-founder of Psych Hub, and board member of Quartet; Arun Gupta, founder of Quartet; and Aran Ron, MD, Founder and Chief Innovation Officer at Kaden Health.

Richard Lungen: I can’t imagine a more dynamic roundtable. Thank you all for being here.

Patrick Kennedy: Thank you, Richard, for getting all the right people plugged in—like introducing me and Aran. When it comes to virtual care for people with opioid disorders, thank goodness there’s Aran and Kaden Health. But being connected with an inpatient treatment center, I see challenges and opportunities there, too. Even though we’re barely meeting the public’s demand for treatment, inpatient centers have a tough time making a go of it—and they’re triple-platinum-rated by all the major payers. A whole spectrum of services exists, but are payers—who say they’re behind evidenced-based care—willing to steer behavioral patients to the most effective treatment?

RL: Thank you for that insight. Here’s my first question: It’s 2021, and we can’t have this discussion without considering the COVID-19 pandemic, which has changed so much, including the way behavioral healthcare is delivered. What’s working, what’s not, and do you think people are getting the care they need? Aran?

Aran Ron: First, the pandemic increased the need for behavioral healthcare. A late 2020 CDC study found that about 40% of people reported serious mental-health problems such as anxiety and depression, and the number of overdoses increased from 70,000 in 2019 to 90,000. Second, virtual visits have increased from 1% to more than 60%. Third, the pandemic shifted people’s acceptance and expectations around care as it exposed system-wide disparities. Certain groups of people received the treatment they needed; others didn’t.

RL: Did age play a role here, Aran?

AR: To some extent. Different age groups accept and access telemedicine more easily than others, but socioeconomic status most determines people’s access to care.

RL: Arun?

Arun Gupta:I agree. We’ll look back in five or ten years and see this as a watershed moment for how we redesigned and reinvested in mental health. Needs have increased dramatically. And though for a long time people have been trying to unlock telemedicine as a care pathway, the pandemic made it happen. The growing demand has shown us how inadequate the current system is. People are increasingly seeking care for clinical mental-health conditions like opioid-use disorders, depression, and anxiety. A whole burgeoning subclinical or pre-clinical set of people are also seeking therapy. In many cases, thanks to the telemedicine revolution, they’re finding it, but this, too, puts more demand on an already inadequate system.

The pandemic has also shown us that we need to update our licensure regulations and reimbursement pathways, which remain a burden for providers who want to practice in technically forward ways. Providers using digital medicine and telemedicine, as well as digital therapeutic and self-serve programs, need to be treated like first-class citizens. Just lowering rates year after year and hoping we have an adequate network at the end is not smart economics.

RL: Patrick, especially in regard to regulatory issues, do some of the temporary changes that were instituted during the pandemic become permanent? I’d love your insights on what’s working and what’s not.

PK:

As you know, Richard, I think we’re a long way from being through this public crisis. I agree with Arun—we have much to do to advance this whole space because we’re truly playing catch-up. As an advocacy community, we don’t have the clout of the American Heart Association or the American Cancer Society. They say, “We want this covered, and this is what’s going to happen at CMS [Centers for Medicare & Medicaid Services]”—and it does, quickly.

Years ago, we invited Patrick Conway, the current CEO at Optum, to an event at the Kennedy Forum where we were pushing collaborative-care codes. He told me that he hears about all the specialty networks except for mental health. While everyone was at lunch, he asked me what I wanted him to say about codes. And because we had a bunch of payers at the meeting, I said, “Well, you could say that you’re going to move forward with collaborative-care codes.” When everybody was back, that’s exactly what he did. Immediately, everyone on the payer side was on their phone calling the home office about potential changes to the way CMS reimburses for mental healthcare. The point is that we all need to focus on and advocate for change.

Value-based purchasing will elevate mental healthcare because everything’s been squeezed into the physical side, and mental health’s value proposition, so to speak, hasn’t been exploited. Two related points: The fact that mental health was thrown out of the house of medicine is part of the original sin of this crisis. During the pandemic, we could have set up a parallel mental-health response where we screened people for depression and anxiety as they were screened for COVID.

As a nation, we could have doubled down on the notion that COVID is a virus that created a mental-health crisis, and that you can’t address one without addressing the other. But we’ve been challenged just to get people vaccinated. We need infrastructure, for sure, but none of the $8 billion appropriated for 100,000 new public-health initiatives are earmarked for mental health. We need to tell HRSA [Human Resources & Services Administration] that community-health workers must be proficient in mental health.

And kids? We know that 75% of mental illnesses begin before age 24, with the youngest kids affected most. We don’t offer social-emotional education or teach problem-solving to help kids deal with stress. Nor do we have trauma-informed education. We can’t address the flood of new cases unless we meet the needs of those suffering already. To Arun’s point, we need greater reimbursement.

RL: Thank you, Patrick. Marjorie, as you ingest all this for your amazing scientific advisory board, what’s your point of view on what’s working and what’s not?

Marjorie Morrison: Yeah, we’re at a watershed moment, and the greater access to telemental healthcare, regardless of issues with state lines and licensure, is a breakthrough. But, to Aran’s point, the pandemic has created more demand on an already stretched system, and where we’ll end up, I believe, is with tiered treatment. Everybody wants to see the best of the best, but not everybody needs a licensed mental-health provider. We need to address this.

Psych Hub is in the upskilling business, but we’re still not going to have enough providers to meet demand. What we can do is leverage coaches and peers and build a tiered model where people are better matched to their current needs. Let’s take a step back, so we can fairly reimburse providers who are working at the higher end of the scale, working with more complex cases, doing more evidence-based interventions—which is what Psych Hub is involved in.

Psych Hub is in a unique spot. We’re fortunate to have the chief medical officers of behavioral health from all the national payers on our scientific advisory board. The group is looking at quality-outcome measures. Everyone’s rolling up their sleeves—and they have some very strong opinions. Together, we are developing different, simpler ways to assess how a mental-health patient is progressing in treatment. If we can’t demonstrate progress, we can’t get higher reimbursements. Payers will pay for quality, so we’re working on that and hope the outcome benefits everyone, not just Psych Hub. If all the payers agree on this, it will become the standard.

RL: Speaking for an organization that’s mostly payer-facing, I think behavioral health offers one of the industry’s best examples of multi-payer collaboration. My next question takes us to the provider side. So, Arun: With the need for behavioral health outstripping the availability and capacity of providers, how do we make care more available and effective? It seems Quartet was built on this issue.

AG: Yes, there’s a sound business case to be made here for inexpensive innovation. Patrick talked about the collaborative-care codes—amazing idea! Frontline mental-health care in primary care is an absolute necessity. It’s low-cost, and the way every other medical specialty under the sun works. Primary-care physicians should all screen for and initiate care for core mental conditions—8% or 9% of people have generalized anxiety disorder, 7% have depression. Physicians care for these people but currently aren’t reimbursed. That’s bad medicine, bad economics, and bad for society. These codes that cost $10 or $15 as an add-on to a visit won’t break any payer’s bank.

However, when these codes are implemented, the patient copays for an interaction they weren’t necessarily a part of. We need to fix this. As Patrick and Marjorie were saying, mental-health providers need to become a valued and integrated part of the healthcare system. Modest costs will lead to big ROIs. For instance, the scaled, specialized telemedicine models for opioids—as Kaden’s doing—that leverage telemedicine and data are more patient-centric and deliver better outcomes.

We also need to invest in digital medicine and therapeutics to match already existing needs. Frankly, Patrick, many people look to you to get this done.

RL: Aran, as a founder of Oscar, the first insurance company to bring digital care to the individual, and as a co-founder of Kaden, how would you answer this question of availability versus capacity?

AR: Yes, the industry’s capacity is already outstripped, but, as Arun says, the economics are compelling, particularly from a health-plan perspective. Of the top 10% of the highest-cost patients, around 50% or 60% have some mental-health disorder. Addressing that population alone is important, as well as economically attractive. The onus is on the plans to incentivize more professionals to provide these services through value-based arrangements or better-structured codes, and to deconstruct the artificial silos of behavioral and medical healthcare. Frankly, at Kaden, we’ve struggled to get payers to see to that this artificial separation in the benefit structure is nonsensical and costly.

RL: Marjorie, would you weigh in a bit more on the disparity between need and availability?

MM: As a behavioral-health provider trained in theory—not in evidence-based intervention—I may have a different viewpoint on mental-health parity, which is Patrick’s great advocacy. Therapists can work with clients for very long periods of time as they uncover deeper issues. Many evidence-based interventions are more effective at treating diagnoses and symptoms. If we could persuade more mental-health providers to use these interventions, their patients would progress through treatment more quickly, addressing the issue of access. That’s why Psych Hub trains providers to specialize in evidence-based mental healthcare.

Providers who hone their craft and use this precision approach, along with giving patients tools to keep things moving between sessions, are able to treat people with fewer sessions—and since nobody wants to be in therapy forever, we see better outcomes, which reduces the cost of care. We line up incentives, and we piggyback with other types of healthcare.

RL: Thank you, Marjorie. Patrick, take us home on this issue of need and availability.

PK: Of course, Arun made the point well: We’re leaving a lot on the field if we don’t convince the existing medical establishment to do more in mental health. We need to train people to deal with mental-health issues. To me, it’s malpractice if an oncologist isn’t addressing patients’ depression and anxiety. To Aran’s point, people have this siloed view: “Well, the mental-health profession will handle this.” Ultimately, this is Psych Hub’s mission: Give every provider the tools needed to address mental health.

Back to kids: Providers need the skill sets to address the self-destructive patterns of thinking and counterproductive behaviors that often lead to serious mental illness and addiction. These could be mitigated by people with the skills to help kids turn off their negative feelings and turn on proactive feelings. We need to replace the current trial-and-error approach and teach these coping skills universally, and early on. Everyone should have these fundamental cognitive-behavioral tools—everyone.

RL: Great response. Now, I know you’re all investors and entrepreneurs, and on boards, and therefore start with certain biases, but I’ll ask anyway: How would you rate the tools, technology, and innovations generally available today to healthcare professionals and consumers? Marjorie?

MM: As we’ve said, the integration of innovative digital therapies is encouraging. For some people, these therapies are great. But patients need to take part in their process. Most patients walk in and are, like, “I’m suffering from depression, fix me.” It’s why we love cognitive-behavioral therapy at Psych Hub, and why we give people homework. We hook up providers with all the tools we have, and they give those tools to their patients. This is taking us in the right direction. That said, we need better feedback. Providers need to know, if not in real time, then in a short time, how their patients are doing so they can adjust treatments appropriately. Payers need to have that feedback, too. To get the most from digital therapies, we need to use the feedback we receive to impact and reinforce treatments and outcomes.

RL: Patrick, then Aran . . .

PK: What’s missing in my view is something you wear, like a Fitbit, that collects passive data. When I was 17, and out of the first of a dozen rehabs, I wish I’d had an app that said to me, in essence: “If you want to maintain your sobriety, it’s critical you get off to a good start. You’ll need a whole support system, including family support, so that we can better intercept when you’re at risk—when you’re spending too much time in a sedentary state, or too much time alone, or you’re somewhere that consistently triggers problems.” Voice modulation is another clue. Signatures of depression and early psychosis can also be found in the repeated use of language in social media.

In addition to a Fitbit-type profile, we could put together strong biomarkers, match them over time with bigger data collection, and see generally what people’s stability durations are and where their instability occurs. Then, to return to the earlier point about finite resources, we could be a traffic cop and get people support as they reach crisis, intervening before they fall off the edge.

If we want to move past regulatory and punitive approaches of parity and get people what they need, we need more innovative solutions. In Rhode Island, we have payers contribute to a public-health fund that pays for what none of them would pay for individually. This is more like the equivalent of inoculations or mental-health-and-trauma-informed care. It produces healthier subscribers for all the payers, no matter the subscriber or plan. That solves a problem that most payers have: they never see the return on their initial investment.

AG: Payers are asking for innovation. They’re acknowledging that they don’t have good models, but that they want to consider the total value proposition. They’ve invited us and other folks to help craft these models. We can’t mess this up, because it will shape the reimbursement paradigm for decades. To your question about tools, Richard: As Marjorie said, we need providers to offer the clinical data aggregation—the pathways to evidence-based care.

On the consumer and digital sides, we still force people through bad care pathways. If you show up in your doctor’s office talking about sleep issues, you’re 30 times more likely to walk out with a script for Ambien instead of getting referred to a therapist for high-quality cognitive-behavioral care or getting an evidence-based digital therapeutic that has no side effects. We lose and the drug industry wins. We need to claim more of that victory for our patients. (There are, by the way, digital therapy apps that can be effective.) We need to reimburse for other forms of care and make them more readily available. Without access to these other options, the consumer is not well served. We need a reimbursement paradigm that elevates them to parity.

RL: Thank you, Arun. Before I ask a closing question, what are your thoughts, Aran?

AR: We do need passive capture of data. There are companies that measure people’s voice intonations and visual facial changes to determine depression, anxiety, and other conditions. If this technology and virtual interactions become more universal, we’ll suddenly have a way to measure outcomes and can begin to compare providers, therapies, and various interventions.

RL: Last question: Where do you see all this headed in two years or five years? How would you sum up the future of behavioral health? Marjorie?

MM: Patrick and I have a podcast, “The Future of Behavioral Health.” We’ve talked about this being an inflection point. We need to be careful that these new innovations move us forward, yet we don’t want to get stuck in analysis paralysis. In response to Aran’s point about new measurement technologies, I’d like to say that we’re going to get ourselves into trouble if providers feel they’re being judged or graded. We can’t afford to lose any of them.

We need to meet providers where they’re at and respectfully nudge them toward evidence-based interventions and outcome collection. The work is laid out for us all, and many of us in this space are collaborating.

RL: Thank you, Marjorie. Aran, your thoughts?

AR: I can think of two peripheral factors that may greatly impact behavioral healthcare in the next few years. One is the move from a pure biomedical to a more social-psychological approach. We need to consider how we treat a patient in a community situation. How are food, housing, and other things affecting their well-being? And we haven’t talked about psychedelics, which are certain to play a role. Early research shows they’re very effective in treating PTSD, depression, and anxiety.

RL: I like that perspective. Arun, you’re next, then Patrick.

AG: As the stigma of behavioral-health care recedes across society, we’ll absolutely need to invest in providers and enhance reimbursements. It’s a very promising time. We’ll have new methods of care that are technology-enabled, and new forms of therapy. How we do this seminal stuff will shape the industry for the next 10 or 20 years.

RL: Thank you, Arun. Patrick, you’re a futurist—give us your point of view.

PK: If I were still in Congress, I’d say: I associate myself with the remarks of my colleagues. Arun, Aran, and Marjorie really put it together. There’s a lot of excitement around mental-health care, mental-illness care, behavioral-health care, and everything on the continuum. In the future, behavioral health will not be only for the healthcare system, but for the education and criminal-justice systems, and for our workplaces.