One of the biggest problems that still exists in healthcare today is integrating mental health services into medical care. There are a myriad of reasons why this has proven to be so challenging, from access issues, to a shortage of mental health providers, to primary care practices treating behavioral health as just another specialty accessed by referral, often leading to patient no-shows. Put all together, industry stakeholders have all been overwhelmed by the massive scale of the mental health crisis, which has only grown during the COVID-19 pandemic.
Behavioral health disorders, of course, affect millions of Americans; in late June, the CDC reported that 40 percent of Americans were struggling with mental health or substance abuse issues. What’s more, these disorders are often associated with physical co-morbidities such as diabetes and heart disease, according to the American Hospital Association. Fortunately, there is now a large body of evidence that supports the importance of integrated models of patient care, which bring these two areas of health together.
To this end, Tridiuum, a provider of digital behavioral health solutions, recently convened an industry roundtable to discuss the critical need to accelerate adoption of an integrated, technology-driven approach to behavioral healthcare in 2021 and beyond.
From the roundtable, four leading voices in the integrated behavioral healthcare movement produced a whitepaper, sharing their perspectives on the opportunities to bridge the gaps in care delivery and accelerate the development of a proactive approach to whole-person healthcare. Healthcare Innovation’s Managing Editor, Rajiv Leventhal, recently spoke with those executives: Katy Caldwell, CEO of Legacy Community Health, a Houston-based full-service, federally qualified health center; Michael Lester, CEO of LifeStance Health, a Bellevue, Wash.-based behavioral health services provider; Marjorie Morrison, founder and CEO of Psych Hub, an online platform for digital mental health education; and Mark Redlus, CEO of Tridiuum. Below are excerpts of that discussion.
At a high level, can you detail the impetus behind the roundtable discussion, and the importance of convening around this issue?
Redlus: The roundtable was a response to the continued challenges that I believe we’re all seeing [around] the lack of presence of behavioral health as part of the integrated clinical experience between patients and providers right now. We’re missing a lot of patients [in the system], and [we have] a lot of incredibly challenging problems leading to outsized costs, dragging down peoples’ overall health and wellness, and without care being deeply integrated, it’s a real struggle to make a lot of progress in total cost of care and outcomes.
Lester: I would argue that pre-COVID, mental health issues have been headline news for the last few years, and now COVID has just exasperated that, almost exponentially. The stigma has significantly diminished for people seeking out mental healthcare services, but the need continues to increase, and access has been a problem. For 45 percent of the country, clinicians are in the cash-pay business versus accepting commercial insurance, limiting access for patients. There is a body of research out there in the market today demonstrating that good mental healthcare significantly lowers overall medical care costs; it lowers cardiovascular care and diabetic care costs, for example, and those are the big dollars in healthcare. So everyone wins when there’s a focus on mental healthcare—the clinicians, the patients, and the system wins in lowering costs.
Caldwell: Legacy Community Health has had mental healthcare co-located with primary care for more than 20 years. So we’re still moving in the direction towards integrated care. The biggest issue we deal with is first around training our providers to make sure they absolutely understand mental health. We still have a lot of young physicians even who tell us they haven’t been trained in medical school or residency to deal with mental health issues, other than what they have seen in emergency rooms. The other piece is that we are still very much in a fee-for-service [environment], and when you integrate it all with one visit and one provider, you get one fee, no matter who the payer is unless you’re in a value-based contracting environment. We are moving toward a value based environment, but we aren’t there yet.
One of your big takeaways from the roundtable is that healthcare is far from reaching a truly integrated approach with behavioral and clinical healthcare. What needs to happen to make that vision become a reality?
Morrison: Michael hit the nail on the head when talking about these greater costs and preventing a problem. Mental health is that first important step. I come from the lens of training, and I would say that what really could drive change is if we actually had providers acting more as specialists, trained in evidence-based interventions on the best interventions that have been proven to treat symptoms. [Clinical] and behavioral health providers are taught to be generalists; and if you think about what happens in healthcare, you wouldn’t see a cardiologist with a broken foot, but you very well could have an eating disorder or have anxiety and end up seeing a therapist who just wants to talk about how you were bullied in the fifth grade for a year. In order to really move the ball, we know enough; we know there are interventions that are more effective at treating symptoms.
While you made the point in the whitepaper that technology alone won’t cut it, what are the IT/data elements that are critical for integration success?
Redlus: Measurement and data will serve as foundational elements to all of this. Without data, you can’t have value-based contracting. If you don’t have measurement, you don’t really understand what a patient is even presenting, let alone if they are progressing or declining. And so much of this can be done at the point of care in primary care with better training, and better integration of technology to help integrate those medical and behavioral [elements] together.
Caldwell: I think we’re the only industry that still uses fax [machines] often. But we have to. I am in an urban area, and all of our clinics are, too. But god help you if you’re in a rural area and trying to find mental healthcare anywhere near where you live. It’s really difficult to find. So you have to look at it from both the urban and rural perspective when looking at the bigger picture.
Also, our EHRs don’t all talk to each other. So if we have a patient who goes to a different provider, or ends up in the ER—and we have transient patients since we’re a community health center, meaning we don’t know where they’ve been—if we’re lucky, we may get this information from their insurance provider 90 days later after all the payment pieces have settled out. So on the technology side, the workflows can break down.
Lester: One big challenge is that it’s such an incredibly fragmented group of clinicians; the technology ranges from a psychiatrist using a No. 2 lead pencil to a larger group that might have a more sophisticated [system]. Good or bad, the bar is really low, and anything we do in behavioral health today is a huge improvement over what’s been done in the past.
Stigmas around mental health have existed seemingly forever. What efforts are taking place today to remove them, and how can that positively impact integration?
Caldwell: We took over a large pediatric clinic about 12 years ago and they did not have any mental health services. We brought mental health into the clinic and put it in a separate area from where clinical care patients would go. We [eventually] found out—due to a patient complaint—that some of the front-desk staff would direct mental health patients to “where the crazy people are.” That actually happened. So we backed up and re-trained a lot of people. We have come a long way since then—people are actually talking about mental health; we have celebrities that have come out talking about it, and I think that’s incredibly valuable. [Legacy] provides mental health in schools, and my firm belief is that all these kids know that some people are getting mental healthcare, and to them, it’s the same as going to the doctor or nurse. In the long-term, that will pay off.
How do you see the future, especially in terms of getting more behavioral health specialists, as well as training and adequately paying providers for behavioral health components?
Morrison: I think a lot of progress will be made because of things like this [roundtable], with people working together. We’re in the process of training providers and certifying them in specialties. A company like Tridiuum can measure [progress] and provide feedback to both payers and providers. So when you’re doing that, you’re already moving [forward]. It’s starting to shape up, and when you then bring in the legislative piece, there is political muscle, regardless of who wins the election. I think this is our time; the winds are with us now.
Caldwell: I agree, and we need to make sure there are enough providers coming out of all the various programs, such as psychiatry and social work. Ten years ago, some psychiatry residency programs had 10 slots, and still today, they have just 10. Psychiatry is still a difficult residency to get into. We do have to open the pipeline for people.
Lester: At the end of the day, we have to have all parties involved, including the payers; they’re the only ones that can sit back and see the entire world since they’re paying all claims paid for that particular patient. They are the ones who could measure if good mental healthcare actually lowered the cardiovascular cost. The cost of behavioral health is a penny of the healthcare dollar. We are trying to lower the 25 cents and the 50 cents of the healthcare dollar—the cardiovascular care, the diabetic care, those types of things.