Behavioral health

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Heidi: Global behavioral health has long been in crisis and was made worse with 2020 stressors. COVID-19, its economic fallout, and issues of social justice have together caused enormous strain on the mental and behavioral health of people across the globe.

Welcome to Tales of Transformation.

I want to welcome my guests today, Jennifer Caspari, a behavioral health professional and specialist master of health care strategy at Deloitte consulting; Lollie Dubiel, director of clinical products, behavioral health at Humana; and Carol Vallone, chair of the board of trustees at McLean Hospital, US News and World report number one–ranked freestanding psychiatric hospital in the country, with me to discuss the challenges the industry faces in addressing the crises, as well as opportunities for industry and non-industry participants to come together to improve health and build stronger, more resilient societies.

Welcome.

Jennifer: Thank you. It’s lovely to be here.

Lollie: Thanks so much for having me today. I look forward to the discussion.

Carol: Thank you. It’s great to be here.

Heidi: Jennifer, let’s start with you. How has COVID and some of the challenges from the past year changed how we acknowledge and address mental and behavioral health.

Jennifer: I think there’s a lot of ways in the last year that COVID has really shaped mental and behavioral health. For example, one in two people globally suffer from COVID-19-related anxiety and depression. This broader recognition has really helped us understand the vast need of people with behavioral health challenges that pre-existed COVID and then that also have come up in relation to COVID.

So more than ever, strategies to address mental and behavioral health challenges are becoming more diverse and really more innovative. So there’s a huge boom in digital behavioral health, both synchronous care, like virtual therapy, and asynchronous care options, like module-based, asynchronous cognitive behavioral therapy, and 2020 was the highest year yet in regard to customer utilization and funding of behavioral health intervention.

Carol: I think first it’s important to look at the numbers. About 10% of children, age five to 16, have a diagnosable mental illness, greater than 50% arise by the age of 14, and about 75% by the age of 24, but more than 60% have not had adequate or any interventions at an early age. If you look at college students, one in four suffer from mental illness, one in five adults experience some mental illness each year, 25% of whom suffer seriously, but more than 50% of adults do not receive care and 32% of people aged 85-plus will have Alzheimer’s dementia. So currently 50 to 60% of the population is feeling a mental health impact from the pandemic, with more than 70% in the workforce reporting an issue. When we look at vulnerable populations and how COVID has affected them, the economic impact of COVID causes people to forgo treatments. Virtual access is not broadly available for lower income people. But the biggest impact of COVID is the geriatric population. We’ve seen 40% of deaths from the pandemic occurred in long-term care. In Massachusetts where I am, that number is around 63%, and McLean Hospital estimates that 80% of these deaths were people with dementia. We see social isolation, disconnection from peers and families that’s exacerbated, hopelessness, anxiety, depression, and trauma. And there’s a huge impact on the mental health of caregivers in long-term care settings and health care overall.

Lollie: I think one of the other things COVID has done is exposing all the gaps in inequity, but what it’s also done has brought the issue of mental health to the surface. COVID, from my experience, has really started to chip away at that stigma and the issues around access and trauma.
So really peeling back the onion to expose the truth and also the opportunity for innovation to start to help solve some of those problems.

Heidi: What steps can we take to break down these barriers in the next five years?

Carol: I think starting with the national shortage of trained psychiatrists, we see 85% of shortage areas are in rural geographies, and it would take over 7,000 behavioral health professionals to reverse that trend. Assuming people actually would go to rural areas.

We also see a severe lack of inpatient capacity. We’d need 125,000 beds across the country to meet the demand. And actually that’s a pre-COVID number. We see the overall cost of behavioral health and inadequate insurance as big deterrents to seeking services. We see regulatory barriers across state lines with licenses that allow treatment in-state only. And we see access and delivery models as ineffective. We see an overuse of emergency rooms, which is frightening for the patients and it’s incredibly costly. The more seriously mentally ill individuals are incarcerated rather than hospitalized. So, what can we do? We need to solve the cross-state licensing issue and insurance reimbursement issues.

We see insurance companies really need to be sensitive to both cross-state licensing and reimbursement for virtual care. We can be using technology to reach people where they are in hard to reach rural areas where the supply of behavioral health professionals is limited, but we still need to fill in supply shortage of trained clinicians.

So we think about training more clinicians in addition to psychiatrists to provide mental health services. And we definitely need to work on additional de-stigmatizing mental illness. McLean Hospital thinks of how do you relate to individuals and humanized content and real data to show they’re not alone and deliver that content in their geographies and localize it to their cultures?

Lollie: So one of the things I’m very aware of is that you have to meet the patients where they’re at. We have all these issues with resourcing and licensure and regulatory but if we become patient-centric, that should start to help to think through what are the ecosystems that we need to create and how do we engage patients.

And that’s where data and technology innovation create that greater access and the opportunity to solve for some of those problems. It minimizes the barriers around things like transportation and other social determinants of health that often get in the way of accessing care.

Heidi: We were talking earlier about technology as a possible solution. What ways can technology play [a role] in solving mental health challenges?

Lollie: You can build the best thing, but if you can’t engage people, it really doesn’t matter. So for me, there’s gotta be a way to engage patients based upon their clinical presentation, their age, their culture. And so it’s creating different engagement strategies so that whatever the solution is, it really speaks to a sub-population that they can engage.

The second piece is around data. So how do you keep them connected using maybe some consumer data to help drive that engagement and that connectivity, but also how do you start to use data for measure-based care and for outcomes so that we get smarter on what we’re putting out in these new ecosystems of care.

So for me, it’s about clinical efficacy, engagement, and both the clinical outcome and the financial impact of better outcomes and quality of care on the back end.

Carol: We think about technology across the continuum of diagnosis, treatment, tracking and monitoring, and analytics for population health management.

So what we see right now is technology is helping with access and addressing the shortage of health professionals. We also have a big push for sensor-focused information that can then be packaged and activated for treatments. So think about wearables that can monitor sleep movement patterns, that can inform depression, anxiety, PTSD, that can really inform clinical care.

And if you can have data available that shows what patterns actually were occurring, that’s very helpful for a clinician. And then we think about AI so we can evaluate tone of voice, inflection point, cadence of speech, word choice, all really important in diagnosis and treatment. And then virtual reality and immersive ways to deliver exposure therapies for phobias, for instance, by simple visualization techniques. And then digital therapeutics being characterized as software that is evidence-based and clinically proven for treatments. When we talk about scale and lack of resources and clinicians, digital therapeutics have a promise of a way to be able to scale behavioral health services. And although I would say they’re thought about to be used independently and standalone, ultimately clinicians need to be educated and trained to prescribe their use, but there is a promise to be using technology more, instead of, or alongside a clinician to really leverage clinician time.

Heidi: Jennifer, with the amount of data, patients can feel really overwhelmed. How do you put the patient and the patient’s family in the center of their health care team?

Jennifer: How do we put the patient and patient’s family in the center of their health care team where they rightfully belong? If patients are able to have the knowledge and understanding about what’s happening with them and with their family and how they’re responding to different societal challenges or what’s going on internally for them, they can have a lot better handle on being in that position as the main stakeholder of their team. And with the amount of data there is now and that will increase over time in terms of being shared with patients directly or mobile apps or other technology, it’s going to be instrumental for them to have the information to be able to make really informed decisions.

And that’s not solely giving information. That’s somebody who is trained to work with patients to help promote motivation, for example, or to help resolve ambivalence. In fact, about six months is the average time it takes for us to go from thinking about doing something to actually making a change.
And so it can be really important to have a trained team that can also collaborate with the patient as they are receiving virtual care or using digital therapeutics to go back to that human connection and that human team. I think this opportunity for training patient education doesn’t have to be a clinician or behavioral health provider or a primary care provider.

We can really use some great task shifting to allow community members or nursing staff to be able to have the skills necessary to teach patients about what’s most important about their data and how they can use their data to improve their health, to meet their own health care goals. I think it’s incredibly important to have physical health, emotional health, spiritual health together in the same ecosystem. And so if they have this data about their wellbeing, my perspective is that it should be their whole health wellbeing. So they can also have a comprehensive picture and understanding of how am I doing in my life completely, rather than just from my emotional wellbeing standpoint.

Heidi: How could innovative partnerships drive positive change? I’ll start with you, Carol.

Carol: What I’d like to think about is we have an infrastructure in place where children, adolescents, youth, adults, and geriatrics can be readily reached. What we don’t have is mental health delivery models to reach them where they are. So we should be reaching people in K–12 schools, in colleges and universities, in the military, in prisons, in companies where people are not only dealing with their own issues, but also their children, their parents, in senior care facilities. We also think about a point that was just made in terms of integrating behavioral health with primary care so we can develop more cost efficiencies and better outcomes. We also think about early intervention and longitudinal care, and we need to focus on susceptible populations. So thinking about wraparound preventive services and foster care programs, for instance. Juvenile prisons, detention centers, senior centers. And then thinking back at the research level, we really need to be investing in brain research to provide more informed, targeted, and personalized treatments based on findings.

When I think about innovative partnerships that can drive positive change, I think about technology companies can enable new models for tech-enabled delivery. The government can fund more brain research so we can personalize care and support the integration of behavioral health into our existing infrastructures. Our education systems, our prisons, our military, and corporate America can integrate behavioral health into existing structures. The insurance companies can broadly address cross-state licensing, clinician reimbursement, and virtual care models. And our medical systems can provide more holistic and integrated medical and behavioral health care.

Heidi: Lollie, what are you seeing in terms of innovative partnerships?

Lollie: One of the things that I think is highly relevant is that many of these models to drive change have to be done at a local level. So think about some of the larger companies and what they’re trying to do and how they’re trying to impact their employees. And how can you stratify the population with different behavioral health needs and look at it from a local perspective to activate those key stakeholders.

The need is so great now that the willingness and the openness to have that discussion could create some real synergies and opportunities leveraging everything in our toolkit that we have now.

Heidi: Jennifer, what are you seeing from a Deloitte point of view in terms of partnerships that are driving positive change?

Jennifer: One of the points of focus for Deloitte has really been on thinking through how do we focus on prevention? How do we help people wherever they are to engage in prevention efforts so they don’t develop mental health and behavioral health challenges? Really looking at prevention as the bulk of the support that we provide for the largest portion of the population and then funneling all the way down from preventative efforts to low-touch intervention, all the way down to your psychotherapy and psychiatry services.

Heidi: Lollie, how can the industry work to create a more equitable future of behavioral health?

Lollie: I think we’re learning a lot right now about inequities in health care. This is one of those sea changes where it’s exposing behavioral health issues, but also health care issues in general. We all have different perspectives, yet our mission is quite similar. So how do we start to leverage that and activate things that need to get done, like changes in funding, leveraging the regulatory issues that may be impacting access?

Some of those were in flight and have changed, but there’s still more work to be done there. So I think there’s a foundational level and then there’s the innovation level that is going to push boundaries and partnerships, create a whole new body of evidence The key stakeholders, there’s the mission, but there’s also the evidence that will drive additional funding and additional methods to tackle some of the inequities.

Jennifer: So, if we look at the population that needs care, and we think about truly meeting people where they are, as clinicians we have to adapt to be able to use new models. We have to adapt to provide 15-minute interventions for folks that have mild challenges. There’s nothing magical about a 60-minute psychotherapy session. We have to adapt along with the wonderful innovations that are coming out to really provide needed services. At a community level, we can invest in access, promoting interventions like internet capabilities, supplying devices through which people can participate in treatment and prevention efforts. We can also consider the ways that we can task shift to help develop a model in which lay community members are able to engage and participate with their fellow community members in prevention or treatment efforts and using referral processes to engage people who have identified more significant challenges from the community to help them really establish care in the health care system as needed.

And then on an organizational level, we can provide access to affordable, effective, and accessible care options for employees. So wouldn’t it be great if our health and wellbeing were part of the work culture? And we also had these really accessible well-known options to engage in care when we need it and to engage in prevention efforts as well?

Carol: I really don’t feel like the point of contact with the medical care system is focused enough on behavioral health issues. It’s oh, by the way, we have to give you this checklist, yet the questions don’t continue within the actual interaction that’s live with the clinician that could really determine there might be something brewing here that we need to take care of other than just the sore throat.

Lollie: One of the things that I’ve seen is that customers, consumers, patients, they don’t feel comfortable still raising their hands saying it’s a behavioral health issue. A lot of the questions that we ask are very pointed and it doesn’t open the opportunity to drill down to a behavioral health issue. So it’s shifting the dialogue a little bit to take away some of the stigma to open that opportunity up.

Jennifer: It makes a lot of sense in the context of health care or another system where you’re not actively seeking mental health services, and I’m air quoting as I say that. I think it’s incredibly helpful to focus on that shift from symptom reduction to functional improvement. And if folks were able to think about questions in terms of, “What are your goals for your own wellbeing?” And if you’re not meeting those goals, how do we help you get there rather than “What are your specific mental health symptoms?”

Heidi: So much to share with our listeners today. The pace of change for the future of behavioral health has accelerated in the face of 2020’s enormous challenges. This shift is driving us towards a health ecosystem in which prevention, early detection, and effective treatment can improve health care outcomes, address pressing social challenges, reduce health care costs and, overall, create a healthier, happier, and more productive world. I want to thank my guests, Lollie Dubiel, Jennifer Caspari, and Carol Vallone for an enriching conversation. Thank you.

Jennifer: Thank you.

Carol: Thank you for having me.

Lollie: Thank you.

Heidi: Stay tuned as we continue our series exploring the future of health and trends transforming the industry.