In the US, one in five adults experience a mental health condition every year. Less than half receive treatment.
Despite increasing national attention and legislation aimed at improving access and quality of care, access to behavioral healthcare remains a challenge. A shortage of providers, a scarcity of successful behavioral health business models, and a lack of motivation from the broader healthcare system are problems without straightforward solutions. Meaningful change in behavioral health won’t happen without passionate leadership, innovative thinking, and collaboration among disparate segments of the healthcare ecosystem.
Ken Wood is CEO at Evolve Treatment Centers, a California-based network of adolescent mental health treatment and rehabilitation centers. Ken has devoted his four-decade career to helping make high-quality healthcare accessible. Ken joins Peter Pattinson and Katie Fellin from ECG’s Managed Care Services Division for a candid discussion about the role payers can play in changing the way behavioral healthcare is delivered.
Despite legislation at both the federal and state levels to help address mental health parity, why has parity still not been fully realized?
Ken: I think the various changes around parity laws have, in general, focused on what I would describe as benefits or coverage. Mandating that health plans, whether government or commercial, provide equivalent coverage just has not directly translated into available access to behavioral healthcare.
Katie: Ken, on that point, one of our clients recently asked us which states have done the most with parity. Our perspective is that many states have put new legislation in place requiring payer organizations to track themselves and report that they are compliant with parity regulations, but there’s no real change in the parity law or regulation itself. States have spent a lot of time trying to figure out how to enforce it but haven’t been successful. Is that consistent with your view?
Ken: Largely, yes. There was a recent law passed here in California called Senate Bill 855, which is probably pushing further than most states have in terms of adding on to parity. The law actually does require a different kind of access to care for health plans. It was aimed at commercial insurers. It requires them to provide in-network coverage, even if they don’t have an adequate network. And it really tries to force the use of medical society standards for coverage decisions, not proprietary guidelines. So selectively yes, you see some of that, but I would say the reality is even the very substantial integrated systems of care have largely failed to deliver mental health parity.
What are the primary barriers to implementation of integrated, equitable behavioral healthcare delivery models?
Ken: Most of the behavioral health professionals—psychiatrists, psychologists, licensed therapists, and so on—have not been integrated into any kind of coherent delivery system. Many, if not most, are solo practitioners. Because of very poor levels of reimbursement, many have elected not to participate in payer networks. So it’s become this cottage industry of cash-and-carry trade. If you can get a psychiatrist appointment, you should expect to pay by cash or credit card. It may focus almost exclusively on medication management. And you will likely feel lucky that you got a 30-minute slot once every 90 days. It’s up to the consumer to find their access point. Access is difficult in this country.
No one’s been motivated to organize that differently. We’re seeing little glimpses of that with some telemedicine and tele–behavioral health. We’re seeing some aggregation of the cottage industry, but we’re not training enough psychiatrists in this country for the need. We still have primary care physicians prescribing 70% to 75% of anti-depressants. We’ve accommodated the broken behavioral health access by shifting the burden over to the medical delivery system.
Peter: Part of the problem with behavioral health in this country is that we moved away from institutional care because the drugs were seen to be effective. That’s something that happened in my country [the UK] as well. But there’s been a push in some other countries to be a bit more responsible about behavioral health. Why has that not happened here?
Ken: Interesting question. And, you’re right—30, 40 years ago, we had a culture that tolerated isolating patients with substantial mental health illness from society. Once that was not an acceptable solution, we didn’t really build out a continuum of care. We abandoned those institutional settings and replaced them with office visits, for the most part. But those patients with severe mental illness need a higher intensity of interaction and support than basic office visits provide.
With the advent of all the pharmacology, I think the psychopharmacology became a more utilized treatment modality. It was relatively easy for a PCP to write a prescription for an antidepressant. And for many people, it provided some modicum of relief for depression or anxiety.
And so the combination of those two factors—focusing on outpatient care and increased use of psychopharmacology—decreased motivation to go build a whole system of care, or build team-based care or more intensive outpatient care. And of course we cannot forget the economic side. Until the parity laws came along, health plans in general saw behavioral health as an area that was difficult to manage due to lack of outcomes data. Behavioral health services in general were perceived as an expense that payers were not sure how to manage. So before parity, payers often relied on high co-pays and limited coverage to help manage overall expenditure on behavioral health.
Now, because of the historical lack of attention on behavioral health, we are seeing the pent-up demand manifest in the medical delivery system. A recent study I saw showed that more than half of primary care visits have a substantial behavioral health component to them, which primary care physicians are really not trained to deal with. And we have not fully figured out how to support primary care providers with professional resources that could be more effectively engaged to help manage comorbid behavioral health diagnoses.
What can we do about it and what steps can provide organizations and payers take to address some of this. And is there a role for a regulatory intervention?
Ken: I think there’s certainly an opportunity for regulatory support. How do you encourage the various participants in the ecosystem to be constructive, to provide not only mathematical coverage, but to care about the access in your network? And having geographic and time-sensitive access? Those, to me, are appropriate regulatory issues.
Until the delivery system, at some level, steps up and tries to integrate behavioral health, it’s going to be very hard for patients, even with a supportive regulatory environment, to achieve adequate access to behavioral health services.
As a patient, you’re still going to go to your primary care physician. And if you’re not comfortable with that physician managing your anxiety or depression, you are going to have to go find that solo psychiatrist, pay cash, and try to have a relationship with somebody who doesn’t have the same medical record, has no idea about the rest of your medical history, and isn’t participating in networks. And more and more, you’re going to do that virtually. So I think the delivery system has to step up. I think physician-led organizations have to be encouraged to embrace the broader notion of team-based care.
What is the impact of private equity firms investing in behavioral health, and do you think we’ll see more nontraditional partnerships emerge?
Ken: I would say private equity can be potentially helpful in bringing capital to bear to create that more integrated delivery system. When you start to have a team or a group of practitioners coming together, all of a sudden they have a much different need for enabling technology for state-of-the-art electronic medical records that integrate with the other ecosystem that they participate in. That’s where the capital of PE can be valuable.
I think that the flip side of that is that there’s no magic to the capital, per se. You’ve got to have the leadership that gets those practitioners coming together. And you need to have coverage and payment from all participants—commercial, Medicaid, Medicare—that can financially support the level of care that you’re trying to provide.
What types of innovation do you think we can expect to see from behavioral health providers and payers in the next two to five years, if any?
Ken: Well, payers—and I proudly count myself as being in the payer community for a lot of my career—are decidedly un-innovative lot. That’s just not their calling in life. And so I think it’s hard to imagine real payer innovation. On a behavioral health provider side, it’s really hard for solo providers to be innovative. If you have some more organized systems of care—behavioral health hospital systems that have stratified delivery capabilities—they’re in a better position to architect a solution of access.
But that takes intent and strategy. You have to see that as part of your mission. And you have to find partners who are willing to compensate you for building it. I do think that large multispecialty medical groups and delivery systems could integrate behavioral health into their teams. I don’t think they have the motivation right now. But it doesn’t mean that innovation won’t spring up in very localized areas where you’ll have somebody who’s a passionate leader.
Have you seen examples of that in action?
Ken: Several years ago, at a company I was a part of in Colorado, we became interested in behavioral health as part of our delivery system, because we were working with a very large multispecialty medical group and realized we were underserving the needs. We adopted a program that was founded by a psychiatrist who convinced us the way to improve access to behavioral health was to do something that, at the time, was revolutionary. First, eliminate co-pays. There’s no cost to get behavioral health in your health plan. Second, don’t predetermine any limits on what behavior health patients can get; let clinicians determine what they need. And give everyone access to a staff model hub of behavioral health with licensed clinicians.
That’s where the analysis and treatment plan was developed. The therapist and the clinicians determined how many visits a patient needed, or if a patient needed inpatient or outpatient care. It was more expensive than the old model, but we more than saved the money, because we were able to pair those patients with the behavioral health providers and free up appointments for our primary care and specialists providers who were less well equipped to address behavioral health challenges. And so it was economically the right decision; it absolutely was clinically the right decision. But it was kind of a one-off experiment with 80,000 people in Colorado. It didn’t catch on.
If you can find innovation in healthcare, it’s so often tied to the personality or one or two leaders who can make an organization think differently and respond. It’s hard to make it scalable. It’s hard to have that be something you can take to another city and network, or another company and network. But it doesn’t mean we shouldn’t look out for it. We should be looking all the time to find those ideas that could work and be innovative. And can we bring those at some scale to other populations.
Peter: Ken, while on the topic of innovation, tell us about the work you’re doing at Evolve.
Ken: Certainly, it’s been great for me to get back on the delivery system side at Evolve—which is an adolescent treatment program with three levels of care. We have intensive residential care—five or six hours of therapy a day for 35- to 40-day period for high acuity teens. We also have intensive outpatient programs at two levels.
It’s certainly opened my eyes to the fact that you can make an awful lot of progress if you have the right intensity of care. We’re covering a year or two years’ worth of therapy in six weeks. And we’re doing individual and family therapy, and psychiatry and group therapy, all in that environment.
There are possible clinical innovations that don’t necessarily fit into the reimbursement world easily in terms of the access to care world. Our residential program has 11 six-bed facilities in California. And yet when we try to hire psychiatrists, I’ve found they’re not trained in residential care—they’re trained in a hospital and for 50-minute sessions in a clinic. The residential programs are led by therapists, with psychiatry providing support. It’s a therapeutic model, not a medical model.
You can create these therapeutic environments, but how do you make them sustainable? How do you make them scalable? How do you replicate them? There’s a huge shortage of child and adolescent psychiatrists in this country. So part of our scaling challenge is finding providers (and frankly offering competitive compensation). Honestly, making that financial model work is always a balance with relatively fixed per diems from payers for our services. In a very practical sense, you just realize how hard innovation is in a system of care, when all forces (demand, provider training, and reimbursement) are not moving in the same direction.
Published June 3, 2021