Rae Woods (00:02):
From Advisory Board, we are bringing you the Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae.

(00:14):
You're actually not going to hear more from me in this episode. I think it's really important that I show you all of the incredible expertise that is housed within Advisory Board, so that's why I've invited one of my colleagues to actually have this conversation. This is a name and a voice you've heard many times. I'm going to pass the mic to Darby Sullivan, our in-house expert on all things health equity.

Darby Sullivan (00:40):
Happy to be here. I'm happy to be here, because I felt like our conversation was unfinished last time. In the summer, we talked a lot about what the problem was in behavioral health, what were the root causes of the dysfunction and the inequities that we see, but now we actually have solutions. We finished our research and I wanted to bring that back to Radio Advisory.

(01:01):
We didn't want to stop at detailing the problems, we wanted to paint a clear vision for what a better behavioral healthcare system would be. So from a patient perspective, we want a system where behavioral health is recognized as an integral part of healthcare. We wanted a system where behavioral health conditions are treated and paid for just like any other chronic condition, and we wanted a system where we don't see any gaps in outcomes depending on your race or your socioeconomic status.

(01:41):
To get more specific and tactical with next steps for leaders in the industry, I wanted to bring some essential researchers who are part of the team for the past year to the conversation today. So Sally Kim, who is our foremost health plan expert at Advisory Board.

Sally Kim (01:57):
Hi Darby.

Darby Sullivan (01:58):
Sophia Duke-Mosier, who can get us into the mind of the provider organization.

Sophia Duke-Mosier (02:02):
Hi, Darby. It's great to be here.

Darby Sullivan (02:04):
And Amanda Okaka whose expertise is around all things life sciences.

Amanda Okaka (02:09):
Hey Darby, good to be here.

Darby Sullivan (02:11):
Welcome. To kick us off, I want to ask each of you to put on your respective sector hat. So I know that each of you specialize in different sectors of the healthcare industry, and I'm curious what your members with the leaders that you work with would say about the vision of the behavioral healthcare system that I just outlined. So for example, Sally, what would a health plan's ideal vision of behavioral health be?

Sally Kim (02:37):
If I'm allowed to include a lot, I would say financially incentivizing providers to deliver evidence-based care, getting patients the care before it becomes a crisis, and then also of course, total cost of care being managed.

Amanda Okaka (02:50):
From a life sciences perspective, a lot of the life sciences leaders that we talk to on a regular basis, it seems like a lot of their data and evidence strategy is focused around clearing those regulatory hurdles. So I think for life sciences, they would like to see a world where we can design trials that fit better into an evidence space that providers can actually use, and sort of break down some of those data silos that would increase the clinical utility of the data that they do collect during trials, as well as the data that gets collected in post-market surveillance as a part of real world evidence and real world data strategy.

Darby Sullivan (03:29):
I heard something in what you said, Amanda, data that providers can actually use. So I'm curious to bring it to you, Sophia, what would that actually look like?

Sophia Duke-Mosier (03:39):
Yeah, so rounding us out from the provider perspective, to make all of this work, you need the people at the organizations to be there to do the work. Every provider that we've spoken to constantly talks about the workforce shortage, which totally makes sense. You need people in place to do the work and you're constantly focused on putting out fires, but this also of course, negatively impacts patients if there aren't people at the provider organizations in place to do the work.

(04:03):
So when we think about what the ideal system would look like, we'd really think about making sure that there are the right providers at the provider organizations to do the patient care. So what this looks like is providers who are in the right geographic location, they have the capacity to accept new patients, they have the expertise that matches the conditions that patients need to be treated for, and they're also representative of the patient's identity or they have training and cultural awareness, because we know that providers from underrepresented backgrounds actually do better when they're being represented by the providers that they're being seen by. Then finally, of course, we need providers who can take insurance and will also stay financially afloat.

Darby Sullivan (04:43):
So what I'm hearing, a theme across each of your answers is that what an ideal behavioral healthcare system would be would a system where we have sufficient providers to actually use evidence-based care in a way that improves outcomes and reduces total cost of care. Which is not altogether super controversial, which is interesting to me, because this is a field that's typically wrapped up in a lot of cross-industry disagreement, if I can put it delicately.

Sophia Duke-Mosier (05:13):
Yeah, I would agree with you, Darby. It's not really the end state that organizations are disagreeing with. We all want to see the same end state, but it's sort of more about how we get to that end state. When we throw things out like evidence-based care or raising reimbursement rates, that's really where the disagreement comes up.

Darby Sullivan (05:28):
Okay, now that's where it gets interesting. So let's start with your first example, Sophia, which is evidence-based care. How would any of you describe the challenges around defining what quality care looks like in behavioral health? So, is it that different providers disagree on quality care or is it more of a cross-industry disagreement?

Sally Kim (05:49):
I think everyone disagrees even within a stakeholder group, so no two providers are going to agree. Honestly, it makes sense, because two different patients could have different desired outcomes, and then also plans also don't agree, which just increases the administrative burden on providers.

Amanda Okaka (06:08):
Yeah, I totally agree with you, Sally, especially what you said about patients desiring different outcomes. This is an area where life science has really struggles to address because when it comes to behavioral health, it's not as simple as quantitative metrics that we might see for other physical health conditions like an A1C change when it comes to diabetes. It's really hard to define the metrics that we use in behavioral health because they are more qualitative and they look different for every patient. And so there are non-traditional metrics that we would like to consider here like quality of life, employment status, relationship health, as outcomes, but it's hard to find that alignment and collaboration between different industry stakeholders so that we can redefine the metrics that we're using to measure behavioral health outcomes.

Sophia Duke-Mosier (06:56):
The other issue we're seeing, Amanda, is that all those metrics are really great and recovery will definitely look different for every patient, but what's difficult is the provider health plan relationship because recovery isn't going to fit into a perfect 12-month reimbursement cycle, but when plans are looking at, of course naturally they need the 12 months to do the reimbursement. So it's sort of level setting between what recovery looks like and how it can be reimbursed, while also keeping in mind what the patient needs are.

Sally Kim (07:22):
There's the 12-month reimbursement cycle, but there's also just member churn and member tenure on a plan. So it's hard to justify an investment that might show up in 20 years if by that time that member has moved across the country and is now another plans member.

Darby Sullivan (07:39):
It strikes me that the issue is scalability here because on the one hand we want to provide personalized care and personalized treatment, but if everyone defines success in a different way, it's going to be really tough to figure out what works and what doesn't. And it sounds like none of your respective sectors are necessarily super thrilled with how the evidence piece in behavioral health is currently functioning, but a lot of problems in this space. I think there's tons of finger pointing on what others need to do differently. So I'm going to ask each of you with your sector hats on to push against, what could your own sectors maybe do differently to make headway in this evidence space? Or how might your own sectors actually be contributing to the problem?

Amanda Okaka (08:25):
It looks a little bit different for life sciences leaders because I think that it has more to do with breaking down, like I alluded to earlier, those data silos that can really impede the clinical utility of the data that they collect. And it also comes to enabling data sharing and interoperability between stakeholders. So with providers on the clinical side and then also with payers on the health plan side. Life sciences leaders can do more to incorporate patient-centered metrics in their trial design and post-market surveillance, and then they can capitalize on that data by enabling cross-functional uses of it.

Sophia Duke-Mosier (09:05):
I would definitely agree with Amanda on the data piece and providers struggle with that as well, being able to collect the data and providers are often a little bit shortsighted, which makes sense because they're putting out fires, but they're really focused on ED utilization and re-admissions. But I definitely think providers can do more work providing care upstream, so focusing more on preventative care and really investing in addressing the root causes of social determinants of health. Oftentimes providers want to leave this to community organizations, to schools, to other people in their area and not take ownership over what they can do over SDOH's. So I would definitely say providers can do a lot more in that space. Of course, the partnerships with schools, community organizations, justice organizations, housing services are really, really important. But making sure that embedding SDOH related goals are in the strategic plan that providers have, which will of course have a positive impact on behavioral healthcare, and of course it'll be beneficial in the long term for providers in reducing costs of care.

Sally Kim (10:02):
One way that plans could be contributing to the problem is scoping out behavioral healthcare. Right now a lot of plans carve out behavioral health to BHOs, and this shows up in a lot of ways, but one that I saw recently that I thought was really interesting is that usually members with physical health conditions have higher NPS scores for plans because they're doing more for you. You're actually getting care that you're paying for your insurance. So that makes sense. That shows up in care management data. That's not that surprising. What was really interesting is that this does not hold true for members with behavioral health conditions. So members with behavioral health conditions do not have higher NPS ratings. Even though they do still have conditions, they should be getting more care. So clearly it shows that we're not giving members the same resources and support for members with behavioral health conditions as members with physical health conditions.

Sophia Duke-Mosier (10:58):
Sally, I have a question for you. Do you think that health plans are aware that they're giving different coverage to people with physical health conditions versus behavioral health conditions?

Sally Kim (11:07):
I don't think it's a coverage thing because I think payment parity is still legal and required. I think it is more are they giving the same support? So if you call into the call center, are they treating you the same way? Maybe there's stigma. It's hard to train an entire culture of an organization. Maybe it's the fact that there are more potential areas of disconnect if they're now being triaged to the BHO. Maybe it's a lack of access issue because like you mentioned, Sophia, the workforce challenges here. So I don't think it is that the plan is maliciously trying to deny coverage for members with behavioral health conditions only.

Sophia Duke-Mosier (11:46):
It's interesting that you mentioned that because I know from the provider perspective we love to say it's the health plan's fault. They're not reimbursing us, but I think there's definitely more underneath the surface there.

Darby Sullivan (11:55):
Yes, Sophia, thank you for taking us to the reimbursement question. And I think our listeners might be surprised that it took us this long before we brought up reimbursement in the behavioral health space, but that's actually on purpose because it's one of the major messages we want to send with our research. It's a lot easier to make progress on meeting in the middle around reimbursement when we've strengthened the evidence base behind different interventions and treatments so that plans can feel confident that they're reimbursing for things that work.

(12:25):
Sally, I know you mentioned parity. That's something that is a constant conversation in the behavioral healthcare space of are our plans meeting parity requirements? Is the government enforcing it enough? But I know also this goes beyond just conversations of payment parity. What are some of the other elements that health plans talk about when they're thinking about sufficient reimbursement?

Sally Kim (12:49):
So payment parity comes up a lot, and then it's also easier said than done to just pay more. So money is not unlimited even for plans. So plans are trying to put in enhancers so that they do want to pay more for appropriate care, but that can show up in a lot of ways. So is it that some providers are managing harder patients with higher acuity? Is it that some providers are offering more hours to address some SDOH needs? Is it that some providers are meeting members more often? Or trying to manage total cost of care? Or supplying more education for their team? So I think there are a lot of reasons that providers could debate for higher reimbursement, but that doesn't mean it'll be true across the board.

Darby Sullivan (13:34):
And I know there's a very different perspective from the provider side, right, Sophia?

Sophia Duke-Mosier (13:38):
Yes. I will say from the provider perspective, it's hard for us to hear that health plans don't want to reimburse us more because we can see the impact that this has on patients. So because of this difficult dynamic when it comes down to patients, the treatment for behavioral health conditions is too expensive, it's out of reach or they are leaving our networks. So that's definitely an issue. But then from the provider side, when we talk about parity, there isn't a set definition for what a behavioral health condition is, versus a physical health condition. So there's a lot of differences amongst providers about what they'll actually treat you for. So I would definitely say what providers can do more in this area is definitely standardizing those definitions like we've talked about with the evidence base and also coming to the negotiating table more with health plans and with governance stakeholders to increase service coverage.

Amanda Okaka (14:26):
You've both made such great points. I want to revisit something that Darby said when she was asking the question about payers want to know that something works before they'll reimburse for it. Because I really think that this is an area where life sciences leaders can have an impact because we know that non-medication treatments are often really essential in sort of amplifying the impact or the effect of medication treatments for better outcomes. So I feel like life sciences leaders can be more intentional about thinking about the ways that they're collecting social determinants of health data. Sometimes when it's collected like in an ad hoc incomplete manner, it becomes not very useful. So thinking about how they can build that in across the product lifecycle to make sure that they are collecting that data and able to use it. But then also beyond that, thinking about how they can work with community-based organizations or hospitals that are providing this type of care, as well as social intervention so that they can collect data and measure how those other interventions are amplifying the impact of their products.

Sally Kim (15:35):
Yeah, Amanda, actually something that you might find interesting that I was at an event this week, an advisory board cross-industry event with life science companies and plans, and we asked a question, do you value trying new innovations first more or do you want to try things that have ample evidence? And all of the life science companies put their stickers on the try new things, be innovative, and then almost all of the plans put their stickers on do things that have ample evidence. So I can see how it becomes hard to sell to plans if y'all are prioritizing different things.

Amanda Okaka (16:13):
Yeah, definitely.

Darby Sullivan (16:14):
And I think that that's emblematic of how far apart different sectors are on the spectrum across different behavioral health issues.

(17:36):
Sophia and Sally are talking about how providers and plans are completely on the opposite end of the spectrum for what reimbursement rates should be. And life sciences companies and health plans are on the opposite ends of the spectrum for how risky we should be with our investments into new treatments and coverage. So knowing that the sectors are so far apart on this reimbursement issue, I'm going to ask y'all to put on your sector hats again and say, okay, not how do we come to the middle necessarily, but how do we at least start to inch our way closer and closer to each other so we can find solutions that are better for each party?

Sally Kim (18:13):
So a place that I think that we could inch closer to the middle between plans and providers is actually administrative burden. So I know reimbursement comes up a lot, that's a tricky subject to change significantly. But what also comes up a lot is providers saying, we need more than just higher reimbursement. We need reduced administrative burden. And I think plans would completely agree with that, and there are things that plans could do to try and help in the meantime. So there was this one plan that we were working with that realized that there were approximate length of stay recommendations for physical conditions, but not for behavioral health conditions. And that was making folks have to submit repeated prior authorization requests when their patients were in the hospital. And so what this plan did was use retrospective claims data to create their own length of state guidelines for behavioral health conditions by diagnosis, successfully reducing the number of authorizations. So while this wasn't already created and a set standard for all plans, at least this plan decided to take action and create this process foe themselves first.

Sophia Duke-Mosier (19:20):
Related to what Sally's sharing about administrative burden providers also complain a lot about administrative burden, and there's a lot of finger pointing between health plans and providers on whose role it is to reduce administrative burden. And of course, if there's less administrative burden rates can also be raised because that takes out of the cost and the time. But I think another thing that providers can do is offer care that's actually worth reimbursing for at higher levels. So when we think about what care will be worth reimbursing for at higher levels, it's definitely care that reduces disparities. So we have an example that we've heard from one of our members, CareOregon and CareOregon is an Oregon based health plan that worked with a local alliance for culturally specific behavioral health providers, and they're able to negotiate with them to create a tiered reimbursement model so that culturally specific behavioral health providers were reimbursed at a higher level at about 20% more.

Darby Sullivan (20:13):
Sophia, I'm so glad you brought that example up because I think thus far in the conversation, we've really been only talking about how to address one layer of what we describe as the meta inequity in behavioral health. Last episode was all about the meta inequity. So I'll have Rae throw that episode in the show notes in case anyone wants to get deeper. But what we basically mean by that is that in behavioral health, there's an inequity between behavioral health and physical health, but also within this sector of course, we see the same demographic disparities that we see everywhere else in healthcare. So the story that you shared, Sophia, was specifically about how a health plan can help try to incentivize a diverse workforce, but I'm curious how else we see these demographic disparities showing up within each of your sectors.

Amanda Okaka (21:00):
Life sciences also faces challenges when it comes to the workforce and building a workforce that is representative of the disease burden. But primarily the bigger challenge here that comes to mind is diversity in clinical trials and recruiting a diverse population of participants for clinical trials that is actually representative of the people who have those conditions that we see in the population. And so life sciences can really move the needle forward with that by creating collaborative partnerships with community organizations and community-based mental health service providers in order to build trust, build brand awareness, and also start to understand and address some of those nonclinical barriers that people face to clinical trial participation. And really engaging patients as well as community leaders and community members in the clinical trial design early on, so that they can effectively leverage that input and also make patients and community organizations feel like they're really true co-collaborators when it comes to clinical trials.

Darby Sullivan (22:12):
Amanda, what I am hearing from you is that life sciences companies have a specific niche that they can play in the broader goal to do things like address structural racism, which is really helpful to call out because not every single piece of the industry has to play the same role or should play the same role in tackling a problem that can be very overwhelming. We should be oriented to large scale change, but it's helpful to break up the problem, right? Like what should our next first step be that we should take on our long journey towards doing something like reducing racial inequities? I'm curious what your reactions would be about the next first step that your sector should take

Amanda Okaka (22:56):
For life sciences, as I just alluded to, building that trust within the communities that they want to reach, but also structuring their data collection from the clinical trial design to the post-market studies to collect data that goes beyond just race, ethnicity, gender identity, age, and language data, to really consider some of those additional intersections that are adding complexity to how products perform for different patients. And also implementing some of those data sharing partnerships and capabilities that I spoke about earlier to supplement that existing data to really help them close gaps and reach some of these strategic goals that we've talked about.

Sophia Duke-Mosier (23:35):
I definitely agree with you, Amanda. I think even though providers in life sciences companies have vastly different roles and responsibilities, where they really can take the first step is in that data collection. So I would say providers are probably a little bit further behind than where life sciences are. So for providers, we're really thinking about do we have the data? Do we have data on behavioral health outcomes? And then are we stratifying that data by REGAL data? So race, ethnicity, gender identity, age, and language. And then once we have that data, is that really giving us a full picture of where the disparities specifically are? So then once we have that data, we can really tackle what the disparities are.

Sally Kim (24:11):
Sophia, I'm glad you mentioned that, because plans really care about that too. They're always asking for it, and not even just of members, but also a providers, right? I mean, access is one thing, but research shows that if you're seeing a provider that you relate to, you have better results. Unfortunately, that's not always possible, especially with the access challenges. But in the situations where there are, I think plan should at minimum have that as a filter on their provider finders. Every plan has it. So make members be able to choose providers by what they care about. I think one way plans are trying to address this is by providing more digital solutions that could be accessible for people regardless of line of business or financial circumstance. But of course, digital inequity is a thing too.

Darby Sullivan (25:00):
The comment about provider finders I think is actually so valuable because it's so specific, and I want to follow up and end this conversation by asking for other specific guidance that you would give to your sector. If there is one piece of advice you would give representative of everything we learned in the past year, what would it be?

Sally Kim (25:23):
I heard this from a smart person at our Behavioral Health Roundtable the other week, and it alludes back to what Sophia was mentioning at the very beginning of this conversation about how behavioral health is like putting out fires every day. And that's an analogy we hear in this industry a lot. I think what we can do as plans is recognize that we need folks who are also focused on fire prevention. So we cannot wait for the people who are putting out fires to finish before we deploy those same people to fire prevention, because that is never going to happen.

Sophia Duke-Mosier (25:57):
I love that idea, and I wish I could steal it for my own that I want to share for providers, but I will offer something different. I would say the one piece of advice that I would give providers is to make sure you're tying your behavioral health back to financials as much as possible. We know that behavioral health will not be the most lucrative line of business you have. That's just the truth. But are you showing how much reimbursement you can capture? Because when you're showing how much reimbursement you can capture, you can advocate for more money being given to behavioral health. And that's really the bottom line of what we need. And one of the ways that we've seen people do this is by having a revenue cycle professional in the behavioral health line of business looking at claims data to make sure that everything's being captured accurately.

Amanda Okaka (26:39):
Both have made such good points. They're applicable to life sciences as well. But the biggest piece of advice that I would give life sciences leaders is not to get carried away with shiny new things, and rather to focus their attention on interventions that we know work. Whether they are medication based or non-medication based. And really focus efforts on trying to collect more clinically useful data and collect data that also considers some of the additional intersections that we might see between social determinants of health that can help to illustrate the complexity of how products perform for different people.

Darby Sullivan (27:22):
Amanda, well, we've ended right where we began, which is that a great place to start is to build a better evidence base for behavioral health. So Amanda, Sally, Sophia, thanks for joining me.

Amanda Okaka (27:35):
Thanks for having me, Darby.

Sally Kim (27:37):
Thanks for having us.

Sophia Duke-Mosier (27:38):
Thanks, Darby. This was great.

Darby Sullivan (27:45):
Rae, my podcast mentor. How was that? Did I do you proud?

Rae Woods (27:49):
I am so proud.

Darby Sullivan (27:51):
Aw, thanks.

Rae Woods (27:51):
You did such a great job. I want to pass the mic to more people like you because you have a level of knowledge, it's just so much deeper than I have, at least when it comes to this particular problem. But you're not going to get away with not answering a question of mine.

Darby Sullivan (28:08):
Oh, no. Let's hear it.

Rae Woods (28:11):
What is your biggest takeaway when it comes to this unbelievable challenge that is advancing towards holistic behavioral health solutions? This vision that you gave to us at the beginning, what's the one thing that you want everyone to know?

Darby Sullivan (28:25):
My number one lesson from the past year is that nothing about this behavioral health crisis that we have today will change, unless we do.

Rae Woods (28:38):
Well, Darby, thank you for hosting Radio Advisory.

Darby Sullivan (28:42):
Happy to. Fun experience.

Rae Woods (28:47):
If you want to learn more about the challenges facing behavioral health and identify next steps for your organization, visit advisory.com/behavioralhealth. I also want you to go back and listen to episode 122, where Darby, our guest host, was actually the one to talk about the root causes of behavioral health inequity and why behavioral health deserves the same attention as physical health.

(29:12):
If you like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts, and leave us a rating and a review.

(29:20):
Radio Advisory is a production of Advisory Board.

(29:23):
This episode was produced by Darby Sullivan, as well as me, Rae Woods, Katy Anderson, and Kristin Myers. The episode was edited by Dan Tayag with technical support by Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk and Leanne Elston.

(29:41):
One more thing, the podcast team wants to know how we can make this podcast better for you. So we created a quick listener survey at advisory.com/podsurvey. Please take it and let us know what you want to hear on Radio Advisory.