Rae Woods:
From advisory board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. We've talked about the behavioral health crisis on this podcast before, and how the events of the last 18 months have resulted in more adults and more children with behavioral health needs than ever before. Well, we're starting to see the market respond to that crisis. Investors are pouring money into virtual behavioral health, but the positive momentum we're seeing isn't without risks. So today, I've brought behavioral health expert, Clare Wirth and strategy expert, Nick Cericola to talk about the unintended consequences that could come from a truly historic level of investment. Hey, Nick. Hey, Clare.

Nick Cericola:
Hey Rae.

Clare Wirth:
Hey there, Rae.

Rae Woods:
It's that time of year where we're all focused on our TVs, avoiding the heat, watching the Olympics. What sports have you been watching?

Clare Wirth:
I played field hockey growing up and in college, so I will watch any field hockey game that's on, even though the US did not qualify.

Rae Woods:
Oh.

Clare Wirth:
I know.

Rae Woods:
What about you, Nick?

Nick Cericola:
Look, I know our listeners are going to come at me for this, but I am not paying attention to the Olympics this time. I'll admit that I never really do that much. I tend to have it on, but this go around for whatever reason, I just haven't been able to get into it. I see the headlines in the morning, but that's about it.

Rae Woods:
It's definitely different this year. I wanted to bring you both back to talk about a topic we've talked about before, which is behavioral health. Clare, I wonder if you can start by just telling me what is different about behavioral health today compared to the last time that we spoke?

Clare Wirth:
So demand for behavioral health is still well above the 2019 levels, even as we're starting to feel a bit better about the COVID-19 outlook. So when we look into the data, the Kaiser Family Foundation has been reporting on adults saying they have anxiety or depression symptoms, and we're still at about three to four times higher than the pre-pandemic levels.

Rae Woods:
Wow. Even though the outlook on the pandemic... I'm going to knock on wood, as I say this and think about Delta, but even though the outlook for the pandemic has gotten much better here in the US.

Clare Wirth:
The behavioral health crisis is not going to subside right when COVID-19 does. These needs are going to take a long time. Recovering from trauma doesn't happen overnight.

Nick Cericola:
And I think about with providers too, where there is a lot of trauma, some of that's only just starting to show up, right? As providers are stepping back from some of the surge activity that they saw across the winter, their needs, I think, are starting to become more expressed.

Rae Woods:
So the crisis is very much still a crisis. What's changed about the market's response to the behavioral health need?

Nick Cericola:
There's been a huge influx in investment and resources to address the behavioral health need. In fact, there was a $1.5 billion invested in digital mental health companies, just in 2021 so far in the first six months.

Rae Woods:
Oh, wow.

Nick Cericola:
And there's about $2 billion for all of 2020. So there's a lot of focus and attention on digital innovation for behavioral health right now.

Rae Woods:
And that literal influx in cash, I think, gives a lot of folks hope. I think a lot of folks would say that this is long overdue. What do you think that means for the behavioral health crisis as a whole?

Nick Cericola:
There's a lot that does give me hope, Rae. So the stigma around behavioral health has gotten a bit better, at least for the more prominent conditions and people have become a bit more comfortable admitting when they need a behavioral health need. We're really starting to normalize this.

Rae Woods:
And that's probably especially true for the two that you mentioned already, depression and anxiety. Coming back to the cultural event, that's happening across the globe right now, I'm hearing conversations about mental and behavioral health even among the world's best athletes. And I don't think that we would have had that conversation last year or four years ago or eight years ago.

Nick Cericola:
No, and I think these young athletes are doing something that's really hard to do, and it reminds me of something we've been advocating for clinicians to do, which is to take a step back and recharge before you crush.

Rae Woods:
Yeah, Clare. I couldn't agree more with the connection to clinicians. I don't want our listeners to think that what's happening is only happening to elite athletes in the spotlight. I was reflecting on some of the comments I heard from Simone Biles, Katie Ledecky, Naomi Osaka, and they're all talking about being in the national spotlight, right? Their country is counting on them. They're talking about being exhausted from having to extend the highest level of performance across an additional year. And they're talking about continuing to feel the effects of isolation and loneliness. There are no fans in the stands. There's no friends or family to hug them when they're done competing. And all of those things remind me of what clinicians are feeling as they're still battling COVID-19.

Nick Cericola:
Yeah, and the general patient population. I think that this is something we're all going to be experiencing for a long time. And I'm just glad that it's more in the spotlight and it's something that we're talking about more openly. I will say I wish that it were across all different types of behavioral health needs, not just the most common depression, anxiety, but also more severe mental illness or addiction. I think those are remaining at similar levels.

Rae Woods:
Well, let's keep this glass half full kind of moment here. Stigma has gone down at least for some conditions, but are there other things that give you hope as the market is kind of finally paying attention to the behavioral health crisis?

Nick Cericola:
So Rae, one thing that I would say, I generally have a lot of optimism about the amount of investment being poured into digital health or digital behavioral health companies right now, right? Any time a marketplace decides that there's financial upside in a sector, that typically signals that disruption is coming and generally disruption in healthcare does tend to improve overall outcomes. However, there's reason to temper that optimism with some cautious pessimism, which I know we'll get into a little bit more as we speak. Overall, though, the upswell in the number of digital first behavioral health companies and the types of access that they're creating for many new first time behavioral health patients is something that I think we can feel confidently encouraged by even if there are some undertones of potential aggravating factors that we need to be spending a little bit more time talking about.

Clare Wirth:
Yeah. Nick has a really good point that not only are these behavioral health digital companies allowing more folks to access this care. And I'm talking within the same day or two days that they'll get an appointment. It also is at a much lower cost point. So that's something that's been very attractive for people who are accessing behavioral health care. I saw a stat the other day that 60% of Talkspace users are new to behavioral health care in general. So we are seeing access, I think a [crosstalk 00:07:43] out of that is the immediate ability to get care, but also at an affordable price.

Nick Cericola:
And I think we have to assume that that 60% number isn't just based on growth and demand. Part of that is demand that existed prior to the pandemic that was just not able to, for whatever reason, due to limited affordability, physical proximity, et cetera, access behavioral health services.

Rae Woods:
But it strikes me that the organization that you just referenced, that's helping to solve the access and the cost problem is a non-traditional player, right? A player that has grown dramatically over the last 18 months has gotten some of that investment, right? Talkspace being one of dozens that we could name on this podcast. And they're not the only ones that are throwing their hat in the ring to try to address behavioral health and actually solve this problem. Let me admit where I get a little bit nervous. We're going to be talking a lot about technology and its relationship to behavioral health, but we know that the rise in digital tools in general has also meant a rise in digital inequities. What is the equity impact of digital behavioral health?

Nick Cericola:
One of the big issues that I worry about with any sort of disruptive force in healthcare, particularly one in behavioral health, is what happens in the near and midterm when that disruption is destabilizing to the traditional landscape, the private practitioners, the primary care providers on whom a lot of the behavioral health challenges historically have rested? And as we see a large proliferation of new entrants into the behavioral health space, I worry that that's going to make it more difficult for traditional providers to continue to operate their businesses on even the fairly sort of unstable footing that they were on before the pandemic. And I also worry that some of what we're seeing coming out of the digital health space is serving a population whose needs are relatively low acuity, who are perhaps employed by large corporations who have the means and the instincts to contract with digital health vendors and that leaves a segment of the need, which is higher acuity sort of caught in the middle between traditional provider organizations and newer entrants who are scaling access for lower acuity needs.

Rae Woods:
Which by the way, probably reinforces the point that Clare made earlier, which is the fact that stigma has come down for those more common, lower acuity, more accessible conditions like anxiety and depression, but haven't necessarily worked on the problem for other kinds of behavioral health needs. Clare, what do you see as the big equity impact that you want to make our listeners aware of?

Clare Wirth:
There are still huge structural barriers that remain even with the entrants of these new behavioral health digital disruptors, or companies, and those lack of incentives still haven't changed. Whenever we receive a question from a chief strategy officer or a behavioral health leader or population health leader, they're still very much asking us to help them make the business case for how they can make these investments because these incentives are still so misaligned, and the business case for investing in behavioral health is very much one undervalue-based incentives and we're just not there yet. And if you want to hear more about those [inaudible 00:11:20] structural barriers, I know that we talked about it a lot last year, right? When we talked on the podcast, so we can direct folks there.

Rae Woods:
Yes, we can absolutely put a link to that episode in our show notes. And the conversation that we're having right now is so important because it's a reminder that even in a moment where there's a lot of positive momentum, we have to be thinking about risks, whether that's the downstream equity impact of an initiative or any of the other kind of unintended consequences that even the best intentioned efforts can have, Nick, what do we risk as we go down this path of heavy focus on non-traditional entrants, heavy focus on digital behavioral health?

Nick Cericola:
There are two things, and I started to get to this a little bit earlier, but one is what happens if disruptive forces erode the underlying economics of the traditional behavioral health marketplace? For example, providers who have moved into a self-pay practice have done so because that's where the most financial upside currently exists in behavioral health. Well, if they see more of their patients migrate towards digital health vendors because they're more accessible and more affordable, those traditional providers may see further challenges in maintaining their practices and meeting the needs of the patients who do continue to rely upon in-person consultations and expertise.

Rae Woods:
You're also talking about a marketplace that just gets a lot more complicated, right? And maybe I'll even use the word fragmented if there are a lot more options for me to choose for care. On the one hand, that is a good thing, right? We said that it improves access, but does it ultimately mean that the behavioral health space becomes more fragmented than it has been in the past?

Nick Cericola:
So that was going to be my second thing, Rae. I think we're going to see... We already are seeing fragmentation on a couple of levels from the standpoint of consumers and employers who are charged with picking digital health vendors in the behavioral health space and elsewhere, they're confronted with a sea of options, right? Some of which have published data on outcomes, some of which are really relying on well-funded marketing campaigns to attract attention and users.

Rae Woods:
Not to mention the fact that some kind of mimic traditional behavioral health and some are kind of text-based, right? Chat bot-based, right? How do you pick between all of the options and figure out what's the best thing for you?

Nick Cericola:
Exactly. There are a lot of asynchronous and app-based tools, some of which promise to do pretty incredible things, some of which have been able to share data, and others that haven't on whether or not those things have actually borne out. But I also think fragmentation exists for people who are in that ecosystem, as far as the inability for them to navigate across the continuum of care, right? Through a series of design choices, some of them intentional, some of them not, digital behavioral health companies have made it somewhat difficult for patients to escalate their needs in-person behavioral health care, to be referred to other specialists even to primary care, if that's where their need is. And that is a problem that we're going to continue to see as long as we are in a marketplace that favors new entrants and before some force consolidates that space for the benefit of a more integrated delivery system.

Clare Wirth:
And what do we think about the traditional care team that the primary care provider who has a patient who is getting care from this digital behavioral health tool, there's no feedback loop that's happening for that PCP to better manage that patient's chronic conditions. And I'm putting my population health manager hat on here and thinking about the implications of if we're going to improve patient outcomes then we need these things to be better integrated. And that's just not going to be possible if this marketplace continues to become so fragmented.

Rae Woods:
I am a little bit struck by the fact that we started off this conversation on a very positive note and talking about barriers that have come down like access, stigma, costs. But I think what you're telling me is that if we're not careful, a lot of the barriers that we've been talking about historically might actually get worse and not better, at least for a portion of the population.

Nick Cericola:
I think they could get worse, but I don't think that's a foregone conclusion either. I want to make sure that we're not suggesting that this is an inevitability. I just think it's going to take active measures on the part of traditional providers, payers and disruptors to make sure that fragmentation-

Clare Wirth:
And employers.

Nick Cericola:
... and employers exactly, to make sure that the risks that we're describing are not perpetuated and not worse. And in fact, I think we still could see a world in which those things are significantly mitigated based on the amount of financing that's being put into behavioral health space right now.

Rae Woods:
So let's talk about how to address some of these barriers. And I want to start off by talking about a barrier that we haven't actually talked about a bunch on this episode, at least. Clare, I know you and I talked about this ad nauseum in the last episode, which is just the fact that there is a massive mismatch between supply and demand, and the size of the workforce isn't necessarily getting any bigger. Is there anything that we can do, and I mean saying we not meaning just the traditional health care space, but all of the new players who are looking to behavioral health, are there things that we can do to shore up more behavioral health supply?

Nick Cericola:
On one hand I think traditional providers in the behavioral space that specialists and PCPs need to adapt, right? Disruption is coming their way, whether they like it or not. So this is a time to think about improving throughput, creating new access by embracing digital modalities, right? If you want to maintain your practice and continue to make yourself available as a provider in your marketplace, then it's time to embrace some of the characteristics of some of these new entrants. But I also want to make sure that we cast that spotlight back on the new entrants themselves, who I think have a responsibility to build and sustain the behavioral health profession that it's not totally clear to me that they're embracing just yet.

Clare Wirth:
And Nick, what I think you're hitting on is that behavioral health management is care management. And that's something that traditional players, PCPs, et cetera, have to get their minds around for behavioral health. And that digital disruptors and companies are doing a really effective job of, is pairing these one-on-one visits, patient engagement types of efforts with asynchronous, ongoing support to help manage their condition.

Rae Woods:
And we've been talking about the market's response to the behavioral health challenge. I have to imagine that you two are watching that response very closely. Are there positive moves that you are seeing that are getting at some of these unintended consequences we've been talking about?

Nick Cericola:
I think so, yes. And so I want to give credit where credit's due. Some of these new entrants are starting to get serious about embedding navigational support into their models, right? Acknowledging that they are part of a fragmented ecosystem right now, and they have a responsibility to their patients and payers to make sure that they're participating in the care continuum in a seamless way. We're also seeing increase in interest in risk-based contracting with employers and plans, right? Which I think is that acknowledgement that quality is something that is a point of at least interest, if not exposure for digital health companies that they need to prove themselves on. And those things I think are strides in the right direction that will certainly mitigate some of the structural issues that we've been talking about thus far. Clare, I don't know if there's anything that you would want to add to that.

Clare Wirth:
I would add something on the provider side. In terms of questions that I've been getting from provider organizations, a big one is how do we think about embedding behavioral health services into other care pathways, such as embedding behavioral health support in a surgical pathway? For a patient who's about to undergo surgery, having the surgeon recommend seeing a behavioral health provider before, during and after that sequence of care. I want to see more collective action on those less traditional forms of integration. We talk about primary care integration a lot with behavioral health, but I'm encouraged and excited to see it in other places across the care continuum.

Rae Woods:
I feel like we could devote hours to this conversation. And I think the fact that you are coming on the podcast again, and again is a testament to the fact that we should. But I do want to, for now at least, give you a moment to speak to our audience and give them an action item that they can take away so that they can work on getting to solutions on the behavioral health crisis. Clare, I want to start with you. What's the biggest thing you want our audience to focus on.

Clare Wirth:
If we take a step back for a moment and look at what we've talked about during this episode, we've talked about what's trending better and what's trending worse. And it's clear that the real successes are in scaling access for people who have means or worked for employers who are a bit ahead of the curve, but there's the continued challenge to provide care to more vulnerable communities. The uninsured, the publicly insured and marginalized communities, and that's the state of play that we're in right now and without really thoughtful integration of behavioral health within our healthcare system, that divergence is only going to grow. And so my action item for listeners is to anticipate that divergence in whatever type of partnership that you work on or any service line that you develop and get ahead of it.

Nick Cericola:
So I'm also going to come back to a theme that we've already touched on, but I think for me, the biggest thing that I want leaders in the field, whether you're at a startup or at a traditional behavioral health organization, I want you to be thinking about what it's going to take to protect and build the supply of clinical capacity. If we are moving towards a world in which there is, let's call it, a gig economy of providers who service the needs of digital health vendors, we want to make sure that there are real incentives for those providers to stay where they are, to build careers and to invite new professionals into the field because no matter how much scale we accomplish through digital tools, the backbone of behavioral healthcare is always going to be talented, qualified, individual providers.

Rae Woods:
Well, Nick, Clare, thanks so much for coming on Radio Advisory.

Nick Cericola:
Thanks, Rae. Been a pleasure.

Clare Wirth:
Thanks for having us.

Rae Woods:
In the healthcare industry we often talk about disruption as being something that is largely positive for consumers and for patients, but when it comes to behavioral health, the destabilization of an already fragile landscape could actually be damaging for patients, especially those that need it the most. And that's why we need to be thinking about these unintended consequences, even as we see hope on the horizon. Hey, it's Rae again. I wanted to let you know that we're going to be going on a little bit of a summer vacation, but you're not going to be without Radio Advisory. For the next four weeks, we're going to be re-releasing it some of my favorite episodes. So be sure to tune in every Tuesday because we really are always here to help.