Rae Woods (00:02):
From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. When it comes to behavioral health, there has been a lot of progress, but there are still plenty of obstacles remaining. You know that there is a ton of new money pouring into behavioral health, particularly telebehavioral health. But here's the thing, the industry might not be putting its money or its resources in the right place, meaning we risk making disparities worse. That's why we need to understand health equity through the lens of behavioral health. And that's exactly why I wanted to invite our behavioral health equity research team to this episode. I've got Darby Sullivan and Rachel Zuckerman today. Hey, Rachel. Hey, Darby. Welcome back to Radio Advisory.

Rachel Zuckerman (00:56):
Hey, Rae. Thanks for having us.

Darby Sullivan (00:58):
Hi. Happy to be here.

Rae Woods (01:00):
All right, Rachel, I am going to do my best to not be distracted every single time Darby says your name, since it is the same as mine. Although, I've found myself in this impossible situation where I'll be perpetually going by both Rachel and Rae for the rest of my life. And I know that is my own fault, so I am happy to have an actual Rachel on the podcast today.

Rachel Zuckerman (01:22):
Yeah, I feel like we had this problem last time too. So we'll just, we'll do our best.

Rae Woods (01:25):
We spend a lot of time talking about health equity at Advisory Board. We have an entire playlist dedicated to anti-racism and health equity. You both have been on this podcast before talking about these topics, and you represent Advisory Board's health equity research team. But when you were diving into health equity this year, you decided to specifically focus on behavioral health, right? Both areas where we hear a lot of talk, but maybe not necessarily a lot of action. Why aren't these things being prioritized more in healthcare, even if we talk about them as being areas of importance?

Darby Sullivan (02:16):
Well, I guess we'll dive into the real talk right away, Rae. What it comes down to, at least for health equity, when we're talking about that more broadly is that... It's my cynical point of view that if our industry was going to do this because it was the right thing to do, we would've done it by now.

Rae Woods (02:30):
Yes.

Darby Sullivan (02:30):
We agree that this is the right and moral thing to do, but I think the reality is that, in our system, it comes down to business. And for most organizations in our industry, not all of them, but most, there's not this sort of slam dunk near term ROI for this work that offsets all of the other incentives that we have.

Rachel Zuckerman (02:51):
Yeah. I think that's so true in health equity in general. And then when it comes to behavioral health, our society has a pretty long history of undervaluing behavioral health and viewing people with mental health conditions as dangerous in some cases, incompetent in some cases, and just generally less worthy of investment, so I think this has led to the separation of behavioral and physical care. So for a lot of healthcare leaders, it's not something that they've historically had to focus on a lot.

Rae Woods (03:26):
But I still feel like we could be having the conversation we're having now about any area of health equity, right? Darby, this is not the first time you've kind of called out our listeners on the fact that we need a business case or this isn't going to happen. So why did your team really decide to hone in on the intersection of behavioral health and health equity specifically?

Rachel Zuckerman (03:47):
We knew that we wanted to get specific within health equity so that we could get more concrete in the research and guidance. We were giving. Advisory Board has published a fair amount on health equity over the years, but what we've observed is that it can be hard to get concrete and tactical. Talk about health equity can get pretty high level or academic. So we wanted to anchor in a specific area so that we could identify clear roles and actions that stakeholders could take.

Darby Sullivan (04:18):
Yeah. And it really felt like this was the moment for behavioral health specifically, because I don't think I have to tell anyone that needs have exploded in the past few years. There's this huge momentum around talking about behavioral health that there hasn't been before. But also, our take is that the money that's being invested to address this problem is actually going into the wrong place. So we see tons of investment in these digital tools and apps that are often available via your employer or self pay, but they're largely targeting higher income, lower acuity patients that just need a little bit of help self-managing, rather than folks that are typically experiencing some of the most high acuity conditions, folks who are low income, folks who are the most at risk.

Rae Woods (05:02):
Hold on. I think this is probably going to be something that's surprising for our listeners. You've said that it's a good thing we've got all this extra investment, we've got all this extra focus. And I think that most folks who are listening to this episode think that behavioral health is something that has largely gotten better when it comes to the US healthcare system, but you're telling me that we haven't actually made progress in the way that we think we have, or maybe not in the area that we need the most.

Darby Sullivan (05:32):
Yes. That is what I'm saying. So even in terms of outcomes, I don't think that we can say, "Hey, we've actually seen an improvement in behavioral health outcomes." In fact, we would argue the opposite over at least the past few decades, but I would agree, there is more attention, there's more investment than we've ever seen before. That is a good thing.

Rae Woods (05:51):
Yeah.

Darby Sullivan (05:52):
But it's only part of the story.

Rae Woods (05:55):
And the result I'm assuming is we've got this uneven distribution of behavioral health attention of our resources, of our money. And worst case scenario is that our efforts, well intentioned as they might be, end up actually making disparities worse. Not better.

Darby Sullivan (06:12):
Yeah, exactly. And that is because behavioral health is... We've been calling it a meta inequity because there's levels to it.

Rae Woods (06:18):
Okay.

Darby Sullivan (06:19):
So on the one hand, I think what everyone realizes is that there are these intersector inequities. So that regardless of who you are, if you have a behavioral health condition, you're having a worse experience, and probably worse outcomes than your clone that has every other physical condition that you have, but not a behavioral health condition. So just between behavioral and physical, there's this gap. But also, when you look at behavioral health on its own, there is a spread in terms of who has better access to care, who experiences the worst stigma, who has better outcomes that fall along sort of the traditional demographic lines that we talk about for all other health inequities.

Rae Woods (07:02):
Rachel, I wonder if you can help kind of make this real for us. Can you give us an example, illustrative or otherwise, about how the kind of meta inequities that Darby is talking about plays out in practice?

Rachel Zuckerman (07:13):
Yeah, definitely. So in terms of the intersector piece, so that first level, we know that life expectancy, for example, is significantly worse if you have a behavioral health condition than if you don't. But then in terms of that second level of how it plays out within behavioral healthcare, something that we heard from one of the psychiatrists that we interviewed for our research was that she really sees a three tiered system in behavioral healthcare. So at the highest level, there's kind of concierge care for people who can pay cash. This care tends to be easy to access. A lot of the digital platforms that Darby was talking about might fit here. Tier two is care for people who have commercial insurance, so it might be harder to find in network care. And then the third tier is care for people with Medicaid. And in this psychiatrist experience that we were speaking with, she sees the longest wait times, the least accessible care, and the worst outcomes. So that's just one example of how these disparities play out in terms of insurance and socioeconomic status.

Rae Woods (08:20):
So if we're going to solve this problem, I think we need to do a deeper dive in how the behavioral health problem actually manifests, the root causes. And if I think about where our audience probably is, they're probably all at the starting point of thinking about stigma, something that has definitely gotten better over the last couple of years, at least in part. But I'm guessing that both of you are going to tell me that solving for stigma alone isn't going to solve the equity problem. What are some of the bigger underlying challenges that we need to address as an industry?

Darby Sullivan (08:54):
Well, I'm glad you brought that up, Rae. And actually I would push back a little bit on our assumption that stigma has gotten better.

Rae Woods (09:03):
What do you mean?

Darby Sullivan (09:04):
As you were alluding to maybe a little bit, stigma is not the same for this high income yuppy that might talk about going to therapy once a week, compared to someone who's living on the streets and has unmanaged schizophrenia. The stigma is different. That gets exactly at that intra inequity that we were just talking about.

Rae Woods (09:23):
And the three tiered system that Rachel was talking about.

Darby Sullivan (09:26):
And the three tiered system, exactly. So while we can acknowledge that maybe as a culture, we talk about depression more, we talk about anxiety more, that doesn't mean we've overcome the barrier of stigma by any means. The other piece of stigma that I think a lot of people don't talk about, but it's equally as important, is stigma against the profession itself. So a lot of folks that are, you know, potential practitioners or clinicians pretty rightly look at behavioral health as a field and say, "Hey, do I want to get into this?Because it's low paid. It's very stressful work. There's so many barriers to actually getting my patient help, which has a whole host of ripple effects."

Rae Woods (10:06):
So we haven't actually even solved for the stigma problem, but what are some of the other root cause challenges that the industry would need to maybe not even solve, but at least advance in order to improve equity in the behavioral health space?

Rachel Zuckerman (10:20):
I want to be really clear when we talk about the root causes of behavioral health inequities. The fundamental root causes are really the same as any other health inequity. So it's structural racism, economic injustice. And then in behavioral health, there's this additional layer that we talked about of kind of the deprioritization of behavioral health. So those are the big historical root causes, but we see them manifest today in five big ways that continue to drive these behavioral health inequities.

Rae Woods (10:54):
What are those five?

Rachel Zuckerman (10:56):
So we already talked about stigma, which is one. The second is the lack of strong evidence for which behavioral health treatments work in which scenarios, third, the fact that our current system doesn't effectively address the social determinants of health needs that increase behavioral health challenges, fourth, we don't have enough behavioral health clinicians, and then fifth low reimbursement rates that contribute to all of these challenges.

Rae Woods (11:24):
Okay. So five root causes is a lot, but let's attempt to kind of go through each of these in turn. Like you said, we've already talked about stigma. Now let's get to evidence. Help me understand what the problem is here.

Darby Sullivan (11:40):
So the problem for clinical evidence and behavioral health is not that there's no research or no evidence whatsoever for what worked, but we just, as a sort of scientific community, don't quite understand why one treatment would work for our particular patient and it doesn't work for another.

Rae Woods (11:57):
Which by the way, our colleagues, Solomon and Lou Brooks came on an episode a couple of weeks ago to talk about this being a problem, in general, when we think about drugs and devices in the life sciences world trickling down to actual patient interactions.

Darby Sullivan (12:10):
Right. But it's even more, I think, heightened for behavioral health conditions that just have less research writ large attached to them. And so what that means is for a patient, they might have to go through multiple rounds of trying different medications with different side effects, combining them to find the right regimen that works for them. And it just takes a long time. So one of the things that we're watching in this space is actually just new innovation in the types of therapeutics we're using to treat these conditions, like psychedelic assisted therapy and deep brain stimulation with the goal of, can we sort of unlock something we haven't found before for some of these more intractable diagnosis?

Rae Woods (12:50):
It is not particularly uplifting for you to tell me that we don't even know how to help people with behavioral health conditions and what kinds of clinical evidence works. And we're only at the second root cause.

Darby Sullivan (13:04):
Buckle up.

Rae Woods (13:06):
The next one you talked about is the social determinants of health. How does SDOH uniquely contribute to behavioral health needs?

Rachel Zuckerman (13:12):
So in behavioral health, if you don't have access to things like healthy food, safe housing, stable employment, we know that you're more likely to develop mental health needs, and it's a vicious cycle. So if you have a high acuity behavioral health need, that might affect your ability to find stable employment or go to the grocery store, or even go to your doctor's appointments. So it's particularly impactful in heightening behavioral health needs. The other thing that's really prevalent in the behavioral health space is social isolation and kind of a lack of agency. So that's another compounding social determinant of health. Historically, as the health equity team, when we've talked about the social determinants of health in the past, we know that those don't tend to be core competencies or strengths of traditional healthcare providers, so we're really paying attention to partnerships where more traditional healthcare stakeholders are partnering with and seeing the value in other organizations that have expertise in addressing some of these other needs that are really crucial to behavioral healthcare.

Rae Woods (15:34):
We've talked about stigma, we've talked about evidence, and we've talked about the social determinants of health. Your last two root causes, I think are going to be the ones that our audience is the most familiar with when it comes to behavioral health specifically, starting with the fact that we just don't have enough clinicians to actually meet demand for behavioral health services. And I am assuming that you are going to tell me that is something that has gotten worse and not better amidst the pandemic and everything else that we are living through.

Rachel Zuckerman (16:05):
You are definitely right, Rae. And probably a lot of people have experienced this personally, just trying to find a therapist for themselves or a family member. It's really hard right now. And I think the problem is a lot more nuanced than people even realize, because when we see folks talking about clinician supply, they're usually talking about raw numbers. And it's very well documented that there is a shortage of psychiatrists in the US, just to take one example of a type of provider. But even if a clinician exists in your area, you also have to take into account, are they accepting new patients? Do they take the patient's insurance? If they don't, do they offer a rate that the patient can afford? Do they have the right expertise for that particular condition? And you also have to think about the relationship. Is it a good fit between the patient and provider?

Darby Sullivan (16:57):
And the other piece of this is, when we think about that second level of inequity, what are the ways in which our workforce can actually deliver culturally sensitive or culturally responsive care to every single patient? Because we know our workforce is not diverse enough to represent all of the communities that we serve. In combination with everything else Rachel said, this makes sense why the supply challenge is a lot more complicated and worse than you might first realize.

Rachel Zuckerman (17:26):
And I think it's not just that the supply is worse than we expect. It also contributes to the disparities in access that we've been talking about. Because if you're a person that can't afford to take off work to get the first appointment that's available, or you can't afford to pay out of pocket, or you have a higher acuity need, that's all going to make it harder to find care.

Rae Woods (17:49):
The last big one is reimbursement, or lack thereof. This also is not a new problem. What do you want health leaders listening to this podcast to know about this root cause?

Darby Sullivan (18:02):
So they're not supposed to be as bad as they are right now because of parody regulations, which basically means that behavioral health services should be reimbursed at similar rates as physical health services would be, which sounds good. It's kind of hard to actually calculate and figure out, okay, what that number should be in real time. And part of the reason why it's hard to calculate that is because our data set for behavioral health is pretty bad, which means that behavioral health is just simply not a profitable service line for most organizations.

Rae Woods (18:32):
That's right.

Darby Sullivan (18:33):
So when we have a call with someone and they say, "We break even ish on behavioral health," we were clapping. We were so happy for them.

Rae Woods (18:40):
Aw.

Darby Sullivan (18:42):
Yeah. And so that means that people say, "Okay, we had to just cross subsidize these services, or just accept this as a loss leader, because we know it's the right thing to do as an organization." So I think the low reimbursement rates, along with high administrative burden for providers to sort of track down that reimbursement, and high demand from patients means that providers don't take insurance. A lot of providers don't take a lot of types of insurance, because it's just, you're jumping through hoops for a small reward, which as Rachel was saying, I mean, a lot of patients have to self pay.

Rae Woods (19:13):
Gosh, I find myself saying this a lot on this podcast where we talk about, dare I say, depressing topics. We talk about crises in healthcare. I am literally sick of having to use the word crisis, and I don't think that anyone would disagree that we are facing a behavioral health crisis here in the United States. My question for the two of you as researchers is, what would it actually take for the industry to give behavioral health needs the same urgency that we give physical health needs and actually solve for some of these underlying root causes that you've determined in your research?

Darby Sullivan (19:50):
Yeah, I mean, I think the first step is actually better understanding and quantifying how behavioral health inequities are impacting our businesses in healthcare, not just how they impact patients, because we well know that. So for provider organizations. Providers under risk obviously care about reducing an avoidable ED utilization that comes from unmet behavioral health needs. Folks under fee for service are consistently thinking about capacity and payer mix to make sure that they can keep the doors open. Health plans obviously are accountable for all of the costs from their members, which are made more expensive with unmet behavioral health conditions. And actually one health plan we were speaking with said, "Hey, we intellectually know that was true, but it was so hard to connect our data sources that it took us a while to actually do so. Once we did, we realized we were leaving money on the table, because our patients with behavioral health conditions were costing us double as our patients without."

Darby Sullivan (20:45):
And then of course, when you think about life sciences and pharma companies, any sort of unmet behavioral health need makes it harder for folks to adhere to their care plans and actually receive the medications that they need.

Rae Woods (20:58):
The behavioral health challenge affects every single stakeholder in healthcare, and the inequities that we see and that you've outlined in behavioral health affect all stakeholders, whether you're a provider, a payer, a life sciences company. What are the first steps that you want to see industry leaders do to actually work together and tackle a problem as huge as this one?

Rachel Zuckerman (21:22):
Actually, Rae, I think it's more than just those three players. There are tons of players, and the behavioral health landscape is really complex and really opaque. And a lot of these stakeholders haven't always worked well together, or even worked together at all. So we think it's really important for leaders to understand the landscape so that they can understand their role in it.

Darby Sullivan (21:45):
And for each of those different players, one thing that we are trying to explore more is how do we push folks from thinking, "Okay, let's do X, Y, Z in order to function better in the current world that we're in" to "How do we actually change the current world that we're in?" So an example of this is, we talk to a lot of health plans that are really interested in behavioral health and making things better, and they are obsessed with helping providers better integrate behavioral health into primary care. Not a bad thing in and of itself, but what I'm curious is, why aren't you as obsessed with raising reimbursement rates? That would actually like do a lot to impact some of those more root causes versus playing around the edges.

Rae Woods (22:26):
But to your point, Darby, you are still telling me that there are players out there that are absolutely interested in trying to tackle this problem, and doing it in an actionable way, not just talk, right? We had one of those leaders on this podcast several months ago, Seattle Children's, that specifically was focused on the pediatric behavioral health problem. Let me give you each a moment to maybe share something a little bit more uplifting in this episode. Is there a leader or an organization that you think is doing well at tackling the behavioral health challenge that you want our listeners to know about? Rachel, let's start with you.

Rachel Zuckerman (23:03):
Yes, definitely. So there is one example I love just about an organization improving access for their patients and removing criteria that was really acting as a barrier to their patients getting the care they needed. So we spoke with one provider who offers a medication assisted treatment program for patients recovering from opioid use disorder. And when they initially started the program, they had all of these criteria in place to determine eligibility. So you had to be free of all drug use, including marijuana, you had to attend these group support sessions, and so on. And they realized, as time went on, that no one was qualifying for the program, and they weren't reaching the people that they were trying to support. So they removed all of these criteria and made a very simple requirement that you just have to be a primary care patient within the system. And I think that's a great example of just taking a critical eye to requirements that we've put in place with good intentions, but are actually contributing to inequities in access now.

Rae Woods (24:09):
Darby, what about from your end? What's the story that you want to share?

Darby Sullivan (24:13):
Yes. I will share a story that comes from a health plan, because I feel like I may have been a little bit too harsh on health plans in my last answer, and everyone's doing the best they can. But one of these health plans that we have spoken to said, "Hey, in our service area, there's tons of psychiatrists, for example. We don't actually have a psychiatrist supply problem in our particular service area, but they're all in sort of these individual private practices. And so it's really hard for us to help navigate patients to these places, because we just simply don't have the contact information and the ability to work with all of these independent groups that's necessary." So what they did is worked with a vendor to sort of parse through all of these individual practices and psychiatrists to say, "Okay, here are the ones that we consider high quality, and we created this preferred provider network so that we are actually better able to connect patients in a more direct way." As a health plan, we're better able to direct patients to the level of care that they need more efficiently.

Rae Woods (25:15):
Well, I know that your team is really still just getting started at tackling the behavioral health challenge. Now we understand the problem much more deeply. With that in mind, what's the one thing that you want our audience to take away or act on?

Rachel Zuckerman (25:33):
Well, I think step one, if you are a healthcare leader who historically hasn't thought too much about behavioral health, is to actually try to understand the importance of behavioral healthcare to your patients and to your business, like Darby was mentioning. Even if you don't see yourself as a behavioral health provider or payer, I can guarantee you that behavioral health is impacting your patients in business, so I think understanding that is step one. And then I would encourage every healthcare leader listening to go back to your organization and understand how behavioral health inequities specifically are manifesting in your organization. And that's going to look different for everyone. But again, I can guarantee that based on whether it's socioeconomic status, insurance coverage, race, sexual orientation, there are some people in your organization's footprint that are not getting adequate access to behavioral healthcare.

Rae Woods (26:32):
Darby, what about you?

Darby Sullivan (26:33):
I would urge people to remember the truth that I think is consistent across all of health equity, which is that when we are focusing our efforts on the most vulnerable, we improve outcomes for everyone actually. So if we build our supply of clinicians and make sure that it can better offer culturally responsive care, for example, that means that everyone has better access to a patient centered experience. If we are launching new clinical trials that are more diverse and more equitable than we ever have before, that means that we have more real world evidence for everyone. So just a few examples, but pinpointing the biggest challenges and starting from there can actually pay the biggest dividends.

Rae Woods (27:16):
Well, Rachel, Darby, thanks for coming on Radio Advisory. Thanks

Darby Sullivan (27:19):
Thanks, Rae.

Rae Woods (27:20):
The pleasure as always.

Rae Woods (27:27):
Look, I know that was a lot. We spent a lot of time talking about the depth of the challenge ahead and just how difficult it will be to get all stakeholders to work together to address the behavioral health challenge. Advisory Board is just beginning to provide our support here. We've added some links to the show notes, including some cheat sheets to help you understand what to do next, because remember, as always, we're here to help.