The number one driver of healthcare costs in the US is behavioral health—a crisis that has only been exacerbated by the COVID-19 pandemic.
Join Kat McDavitt, Head of External Affairs at Collective Medical and Dr. Enrique Enguidanos, CEO and Founder of Community Based Coordination Solutions as they interview Dr. Scott Zeller, VP of Acute Psychiatry at Vituity and Deborah Jean Parsons, Ph.D., Director of Integrated Care at Aspire Health Alliance to discover the challenges facing both behavioral health care teams and their patients.
- What behavioral health looked like pre-COVID
- Why behavioral health is separated from physical health
- How the pandemic has exacerbated behavioral health needs
Listen to the full episode on Spotify, or on Apple Podcasts. Continue reading for excerpts (edited for length and clarity) from the conversation.
Enrique: Can you provide an overview of the status of behavioral health pre-COVID?
Scott: I’m really focused on the acute care side of psychiatry, both in emergency departments and hospitals. Before COVID, I think one of the main problems around the country, at least in my area of focus, is inadequacy of opportunity for care for a lot of these high-acuity patients.
Interestingly enough, the highest acuity patients on the behavioral health spectrum have traditionally been the most underserved, which doesn’t make any sense. That’s like saying you have places where people are getting a lot of heart attacks and you don’t really have anything for them, but you do have a place where they can go and learn about good nutrition. And that’s unfortunately what we’ve seen a lot of in the pre-COVID space. COVID has exposed a lot of these shortcomings.
Deborah: First and foremost, Scott is spot on that the patients who are in the most pain, suffering, and need in behavioral health care are the ones that have been the most misunderstood and least served. This is a population that has gone years and years without lack of access because we call it behavioral health and put it in a separate category and make it other, which makes it less than. We don’t provide them with the continuum of care that they need. If they had cancer, we would never have someone boarded or tell someone they have to wait months for chemotherapy because we don’t have an opening.
It’s a separate, and less than, system because of the way we pay for behavioral health services. We have set up separate systems for physical health coverage and mental health coverage. We have separate insurance systems, authorization systems, and providers. We’ve made them completely separate and separate does not mean equal in this case.
Enrique: I don’t think many people understand the background of why payment is different. Can you dive into the payment issue a little deeper?
Deborah: It goes all the way back to how we understand mental illness. It wasn’t too long ago when we used to call people crazy. The whole idea of mental is that it’s something different than physical. So, that’s why a separate system of care was developed in the first place. We never considered it a bodily problem, which it is. We know it’s real neurophysiological, biochemical disruptions in the brain and in the body. But, we didn’t understand that years ago. It really came out of developing separate expertise to treat it and it’s never been integrated into physical healthcare.
However, I do see hope on the horizon. Massachusetts is redesigning, fundamentally, how we pay for and deliver that care to our Medicaid population. They have carved in behavioral health services as part of the payment instead of carving it out. The idea is we’re going to do what we should be doing—which is getting to these vulnerable patients, finding out what they need, and getting them what they need in real time.
Scott: The main problems that I’ve seen here in California where I live is that the carve-out system is so predominant for mental health. So, the idea of bringing it back into the fold, making it part of the central system is important. The brain is part of the body too and we’ve got to quit pretending it’s in a different bucket. That also adds to the stigma of mental health. A patient might think if they are problematic if they have a behavioral health condition, because it’s not something like diabetes or asthma, which are treated so separately.
Kat: From what we’ve heard, we should be expecting a massive increase in people with behavioral health concerns because of the COVID-19 pandemic. What do you think we’re up against in the next couple of months?
Scott: I think there’s a universal opinion among people who work in behavioral health that we’re going to see an enormous increase in behavioral health demand. There’s just been so much that’s been bubbling beneath the surface with everything going on. We’ve been missing out on what it’s doing to so many people; how the stresses are really bringing out a lot more of their underlying mental health concerns.
I think every one of us is expecting that as more people are allowed back out into the community, that people are going to realize they really need help. For example, knowing that they were close to suicide or became dependant on drugs or alcohol while being stuck at home for months. And that’s just scratching the surface. I think we’re going to see an incredible amount of demand and I think many of us have been cognizant of that and preparing for it. But I don’t think we’ve even really started to imagine how we’re going to deal with everything once it starts coming.
Deborah: We’re already seeing the demand for behavioral health services go up. And again, unless we’re going to pay for this kind of service, the waitlists are going to get longer and longer. One of the silver linings I see is that perhaps this is the time we can take mental health off the back burner. There’s going to be people from all socioeconomic statuses who are suffering from mental health problems. Maybe this is a way to highlight that mental health is legitimate, just like any other condition. Maybe we can use this as an opportunity to say, we have to do better in our healthcare system by opening up access, paying for more therapists, and recognizing that it isn’t just the down and out that struggle.
Scott: I couldn’t agree more than we really need to bring mental and behavioral health treatment into more parity by understanding that this is just the same as any other medical affliction. I think some of the biggest pushback that we get on this is from our own colleagues in behavioral health, who almost wanted to remain separate because they worry that integrating with medical care is pushing in the wrong direction.
Deborah: One of the fears of community-based mental health centers, right now in Massachusetts, with integrated care is that they will lose their own identity as a separate service and be bought out by the healthcare system.
I happen to feel differently about that, because I see this as an opportunity for more parity for behavioral health, when we incorporate it into the healthcare system. When we make it equal and worthy of the same care and payment, I actually think we’re going to improve it. But it does mean a different role for community-based providers. And it means an acknowledgment that we need to work together in order to help the people we’re trying to serve.
Enrique: Virtual care was a huge topic in our podcast episode last month, do you see that moving forward with behavioral health?
Scott: I think it’s going to be enormous. I was fortunate enough to be part of the first on-demand telepsychiatry organization in the country 15 years ago. Back then, people were saying it would never work.
Even pre-COVID, we saw an enormous acceptance of telebehavioral health, teletherapy, and telepsychiatry within clinical settings. It was already becoming a billion dollar industry. What’s been amazing is that COVID brought in some rapid changes in laws and we’ll see whether or not they remain temporary. Everything being done in behavioral health, and many other medical specialties, that had to be done in person before can now be done via telemedicine and compensated the same as in-person treatment.
By doing that, the people using it exploded and made people feel much more safe because they weren’t in a situation where they were exposing themselves to potentially infectious individuals. It also eliminates many of the delays, driving between sites, and people who can’t make it in or are late. All these things can be better done if you’re just doing it online. The fact that Medicare, for example, was restricting telepsychiatry and telemedicine to only rural locations in the past just didn’t make any sense. Because it can be just as difficult for a doctor to see two patients in the same city with busy traffic in between those two sites, as it would be for them to drive 100 miles between small rural communities.
I think what they’ve really learned from COVID is that beefing up access is bringing us into the 21st century in terms of technology. We can do wonderful visits with high-definition video technology and work together with our behavioral patients in a way that’s beneficial. We need to continue this and not go backwards, but only forwards.
Deborah: I think we’ve taken the genie out of the bottle and it’s going to be really hard to put that genie back in the bottle. Now, we have clear evidence that people accept this form of therapy—that it is an effective tool to open up access for both behavioral and physical healthcare. It’s just as legitimate as in person, and sometimes even easier and better.
We’ve seen regulations change, and I think it’s going to be hard for them to take those back now that we’ve been in place. In Massachusetts, we’ve seen data on usage, and it has not only skyrocketed during COVID, but the number of new people entering into services has gone up as well. It’s evidence that this is a new way of doing business. Telehealth doesn’t eliminate face-to-face or other kinds of services, but it’s another tool in our tool belt that’s just as effective as traditional models of treatment and care.
Resources for Physicians
About the Speakers
Scott Zeller, MD is Vice President of Acute Psychiatry for the multispecialty medical partnership Vituity. Prior to joining Vituity, for 20 years he was Chief of Psychiatric Emergency Services of the Alameda Health System in Oakland, CA. During this time, Dr. Zeller developed the innovative approach to eliminate emergency department psychiatric patient boarding that became known as the “Alameda Model”.
Dr. Zeller is an Assistant Clinical Professor at both the University of California-Riverside and Touro University medical schools and is Past-President of the American Association for Emergency Psychiatry. He is the author of multiple textbooks, book chapters, and numerous peer-reviewed articles. Dr. Zeller is known as the creator of the EmPATH Unit concept (Emergency Psychiatry Assessment, Treatment and Healing Unit) and as the co-inventor of On-Demand Emergency Telepsychiatry. He also founded and directed Project BETA (Best Practices in the Evaluation and Treatment of Agitation).
Deborah Jean Parsons, Ph.D., Director of Integrated Care at Aspire Health Alliance is an experienced professional in the fields of children’s mental health, social services, and healthcare in Massachusetts—working for over 25 years in program design, operation, and management and serving as a consultant for the Association for Behavioral Healthcare and adjunct faculty at Quincy College, Lasell College, and the University of Massachusetts at Boston. She currently leads two Community Partner programs in a Massachusetts Medicaid incentive program, providing high quality care coordination for adults who have complex physical, behavioral health, and social needs and integrating primary care, behavioral health services, and social resources to achieve healthier outcomes and community stability.
About the Podcast
The Collective Conscious is a monthly podcast aimed at addressing gaps in healthcare for some of our nation’s most vulnerable patients. Each month, we’ll meet with healthcare leaders to discuss what care teams, communities, and government agencies are doing to better support individuals with unique care needs—this includes mental and behavioral diagnoses, substance use disorder, homelessness and social determinants of health, and other complexities of care.
About the Hosts
Enrique Enguidanos, MD, MBA has over 20 years of clinical experience in emergency medicine—much of which has been spent also serving in organizational and systems management roles. As CEO and founder of Community Based Coordination Solutions and a practicing ED physician, he has spent over a decade developing and fine-tuning systems of care and community management systems that have proven very effective for frequent utilizers. He has organized these systems in a manner that allows CBCS to continuously reproduce care results across varying communities and healthcare systems.
Kat McDavitt is Chief Marketing Officer and Head of External Affairs at Collective Medical. With over ten years of experience in healthcare marketing, communications, corporate, and government strategy, she has positioned healthcare companies from small angel-funded start-ups to multi-vertical public corporations. Her knowledge of the healthcare industry spans both clinical and administrative innovations—as well as professional services—in the patient, physician, institutional and payer markets.