National Behavioral Health Quality and Best Practices Voluntary Pledge - Part 3

I could see that what they were talking about really resonated with the audience and really hit home. And on behalf of HHS, I'm really thankful for their service and the work that they do. For those of you just tuning in, I'm Tim Westlake. I just brought in to be the leader of SAMHSA. I'd like to spend a moment underscoring the purpose and significance of why we're here today. And I can think I can summarize this extraordinarily complex issue by stating that we're here to create accountability, consistency, quality, and access. We're here to help millions of Americans struggling with serious mental illness, addiction, or both get on a path to recovery. And we're here to help these people get the right kind of care that they need when they need it, where they need it, at the time they need it, so that they can rebuild their lives, reconnect with their families, and live meaningfully. In just a short time, all of us will voluntarily pledge our commitment to following evidence-based practices, clinical pathways to ensure that people living with these chronic conditions and diseases can access quality evidence-based care regardless of where they live, help clinicians coordinate treatment across the continuum of care, and create measurable standards that improve outcome and using science and compassion, most importantly, with the person struggling. This is long overdue, and the responsibility falls upon all of us in this room to do this. No industry alone by itself can accomplish this. Today, two people with addiction or mental illness can receive very different care depending on where they live, what zip code they're in, what treatment program they enter, or what emergency department they end up in. We don't, in many cases, have a roadmap for people struggling with behavioral health and addiction problems to get the highest quality of care, and in ways that are meaningful to them. In the 30 years that I was practicing emergency medicine, I saw firsthand the urgency to get people the treatment and the help and the care that they need when they need it. I've seen how these small windows of opportunities when people come into contact and touch points with the care system, if those aren't in place, what happens? I've seen overdoses, the people, I could not get them medication-assisted treatment. This was before it was commonplace. They would call their family to pick them up, but before that, one gentleman called his dealer, and we found him in the bathroom overdosed. Luckily, he knocked over a coffee machine or else he would have been dead. Far too often, addiction is not treated as a chronic disease. It's treated as episodic care. Addiction is a chronic illness. Mental health is a chronic illness that needs lifelong treatment. Treatment is effective. Recovery is possible. We just need to come together to create the map and the road to get there, and this can't be done if we continue to be a pill culture where our attempts to treat addiction and mental health stop with just one encounter, one treatment, one medication. We must change how we provide behavioral health care, transform America from a pill culture into a purpose culture so we can provide the best possible care to the millions of Americans who need it at the time and the place that they need it. I'm thankful that the emergency services exist because they are the safety net for people when that system has failed, but now we're here together to take historic opportunity to forge a system that works, one with the windows of opportunity opening to care that can be given at the bedside at the time that they need it, and turn fragmented care into coordinated recovery. Many of you are already doing this work. All of us are doing this work. For many of us, this is our life's work that is coming to a head. We separately in our respective fields do this, and we can't understand, we cannot underestimate the tremendous amount of appreciation that we have for the work that everyone's doing. We're here at HHS to bring people together, best minds, the best practices, best solutions, best ideas, break down the silos, get rid of the useless regulatory burden that we see, and make sure that the people that receive the care are receiving the best care regardless of where they live. So again, thank you for being here, for reaffirming your commitment to treating addiction as the chronic disease, and for your willingness to work together using evidence-based practices and for a whole-of-person approach, and also for looking to strengthen the clinical pathways, create those windows of opportunities that we can deliver best care to the patients. I'm gonna turn over to the panel for discussions. We have three panels today, and I'll be moderating each of them. It's my pleasure to invite up to the panel Dr. Taft Parsons, Chief Psychiatric Officer at CVS and Aetna, Dr. Caroline Carney, CEO of Magellan Behavioral Health, Dr. Shantanu Agarwal, Chief Health Officer of Elevance, and Dr. Catherine Suberlack, Vice President of Behavioral Health Transformation at Humana. Thank you again all for coming up to the panel. Dr. Parsons, Dr. Agarwal, Catherine, and Dr. Carney. Thanks for being here today. We're gonna get started. We're all here today to renew our commitment to advancing evidence-based practices with high-quality behavioral health services. All too often, the payers and health plans have been seen as gatekeepers of services, and the focus had been, at least would look to be, in barriers and hoops that providers and patients had to navigate to access care, which I don't think is necessarily the truth. But we also know that the payers are incredible partners in innovating care, driving use of evidence-based practices, and improving patient outcomes. I'm gonna first open questions up to all of you. We'll do about a minute apiece. The national conversation has traditionally focused on expanding access to behavioral health services. Why is it important to shift now to an emphasis on quality outcomes and accountability? I can start with you, Dr. Parsons. All right, well, when I saw the seating arrangement, that's when I figured out that I'd be going first. So, you know, one of the things that I think for folks that are knee-deep in behavioral health have known for a very long time is that we just simply have not had enough providers giving care to the folks that need it to really kind of meet the need. I, you know, I think this is something that hit the general public during the pandemic and shortly after the pandemic. I think a lot more people started to present themselves for care, ask for care, talk about the things that they were struggling with. And that thing that we already knew on the inside became very public very quickly. What we've done since then is really worked to figure out how do we get more providers into our own networks to take care of the members that we have? How do we distribute the care better? So a lot of kind of in-office care became telebehavioral health care. And so we were able to kind of reach more rural settings than what we used to reach. But we already know that we simply are not going to have enough people to meet the total need for the population. So we have to be much smarter about how we support folks and meet the needs that they have, you know. But as we've improved access to care to the number of providers, we then started to ask the question, what are we getting folks access to? And, you know, the good thing is, you know, you can't judge the quality of care if somebody can't get into care, you know. So getting folks into care is kind of that first step. What we're now doing is really trying to say, now that more folks are getting care, more folks have providers to choose from, more folks who live in far-flung areas that Dr. Oz was talking about that may not have that psychiatrist in their zip code, you know, are able to access care through virtual means. You know, how do we make sure that people are getting actual evidence-based care, that the practitioners that are providing the care are doing what we call measurement-based care, making sure that that actually guides treatment decisions that providers are making. And that's where, you know, that's where we are still kind of in our infancy in behavioral health. We are, you know, I will say pretty far behind what's being done on the physical health side from that standpoint. And I think that we know that there are best practices out there. There's a good body of research to say what good care looks like, but we don't necessarily have the tools within the system to always measure that and demonstrate that. Great, yeah, thanks. That's a great perspective, Dr. Carson. Dr. Carney? Thank you. I'm not sure if this is on now. Thank you. So I think we have to agree on a few things. First is that mental health care is foundational to being a human. And everything that flows from our mental well-being as a human is essential then to how we build families, how we build societies, how we function in the world. It should not matter as a human with a condition of the chronic disease of addiction or a serious mental illness, what kind of care we get is different by who our payer is. We know what the evidence base is for all of the conditions that we're talking about today. We know what works. We know what individuals should get. So if I am a person who is covered by a Medicaid plan and I have access to services that my private payer would never cover, how can we ever say that we have quality of care across the system that we've developed today that's been very payer-based, that's been based on fee-for-service reimbursement instead of looking holistically, and that has been based frankly on fragmentation across the type of provider you might happen to see when that provider picks up your illness or if that provider has anyone to refer you to. And so as a payer, as a provider I like, Dr. Conway still continue to see patients in an FQHC setting. It's incredibly important that we align together to level up what quality is. Quality is more than process metrics. We have for years looked at a seven-day follow-up metric as a measure of quality of care or whether a PHQ was done, not what the results were, not what happened as a result of that screening, not what happened at the subsequent visits over time, or whether an individual who screened positive actually ever stayed engaged in care. We've looked at what has happened as a unit of care but not what's happened inside that unit of care. And that's really where we need to align together to get to level up quality. We care about it as payers and as providers because we've seen double-digit increases in costs of care for behavioral health since the pandemic, but we haven't seen markedly lowered rates of suicidality, of depression, of anxiety, of any of the conditions that we're out there treating. So something's going on and we have to fix it. Great, thank you. I really appreciate that. Dr. Agarwal. Yeah, thank you. Don't be bringing the mic up. All right, okay, great. First off, just thank you for the opportunity to be here. This is an incredibly important event and I'm glad that as a community we are really bringing the focus to behavioral health that is required. I agree with, frankly, so much of what's already been said. We do have a focus today, too large a focus on just sort of the process of care that's been occurring in behavioral health. And to some degree that's understandable, right? There is a natural evolution that's occurring in this area that's taking us from just getting to a better place of access. And believe me, that journey is far from over. We saw Dr. Oz or heard Dr. Oz really talk about some of the data there. That's incredibly important. We are not past the access issue, especially as Americans are sort of, thankfully, recognizing behavioral health, mental health issues more, and frankly, feeling more free with less stigma to come forward. That process I expect to keep continuing. And so access will have to remain an important priority as that process evolves. But to Dr. Carney's point earlier, a lot of our measures today, and measurement is something I deeply care about, I think we all do, because that is the starting point for driving appropriate care, driving value. But measurement today is largely focused, especially in high-stakes accountability programs, on processes, those transitions of care, medication adherence, certain screenings being done, but not really looking beyond that at the outcomes. So maybe I'll just add two things. One is as we think about outcomes, there's a great value to getting there because it brings behavioral health treatment on par with the rest of the system. We need to get there. It needs to be better integrated with physical health care. It needs to be part of the daily practice of medicine, and I think there's some real challenges in doing that that hopefully we'll have a chance to discuss. But I think outcomes measures align the whole system and aligns clinicians with actual patient needs. And by the way, patient-reported outcomes are a really important part of outcomes in general, and that's, I think, significantly lagging in BH today. The second point I would make is I wanna see not just integration between behavioral health and physical health, but that social health component is really, really critical. We did a survey of our members not too long ago and found that there was an incredible overlap between, let's say, food insecurity and depression and anxiety. That is not surprising, right? On the face of it, that is the human condition. When you do not have access to the right social needs, when you do not have access to sufficient coverage, sufficient care, of course it shows up. It emanates as a mental health, as a behavioral health issue. And so part of integration to me is not just that integration with physical health, which definitely needs to be discussed. I think we've made some good progress on, but how do we bring our system of traditional health care closer to the social environment and really make sure that it is integrated and that people are experiencing that integration? I think that's how ultimately we will drive improvement in all of these domains together. Yeah, thank you for that. I think something that really resonates with me on what you said as well is the regulatory burden. You all have mentioned that. And coming from the docs here in the room, we see that. And one of the things that I really look, one of the reasons I quit my job and came out here to do this is to be able to get rid of that useless regulatory burden. I call it regulatory jujitsu, where we just put in the things that will make the changes, but get rid of all of the rest of the burden. So that's something that if confirmed, I'll look at SAMHSA doing, would be to look at everything that's unnecessarily there that doesn't add to the quality. And I think we should look at that everywhere in medicine. I think the insurance companies and payers should look at that. I think we need to look at that in the hospital systems. We need to look at that at the federal level, at the state level. I think one of the things that we need to do is get rid of the obstacles that get in the way between the patients and the people that are giving them care. And that's what the system should be. And that's the vision I have for American Healthcare is providing the tools and services that gets the best care at the bedside. I know we all share that, but I think we really need to focus on it. So, and again, Mrs. Suberlak, do you wanna? Yeah. Hi, it's great to be here. First, I'd like to say thank you for elevating me to doctor. What I'll clarify is that I'm a clinical social worker and I think it's great to represent multidisciplinary individuals up here, particularly piggybacking off of what you talked about about the experiences of our members that require whole person care. So, agree with so much of what my colleagues have said. What I would add is why quality is important beyond just the access piece is we're very interested in understanding not just are our members being seen, but are they getting better? And what does that look like from a perspective of right care, right time, and in the right place, meaning talking about the patient stories we heard earlier today, we wanna ensure that we can reduce suffering. So many in this room, I see head nods, you know this, but often an individual who experiences a chronic behavioral health condition, they may suffer for close to 11 years before they are receiving the care required to have recovery. And I think as good stewards of both taking care of our members and the provider experience, we can create a simpler opportunity for both reducing friction, reducing how you access that care, and then overall feel better. Great, thank you for that perspective. Kind of jump around a little bit. I think this is an important question. I'm gonna start with Dr. Parsons. I'm gonna go, if you could advance one policy system or change, if you could kind of wave kind of a magic wand over the next five years to improve behavioral health care, what would you do and why would you do it? Well, one of the things that we continue to go back to in conversations with the providers that are within our network is from a behavioral health perspective, one of the things that happened when they brought in meaningful use requirements in the HITECH Act is that behavioral health was kind of left out. And so we have a substantial portion of our provider network in behavioral health that is not using an EMR that meets meaningful use criteria. And what that does, especially when we're trying to look at quality that's a little bit beyond what you can find in a claim that gets submitted for payment. So claims, so insurers, we get a large amount of data about a very limited set of things. What comes across in a claim is like, who was the person, who was the provider of care, what setting was it in, what diagnosis was treated. But there's not a lot more that we get. We get that for a lot of people. But we don't really know that beyond that unit of service that was delivered, did that clinician use a measurement-based tool to assess the severity of the condition? And was it an appropriate tool for the condition that the person's diagnosed with? We don't have that level of visibility to be able to make a judgment of whether or not that person's getting good evidence-based care. And on the physical health side, the use of meaningful use EMRs has really helped to advance that discussion. It's helped with national quality standards. It's helped with the conversation going into value-based care. And that's something that we don't yet have on the behavioral health side. And so I think that if there is a policy issue to be addressed, it's kind of bringing the behavioral health providers up to speed from an EMR perspective because that facilitates a lot of these kind of discussions and conversations that we can have about the use of clinical care pathways, about how that changes the manner in which we contract with providers. And so that's a big issue for us. Yeah, that's a great perspective. Thanks. Thank you. Dr. Carney? Mine is a very different answer. And so I'm going to say I would fundamentally blow up the system of care as we have it today and look at a very different model of care. We have a model of care that could work, that we've seen in other parts of health care, that should be led by individuals at the highest level of their license. Those today are psychiatrists, and we have dwindling numbers of psychiatrists across the country. And in a team-led model of care, we can see thousands of patients on a psychiatrist's panel instead of hundreds of patients. A psychiatrist at the top of a panel or an equivalent physician can then work with the therapists, the peers, the faith-based organizations in the community, the social connectedness that we need to have in that system of care, and really create a team that gets the diagnosis right from the top, and it trickles down to ensure that the right care pathways are used, the right evidence is used in terms of treatment, and the right reach into the community and into the patient's other needs are being met. Maybe that's a dietician. Maybe that's a worker in the peer space or in the addiction space. But we can set up a model of care where we can really expand the reach of the psychiatrist into a much greater level than it is today. And we see some models like this in the FQHC setting today. I'm going to talk about one that's very near and dear to me where we created an integrated behavioral health clinic into an FQHC that now has wide reach into the community. Yesterday morning in rounds, just yesterday, a very well-seasoned therapist said to me, Dr. Carney, we have a patient who has depression as a diagnosis and bipolar disorder as a diagnosis. How am I supposed to treat this person? How is it they have both diagnoses? If that's the level of thinking that a therapist may have because they haven't been trained in the hierarchical use of diagnoses, then we're going to get off on the wrong foot of care almost every single time. We can fix that by creating a different model across every community in this country that will work. And if that model is foundationally where people first come to care, whether it's in primary care or whether it's in specialty medical care, that group, that model can then extend into inpatient care and other levels of care to pull everything together. It is the quarterback of behavioral health care that we could use to ensure that no one falls through the cracks and that we are linking from inpatient to partial to residential to outpatient care in a holistic, patient-centered, integrated way. Yeah, that's awesome. The ideas that you guys are, that we've had are just amazing. I'm so grateful that y'all are here and that we're able to share these. I think that's what we need to really transform the system that we have into what the system could be, not just what it has become. Dr. Agrawal, we'll take a crack at it. What do you think? Yeah, so again, there's just so much potential between HHS and CMS and other agencies on what can be done to further this field. I think the whole audience knows, right, like the incredible role that you all play in clinical standards, in quality, in payment, in value-based purchasing, in the adoption of technology, to Dr. Parson's point, all incredible, all very important and cannot be overestimated. There is one point that I just wanna focus on a little bit, which is the education of clinicians and other health professionals. Again, CMS and HHS play a really important role. And Tim, you're an ER doc, right, I'm an ER doc. I would bet that you, like me, feel so much more comfortable treating hypertensive urgency and emergency than depression, than anxiety, than bipolar disorder. That's a problem, right, especially in a system that continues to have access issues where there are going to be ER docs in every community but not maybe a psychiatrist in every community. You don't always have the opportunity to be surrounded by behavioral health therapists and experts like I happen to be here at this table. Right, not everybody has that asset. So how do we make sure that this area, again, the whole point is let us not make it exceptional. Let us make it part of the normal standard of care delivery that everyone gets to experience. And in order for that to happen, it needs to be part of the daily education of our clinicians. So again, I think an incredible role that HHS plays, I think it needs to be embedded in all of the residency programs and the undergraduate medical education in all of the different clinical fields so that one day, and I don't think it's happened yet, but when an ER doc graduates from a program, they'll say, yeah, I will go treat that depression or that anxiety patient because I know exactly what I'm doing. I'm as good at that as I am trauma. Thank you. Ms. Zuberluck. The benefit of going last is I get to just build on the ideas that have already been shared. Where I would love to expand on the model of care that Dr. Carney so eloquently said is that I do think it can be bidirectional and done well can both simplify it for the patient, but then also if we can reduce the administrative burden. So if it is about dynamiting it, which I do like, it offers us then to also build in peer supports for individuals with lived experiences, having it be patient-centered. We've done incredible work as a country over the last several years to reduce stigma, but I think we still have quite a bit where we in this room can identify those that may need care, but are individuals engaging? So they may access it, they may know where to go, but how can we maintain their engagement in high-quality care so then we can see prevention in relapse and prevention in ongoing episodes? So I think both being bidirectional, because I completely agree about the specificity. If we do not get the original treatment and identification right, it can become very complicated. What I would call into that too, it was brought up earlier, which is leveraging digital technologies to also get it right from the start. If we think about that patient case that you brought up that just happened yesterday, I as well have seen patients for over 20 years, west side of Chicago, started in FQHC, so sat through several of those morning huddles, know exactly the scenario that you're talking about, and it's all too common. And it's often because individuals with behavioral health conditions, whether that is mental illness or substance use, present at several different places. And they may have short stays, they may interact with a workforce that maybe has not received the highest quality that we can provide. And so at their next point of care, you may be looking at a host of diagnoses that don't help you in that point of care. And so how can we both identify early, leveraging technologies that are available to us today, looking at that 400 page medical record and getting to it quickly, leverage and optimize the entire workforce from patients with lived experiences all the way up to our highest trained individuals, and go both ways. So there's kind of no wrong door for our members, which then lastly, what I would add, would just reduce the entire system. Because if we can build what Dr. Carney and the rest of my colleagues have described, it can reduce the burden for those specialists, for those primary care providers that we would like them to work doctor's license as well. So then how can we offer our expertise to wrap around that member experience and ensure that they're getting the best care possible? Great, thank you guys so much. I really appreciate y'all coming, taking the time to come out here. That was, I think, an amazing panel. And I really appreciate your work and your service.