How we think about mental and behavioral health has changed significantly in recent years. While we’re seemingly heading in the right direction, a wealth of evidence suggests we still have a long way to go in achieving better outcomes for more people.
We recently sat down with Regence Executive Medical Director of Behavioral Health, Dr. Mike Franz, to discuss how attitudes have changed, what the future of behavioral health could look like, and how innovative approaches like community-based initiatives and digital platforms could impact the field in years to come.
You’re both a healthcare executive and a psychiatrist, so it’s not surprising that the mind-body connection is a passion of yours. Could you tell me a bit about how healthcare is changing to integrate behavioral and physical health better?
Dr. Franz: For the past ten years of my career, my priority has been on this issue—trying to figure out how we further integrate behavioral health and physical health or medical-surgical health. But that’s a false dichotomy; there never really has been just behavioral health or just physical health. I’m pleased that the field has started to learn that over the past ten years or so. Everything we do in behavioral health is health. Whether it’s depression, anxiety, low-line stress, or more severe behavioral health conditions like schizophrenia, they impact our overall physical health and vice versa. The same happens for physical health conditions affecting our behavioral health. Then you put the social determinants of health on top of that, you start to get close to the soup that we mix that creates our overall health experience.
The other part of that is what happens on the health delivery system side of things, and that’s where I’ve seen an opportunity. We’ve done some good work in recognizing that we need to move behavioral health screening assessments and treatment into settings that are more traditionally medical. Starting with primary care, we have initiatives underway at Regence to further support and financially sustain the fidelity integration of behavioral health into primary care settings. But it doesn’t end there; we need to do that in other medical settings, especially outpatient medical—from women’s health services to cardiology, oncology, and endocrinology, and also in the hospital facility settings that have historically been medical, doing proactive psychiatric consultation on med-surg units. For example, a patient admitted with pancreatitis through the emergency department is sent upstairs to the medical floor, but it’s their alcohol use disorder that’s driving their underlying issue.
We need to address that while they’re a captive audience on the med-surg unit. The behavioral health treatment received there is just as important, if not more important, than the physical health treatment to address the underlying causes and have a better whole health outcome. That’s just one example. I chose the hospital setting, but we’re starting in primary care. Why? Because it’s going to reach the largest population and build up tools so that the primary care providers and their teams can adequately assess and effectively treat mild to moderate behavioral health conditions without the need to refer them out to specialty care.
Primary care is important because we know that people do not always go to specialty care when referred. Only 30 to 50% ever show up for their first appointment, and there’s a lack of workforce and access to specialty care. The more we can do to leverage and scale up primary care to treat the population’s behavioral health needs, the better. That is for the mild to moderate population; once you get into that moderate to severe population, specialty behavioral health, like NOCD, is going to be indicated to address the underlying behavioral health condition.
You work a lot with children and adolescents. Are you getting the sense that stigma is lessening around mental health among younger people, and if so, what does that mean for the future of mental healthcare delivery?
Dr. Franz: Absolutely. One silver lining from COVID was the focus on people’s behavioral health and allowing it to be okay to address that and get some help. I think that’s continued, and I think our younger generations believe in that approach, probably even more than older generations at this point. I have two young daughters, and around our family dinner table, we frequently talk about behavioral health issues, behavioral health conditions, and stress at school. We know the same conversations are happening throughout the country.
Unfortunately, we have this increased prevalence of behavioral health conditions that started well before COVID—probably with smartphone availability, social media, and more recent stressors. I know gun violence tops the list of concerns of young people, followed by climate change and political discord. These issues, combined with COVID and the experience of young people missing out on so much, have led to a surge, unfortunately, in depression, anxiety, eating disorders, and OCD, unlike we’ve seen in my lifetime. Fortunately, there’s been a concurrent understanding of the importance of addressing behavioral health, and a decrease in stigma.
We like to think that we’ve come a long way in terms of how we think about mental health. In which areas are further changes urgently needed, and in what ways will behavioral health systems bring them about?
Dr. Franz: It’s a two or three-pronged approach. Number one, we still need to invest more in community-based resources. We need to create the capacity for effective, lower levels of care to treat patients so that they don’t rise to higher levels of care where they’re already maxing out system capacity. For example, I think we need to make sure both Medicaid and commercial members, regardless of insurance, can access the historically siloed community mental health system that has been publicly funded and outside the domain of traditional medicine. Community mental health programs often cascade up in a governance structure to a local mental health authority. A county commissioner runs the public and Medicaid-funded behavioral health system. Hospital and health delivery systems are outside of that. They run up through CEOs, whether they’re nonprofit or private.
So we have this very different system for how we manage behavioral health and physical health. We need to ensure everyone has access to the same great existing services. Those community mental health programs often have crisis respite programs, mobile crisis services, outpatient programs, intensive outpatient programs, early-onset psychosis programs, assorted community treatment programs, in-home behavioral health treatment, and all of these things can help keep people in their homes, in their communities, and in their schools getting effective treatment.
The private sector does a good job, too. We just need to blend these because each sector offers something different. If we do that, we have a mental health system that can help us recover in the community setting and, in many cases, prevent the need to go to higher levels of care.
Unfortunately, right now, we don’t have that capacity, and we don’t have those systems built up in the community. Some of our members, for example, may be commercially insured members and may have access to fewer systems than Medicaid, which might seem ironic to some folks. On the other end, though, I have to say we’re in such an emergency right now with access. We have young people sitting in emergency departments for days, weeks, and even occasionally months—which is a horrible, inhumane practice called “ED boarding”—because there is no higher level of care available to get into. So while we build our community levels of care, we also need to let out the release valve to get these folks out of the emergency department, and get folks who can’t be safely treated in the community access to a brief stay in a subacute program or a residential program, inpatient psychiatric treatment or detox.
We have to attack both ends of that spectrum. I said a little about integrating this publicly funded historical behavioral system and this more privately funded medical system. But beyond that type of integration, we also have to build integration of behavioral health so it takes place in every medical setting and with kids in schools—because these are where the kids are, right? They’re in pediatric offices; they’re in schools. Unfortunately, they might have to go to a specialist or an emergency room. The same is true for adults. To build that capacity to meet our population’s health needs, we must move behavioral health treatment into those settings.
In what ways can innovative approaches, such as digital platforms and AI-driven interventions, contribute to overcoming barriers to access and making behavioral healthcare more widely available and inclusive?
Dr. Franz: I was initially skeptical that digital platforms could move us in the direction we need, but now I welcome some of the behavioral healthcare delivery system disruptions that have come out of COVID. There was recognition that we haven’t moved the dial in behavioral health outcomes in decades—30 years, or more. Then we’ve had this groundswell of privately, often venture capital-funded companies move into this space with virtual health solutions.
Some are better than others; there are bad apples in every basket. But on the whole, I think it’s been a welcome disruption to the system, partly because it’s moving us towards measurement-based treatment due to the digital platforms that are used as the interface, and I think that’s really one of the unique things. The other thing is for those for-profit companies, the investors or the stockholders, they want to see the solutions work, and they want to see good returns, which usually means good outcomes.
As the health plan, we want to see measurement-based care that indicates our members are improving; that their PHQ-9 scores are decreasing, and that their GAD-7s are improving. That they’re having fewer admits to the ED or the inpatient unit. Maybe they have a quality of life score that’s reported. Digital platforms allow that data to be collected pretty much at every interaction between the national digital provider and our members. Not only does that allow us to see that our members are improving, but also maybe that we’re decreasing the total cost of care. Ultimately, we want to take those metrics and put those in alternative payment methodology contracts so that the provider, if they improve our members’ healthcare condition and decrease the total cost of care, gets reimbursed on the value they provide, rather than the historical fee-for-service model, which reimburses just for volume.
There’s this major opportunity for digital to move us to pay for quality, outcomes, and measurement-based care, and I think it’s where the workforce is going. We have data that suggests patients like digital, virtual interactions just as well as face-to-face. And the quality outcomes generally look favorable. We’re now taking a virtual-forward approach to solving the access and quality problem because of all that.
AI is very promising. My best hope at this point is that it could become an extender of sorts that helps leverage a scarce workforce so that we can use it as a tool to reach a large population with effective treatment.
But I also have to put in a plug for good old psychotherapy. There are organizations like NOCD that have proven that if you can do an evidence-based, fidelity type of psychotherapy, like exposure and response prevention (ERP), for a specific disorder such as OCD, it’s the best treatment out there. So let’s not get too focused on the best and greatest technology; a therapist who can do exposure and response prevention to fidelity is worth their weight in gold.
What kind of an impact can organizations that can accurately identify and effectively treat specific conditions have in lowering costs in the behavioral health system?
Dr. Franz: Some conditions, such as OCD, don’t get identified or treated sometimes for 10, or even 20-plus years. There are huge costs from the impact of that delayed treatment on the person’s level of disability, whether it’s subclinical or more than clinical functioning in the home, occupationally, as a parent, or as a child in their relationships. Academically, it has real impacts and can affect the overall trajectory of one’s life outcomes. Because of that interaction with physical health, it can also combine and create chronic medical conditions.
Someone may be nearly housebound because of their OCD, and maybe they aren’t getting enough exercise because of fear of an environmental concern or contamination issue. They’re going to be sedentary. Maybe they develop diabetes or another metabolic issue, or a cardiac issue because of that. All these things are tied together. If you can treat the underlying behavioral health condition—in this case, OCD—you can either prevent or completely change the course of the comorbid chronic medical condition—in this case, diabetes.
This is huge because if you have a comorbid behavioral health condition like OCD with a medical chronic condition like diabetes, the total cost of care of that member is going to be two to three times as much on average as the member that just has diabetes without the OCD or without any behavioral health condition.