We are in the midst of a mental health crisis in the U.S., but there are signs of hope. Stigma has decreased, and there are new innovations like virtual care. These innovations allow millions of people to access the mental health care they need.
In this episode of the HealthChangers podcast, host Ashley Bach spoke with Dr. Mike Franz, executive medical director for behavioral health for Regence. Besides overseeing behavioral health programs across our four states, Dr. Franz is also a practicing psychiatrist. He discusses what Regence is doing to improve mental health access and what innovations are on the horizon to help more people get care.
Listen to the full podcast episode on the player above. Below are some highlights, which have been edited for length and clarity.
AB: Dr. Franz, you appeared on the HealthChangers podcast a year and a half ago to talk about the state of mental health in the U.S. What has changed since then, and what has stayed the same?
MF: We are definitely still in a behavioral health crisis across the country, and certainly in our region here in the Northwest. There's still very high demand for behavioral health services that's due to very high prevalence of diagnosed and diagnosable behavioral health conditions, as well as some general malaise and stress that we continue to feel as a society coming out of COVID, and along with the political discord and division we see in the country, as well as some other concerns, such as climate change and the impacts of social media on our youth.
Just recently, the U.S. Surgeon General recommended that we put a warning label on social media, as we do on cigarette cartons in boxes. This is a major recommendation about the potential harm that can be done with social media to our youth. So that's something that's evolved since we last spoke, more of an appreciation of the danger, quite frankly, of social media for kids.
Also in our youth, we are seeing more concern around the fentanyl epidemic that's been ravaging our adult population now for several years. We're seeing an uptick in accidental overdoses of youth in regards to fentanyl, because it's in almost all illicit pills and substances now, and there is increasing need for campaigns to make people aware that you cannot take anything off the street right now without assuming that it's going to have fentanyl and potentially cause an overdose and death.
I would agree with you, we have seen some decrease in the mental health stigma, just because every family, it seems, is struggling with some sort of behavioral health issue, or someone we know, if it's not ourselves. This is an issue that crosses red and blue states, Republicans and Democrats. It's one of the few things that actually unites our country right now, is the understanding and the desire to try to develop solutions to address the behavioral health crisis. So in that regard, if we've got to look for a silver lining, it's a bit of a unifier, and we should leverage that as much as we can.
AB: What is Regence doing to improve access to behavioral health care for its members?
MF: We're doing quite a bit in this space.
- We have a “virtual-forward” approach, where we are proactively continuing to bring on national and regional virtual behavioral health providers, as well creating policies for brick-and-mortar providers to be able to render services via telehealth as well as in person. We appreciate that a hybrid approach (between virtual and in-person care) is often most effective and quite frankly, often desired by our membership. All in all, we've added over 3,600 individual behavioral health providers across our four states in just the last two years.
- We've also brought on additional provider types, or licensure types. We've brought on licensed professional counselors and licensed marriage and family therapists, in addition to social workers. And then we've also adjusted something, and this gets a little bit in the weeds, but something called our “incident-to” billing policy, which allows for unlicensed providers who finished their terminal professional degree. So they've gotten, say, their master’s degree in social work, but they don't yet have their licensed clinical social work license. As long as they're under supervision and working with the board towards licensure, they are now able to render services to our members, which has greatly expanded the network available to see our members.
- Additionally, we are working to improve our provider directory. It is certainly not perfect yet, and we have a long ways to go, but we have updated information related to the providers, including their competencies in various cultural aspects, such as the LGBTQ+ community, and in helping our members who might have a preference for an ethnicity of their provider. We're dependent on the providers to provide us this data, but when they do, we can get it in our provider directory to give our members better understanding of the choices that they have in regards to matching with the most appropriate provider.
- We are also continuing to increase reimbursement across our network so that we can remain attractive to bring on new providers. I think that's one reason we've been able to bring on the 3,600 providers that I've mentioned, as well as to retain providers that we have in our network.
- And finally, our corporate foundation (Cambia Health Foundation) has engaged in significant giving to the community in the order of a million dollars just in the past year to strengthen the behavioral health care workforce in our four states.
AB: I was curious what you mentioned about improving provider directories. What kind of impact does that have on our members when they are able to search for doctors by their cultural competence?
MF: It allows for a better match. It allows for the member to have a more open and transparent patient-provider relationship. It engenders trust with the provider when the member feels like they're actually matching to someone that may better understand them, their culture and their needs. It can also make a real impact clinically, on the outcomes that they get out of that relationship.
AB: What role will virtual care play in improving behavioral health access, not just in the states Regence serves but nationally?
MF: There has just been a tremendous amount of venture capital moving into the behavioral health space, really, since the beginning of the COVID epidemic. I, quite frankly, welcome this because we have not moved the dial in 30 years or so in regards to significantly improving either access or outcomes and certainly costs of care when it comes to behavioral health.
Less than 20 percent of the brick-and-mortar behavioral health community uses any form of measurement-based care, and therefore we don't know what we're getting from that treatment. I like to say sometimes it's “50 minutes and a fern,” and we don't know what else. Whereas these national virtual providers are really able to demonstrate that they're improving outcomes and people are getting better.
Across the nation, (virtual providers) really allow for unique ways to access care where it can be done from one's home, one's car, almost anywhere. And not only is this convenient, but it obviates the need for driving 30 minutes, 45 minutes across a metropolitan area to get to an office, let alone just providing any access for care in a rural or frontier area. So in that regard, it's been transformative, and it makes it much more efficient for both the provider and the member.
AB: What have been the results of virtual care?
MF: The national data suggests that people like it just as much as in-person care once they do it, that they have the same or better satisfaction with it. And in the outpatient world, outcomes look to be just as good if not better. And as I mentioned earlier, it creates a more sustainable and satisfied (behavioral health) workforce.
And for Regence members, we have shown that our national virtual providers can usually get our members access to care within two days. This is very different than the weeks to months that we typically hear about in the brick-and-mortar world, predating virtual care.
AB: You've spoken about the importance of integration in improving access to care. For instance, we have a historically siloed community mental health system that is largely publicly funded. And then we have primary health care facilities, like pediatricians’ offices, that could also be used to address mental health needs. How is our health care system so siloed, and how can integration help increase access to behavioral health care?
MF: Historically, behavioral health has been very siloed from the medical world. I'm even going to go back 15, 20, 30 years, where it was very common that we had different behavioral health and medical payers. It's only in the last 10 years or so that we've developed integrated health plans that actually manage and reimburse in an integrated fashion for behavioral health and medical services.
Another topic you mentioned, which is this historical divide between the publicly funded behavioral health world and the privately funded, so just let me break that down a little bit. The publicly funded world, which I think of primarily as Medicaid and indigent funding, is usually done at the state level, even down to the county level, and stood up what have been called community mental health centers that often report up and are managed by, in many cases, county commissioners or elected officials.
Whereas in the medical-surgical world, we have health delivery systems and networks of providers that have CEOs or are independently owned and operated. Well, these community mental health centers offer really important treatment, and specifically some clinical models that are critical for everyone to have access to, even if that patient is not publicly funded, or is uninsured and relying on general funds from the state. Likewise, the privately funded health care organizations have historically relied a lot on commercially insured members that may reimburse more, and target working with those members, perhaps more than some publicly funded members.
But what we need to do is say commercial members need to have access to these community mental health programs that have historically been publicly funded. And we need to start working together.
That takes me into maybe the most important and active area that I'm working on, and that is the integration of behavioral health into medical settings. This is moving behavioral health care into the primary care office, making sure that those teams are staffed with behavioral health professionals as well as medical professionals, and fully integrated working as part of that team, going to morning huddles, being available to do handoffs with the primary care provider to the behavioral health professional, tracking outcomes and metrics holistically that include not just how patients are doing with their diabetes, but also with their depression.
And the opportunity extends beyond primary care. We can do this in specialty medical offices, like oncology, cardiology, endocrinology. And this also extends to more acute settings, such as the emergency department. For instance, a patient might get admitted through the ED with pancreatitis, but it's secondary to alcohol use disorder. They get moved upstairs to the fourth floor. They've got a weeklong stay. And in the old days, that patient may never have a behavioral health assessment, or may never even talk to someone about their alcohol use. That needs to change, and it is changing such that we understand that the pancreatitis, which does need to be treated in a medical setting, is driven by an underlying behavioral health condition, so we have to bring that treatment into that environment and do it holistically.
AB: You mentioned how much progress we've made, even just from a decade ago when we had different payers for behavioral health. Do you find that the trajectory of the rate of innovation, and even reduced stigma, has sped up in the last few years, or has it all been fairly steady over the last decade or so?
MF: It sped up, but COVID turbocharged this. It turbocharged the appreciation that so many of us struggle with behavioral health conditions, and that everybody essentially is vulnerable, no one's immune, and that it's okay. It did decrease the stigma, which just really accelerated the ability to just talk about it and bring it out into the open.
And then also, it really highlighted the interdependence of behavioral health and physical health. In the last 10 years, there's been a tremendous amount of data indicating that untreated or undertreated behavioral health conditions really drive poor physical health outcomes, and that the vast majority of the costs of someone who's struggling with both behavioral health and physical health conditions is borne on the medical side. Let's say we have a patient with coronary artery disease who also has comorbid depression. If that depression is not effectively treated, that patient may cost two to four times more than the patient with coronary artery disease that does not have a behavioral health condition. And of that two-to-four-times increase in cost, 80 percent is borne on the medical side. So now the financial leaders appreciate that addressing total cost of care and bending the cost curve really depends on having an effective behavioral health system that's integrated into the broader system.