Behavioral Health Stigma- Alive, Thriving…and Very Much in the Way of Healthcare Operations

I’ve been in the behavioral health (BH) field for forty-three years, so I’ve had opportunities to look at BH treatment and integrated treatment operations through many lenses. We are better off than when I entered the field in 1976, but not significantly, and I believe that a version of stigma is the root cause. I don’t believe its intentional, overt stigma causing the barriers we’re dealing with. Instead, I’d call it ‘covert’ or perhaps ‘micro-stigma’ and I define that as failing to effectively manage evidence about the role of BH in treatment needs and outcomes in favor of other priorities.

Let’s take a look at some simple statistics on the prevalence and cost of BH care, and the effect of BH issues on general healthcare.

2018 Open Minds article (paraphrased): 32 states do not adequately enforce and/or have weak laws to enforce parity laws enacted a decade ago.

2016 Brief, Centers for Healthcare Strategies, Inc (paraphrased):

o  1 in 5 people in the US experience mental illness (approximately 42 million people) and they account for HALF of total Medicaid expenditures.

o  The addition of a BH diagnosis to a common chronic physical condition can increase treatment costs by 75%

o  US healthcare costs are now nearing $3 trillion annually- and 31% percent of that cost could be directly attributed to behaviorally influenced chronic conditions.

o  69% percent of total healthcare costs are heavily influenced by consumer behaviors

o  Poor medication adherence costs the US more than $100 billion annually

These statistics are all indictments of a system of care that is ignoring a major component of that care- behavioral- and the cost consequence are staggering. Logically, integrated care and attention to behavioral components of disease management for all chronic physical conditions is absolutely the only thing that makes sense- so how do we explain continued failure to do so?

Accreditation bodies and state/federal contracts are filled with regulations aimed to move that needle in the right direction; however, any Internet search shows current articles citing the barriers and concerns that persist. Anyone in the BH field could tell compelling stories about what is still not working for the management of BH treatment, integrated care models, and healthcare costs resulting from neglect of BH in the equation.

Why, in the face of all this data, is integrated care, parity, and behavioral change-focused treatment a ‘market differentiator’ rather than the standard of care? How could we possibly explain our failure to adequately tame this beast? It’s certainly not from lack of trying.

The persisting problem is that good intentions and logic cannot make strides if we don’t have the resources (human, money, time, measures, research and development, supportive services) to accomplish what we need to do. Seeing how the healthcare field has attacked healthcare problems like AIDS and Cancer, I’m convinced that it’s possible to do a better job on any healthcare problem if you have those resources. So, why are we still where we are with BH and integrated care? I would like to postulate that covert/micro stigma is still at work and is interfering with how the healthcare community perceives the problem and acts to address it. The building blocks of this stigma and lack of action include the following.

·       Language is an issue. We still don’t have the right words to do ‘integrated care’ correctly. We delineate providers by calling them by their specialty. Even at the most basic level or provider description we have a language gap. We label providers and treatment as ‘behavioral health’ or ‘physical health’. Those are actually pretty silly terms but they serve to continue to divide treatment perceptions. The brain is part of the ‘physical’ part of a human, and all humans have ‘behavior’. How does any integrated care get done well when we can’t even integrate our language? We create terms like ‘whole person care’ trying to combat the issue, but when it comes time to staff those teams- take a look at the dynamics. Often those approaches are used for a small percentage of the population, so, the creation of the term only means we created something separate and unique, rather than creating true integration of treatment.

·       Expectations and capabilities are issues. Providers spend a great deal of time and money learning to treat something- and mostly they all treat something- not everything. Perhaps we were better off in the days of the country doctor who treated it all and had a nurse in his office instead of non-licensed assistants. I’ve watched that pendulum swing wildly over my time in healthcare. I believe that specialists have improved healthcare tremendously- but we have lost the truly integrated belief in who we are as treating providers- and let’s face it, for most providers, BH is mysterious and not well understood. It doesn’t show up on a lab test and go away after a ten-day course of treatment.

·       Outcome measures are faulty. There is no integrated and consistent view of outcomes. We measure things distinctly. I can hardly blame physical health teams for not wanting to dive deep into BH outcomes- even though those issues are sabotaging physical health outcomes. Taken separately, we still have a ‘black hole’ for BH outcomes because there is no agreement what really should be measured. HEDIS, accreditation, states, and CMS all have their own ideas that become regulations, but do we measure the right things? Even if we did, does it matter if they are not measured consistently if providers are not equipped to manage the co-occurring disorders?

Payers create standards trying to tame the beast of BH spending, but they are not experts in the field so they create measures on professional behavior and access to care. Regulatory bodies do the same, but they have an added incentive of trying to sell their standards as best practices. Again, they are not experts in the field. Between the payers and regulatory bodies, all we get is multiple ‘views’ of how outcomes should work. None of it is consistent or even necessarily correct. For example:

• Does length of time from diagnosis or hospitalization to the first follow-up appointment with a specialist really matter? Or is it just something that we can measure?
• Does it matter that we did a diabetes screening on a consumer taking antipsychotic medication if we have severe BH workforce reductions and 56% of adults experiencing BH issues don’t get into care? Or, if the physical health provider is not adequately able to manage the BH condition in conjunction with diabetes?

Where are the experts? Why don’t they create the standards and outcomes needed? They do, in part. For example, the American Psychiatric Association (APA) and Substance Abuse Mental Health Services Administration (SAMHSA) create treatment guidelines- but not a standardized outcome measure. If they did, there would still be a problem with enforcement as both are advising entities- not governance.

·       BH is clinically behind the curve. Despite successes due to new drugs, BH treatment is still not working effectively. To an unacceptable degree, it’s not understood, not funded, not researched, and not supported with parity. I believe that our members and their BH issues would be welcomed into the physical health fold easier if we were on equal footing in terms of attention, research, and innovations- and if we ‘looked’ more like standard medical treatment. People don’t understand the therapy components of BH treatment well- and the scientific components are not well researched. For example, though I first started hearing about genetic testing capability for BH disorders, to find which medications might work best on specific individuals almost ten years ago, it is still not widely accepted or funded.

·       Healthcare is under siege in general. It’s not a secret that healthcare is undergoing huge transformations. The 2015 American Hospital Association Environmental Scan did an excellent job overviewing the challenges and expected changes coming in the next decade (https://www.hhnmag.com/articles/4012-take-a-look-at-how-market-forces-will-impact-health-care). 

Given the issues illustrated in that article, there are always ‘bigger fish to fry’ when trying to tame the beast and balance outcomes and costs. Like fingers in a leaking dike, we are constantly trying to stem the bleeding- in dollars, in missed regulations, in poor outcomes- and we just don’t have enough fingers.

Having worked in managed care for 22 years, I know first-hand that regulations are choking operations and eating into the administrative budgets needed for innovation that is vital to survival. It’s often called ‘death by a thousand cuts’ because of the domino effect of each thing as it leads to the next. If the dike blew out totally, it would draw the needed attention and resources to save the village. On the other hand, a thousand slow leaks that people are madly trying to stem- with some success- doesn’t draw that kind of support. Instead, it exhausts the helpers and keeps the system in chaos. If the regulations were producing profound customer change, success, and satisfaction, the frustrations could be tolerated, but they don’t. We must look to the future with a different perspective.

Technology will help- but it’s slow, expensive, uncoordinated, and implementation is initially disruptive and not always positive for consumer engagement. I know that I personally have access to five different patient portals for my own care, which certainly highlights what happens when electronic medical records don’t coordinate with each other- the need for technical savvy- and consumer tolerance for fragmented care. it’s challenging to manage even for someone like me who knows my way around technology and healthcare. However, I do believe that technology and consumer-access to behavior-changing apps are vital.

Integrated care via value-based contracting is certainly a solution that will eventually help BH get the equal footing needed to improve outcomes for all treatment, but it’s moving slowly.

Conclusion: After 43 years, I’d love to just have the magic wand. Sometimes, I even think I know what I’d do with that wand. Other times, I know that it’s just not that easy. No matter what we need to fix this problem, it’s only one of the problems that need attention and intervention in our country. There’s a finite amount of resources that has to take care of everything from education to roads and everything in between. So, I’ll skip what I think we need and tell you what I think we can’t survive without.

1.      Re-Focus Healthcare Education. Nurses and doctors must be trained to see disease as a syndrome that includes everything from the top of the head to the tip of the toes- and most especially the space between the ears- and not a specific disease state. Specialists can be invaluable as advisers, consultants, and educators but the prevalence of specialty care has moved the needle the wrong way. Primary Care Physicians (PCPs) really should be the driving force behind all treatment.

You cannot treat ‘heart disease’ and win. You can only treat ‘Sam’- who could have an issue with how his heart pumps blood, high blood pressure, obesity, smokes, is divorced, doesn’t like to cook so eats fast food every day, is depressed by his divorce and inability to eat/act like he wants to if he’s to follow treatment orders, dislikes his job, drinks to excess, and has no time to exercise. Giving Sam a pacemaker is ultimately as effective as putting paint over a moldy wall.

2.      Create National Integrated Outcome Measures that are separate from provider performance standards. Once the standard of care is understood and part of the culture, we must have ways to show what works and what does not- it has to be the tool used by every provider for every payer and every accreditation body- and it has to be based on consumer FUNCTION, not consumer symptoms- and definitely not quality and timing of professional actions. Effective and accurate professional actions are important and should be dictated by licensing and provider quality monitoring- but they don’t dictate consumer outcomes. Great providers who do great things can still have negative consumer outcomes. Outcomes are subject to a huge variety of factors that providers cannot control. If good intentions and good services could solve our healthcare issues- they would have been solved many years ago.

In fact, some outcome results are totally counter-intuitive. I remember a study we did in our treatment center on medication adherence in the 1980s. We discovered that the best-informed consumers had the worst medication adherence! Medication education should be done because it’s a best practice to have informed consumers- but it was a revelation for me to see first-hand in my first decade in the field that good work by the clinicians didn’t move that outcome needle in the right direction.

Likewise, reducing readmissions is a worthy goal. No one should go through the trauma of a health crisis and hospitalization unnecessarily. However, that measure is meaningless if the syndrome is still untreated, and the issues are still interfering with functioning. For example, Sam’s heart might beat well with that pacemaker and he might not ever go back into the hospital for a heart conduction problem, but if the other issues he has are not managed, cost shifting will still create burden on the system of care- and poor outcomes for Sam. It might be detox treatment, the trauma of inability to breath well and toting oxygen the rest of his life, or lost state/federal tax revenue after a suicide- but an untreated syndrome is a system waiting to break someplace.

3.      Fund the goal- and ONLY the goal. The only way to achieve #s 1 and 2, is to limit reimbursement to the services that meet the standard of care we want. Neither standard outpatient or standard inpatient is well-equipped to do the job. If Sam was also bipolar, you may need a therapist to help him deal with depression and participate in healthcare treatment effectively, but waiting for him to make and keep appointments with a cardiologist, psychiatrist, a support group to stop smoking, AA, the gym, a dietician, and a life coach is absurd. Since the PCP can’t do it all, we do need a treatment environment. Healthcare Homes and value-based contracting is the only way to reimburse for services that work for Sam. The PCP can’t see fifty patients a day in this model, nor can we coordinate Sam’s many needs by running him around to ten places.

Healthcare is a business and we need to act like it is- which means adopting new operational paradigms and getting past ‘how we’ve always done it’. The general consumer marketplace is finding ways to thrive using convenience, technology, and the equivalent of the ‘medical home’ concept for ‘one-stop shopping’, and we can learn a lot from it. For example, look how the changing market place- meaning what people expect and will pay for- forced a change in mindset and service delivery for these companies. 

• At Walmart you can get a mani/pedi, pick up a prescription, get an eye exam and buy glasses, buy groceries, get clothes, buy make-up, buy tires for my car, and <fill in the blank>.
• Publix will let you order online from your computer or phone app, determine the day/time of your delivery- and will make stops at the liquor store and the drug store as well before delivering.
• Amazon will deliver anything imaginable, and usually on your door step the next day.
• Martha Stewart in partnership with Marley Spoon will deliver everything you need to make gourmet meals you choose- all you need are things like salt, pepper and oil.

Lesson Learned: what gets funded, thrives. Payers know this and step by step they are funding change. I do believe that they intend to get where we need to go, and forward-thinking healthcare providers and managed care companies need to be re-tooling operations to be ready. Ultimately, these financial changes will create the system of care that is needed and the landscape will look very different. I predict that you won’t see many private doctor’s offices- and those that survive will be ‘private pay’ for a ‘boutique’ medical doctor experience. Instead, I believe that you will see large health and wellness centers- owned by provider groups or hospitals, that have the capacity to meet a multitude of integrated needs, including specialty care.

In the end, it doesn’t matter if BH is well-understood or if stigma is still alive and thriving, even in ‘micro’ form in 2018. What matters is simply an acceptance that healthcare must include BH in order to work, and that we must fix what is still broken in order to have an efficient and cost-effective healthcare system that makes a difference in people’s lives.