Industry Must Build Out Entire Behavioral Health Continuum, Says NABH CEO

To say Shawn Coughlin has a lot on his mind these days is putting it mildly.

Throughout the pandemic, behavioral health conditions nationwide have worsened and substance use disorder (SUD) overdose rates have continually broken records. Although the numbers paint a bleak picture, Coughlin — who heads one of the behavioral health industry’s leading groups — says he is up for helping providers meet those challenges.

“We’re at a unique time in history with a lot of opportunity,” Coughlin, the president and CEO of the National Association for Behavioral Healthcare (NABH), recently commented to Behavioral Health Business during the organization’s 2021 Annual Meeting in Washington, D.C.


Industry leaders like Coughlin — along with executives and policymakers — gathered for the three-day NABH annual event held from October 6-8, which last year was cancelled due to the coronavirus. For many in attendance, the pandemic only made more urgent the litany of concerns surrounding behavioral health, whether it be mental health parity or telehealth access. Additionally, other topics like the IMD exclusion, workforce challenges and the industry’s move toward value-based care were not too far from the minds of those like Coughlin.

BHB caught up with Couglin during the event to get his thoughts on the state of affairs in behavioral health. Portions of this interview have been edited for length and clarity.

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BHB: From interacting with attendees at NABH’s 2021 Annual Meeting, what are the main issues facing the behavioral health industry at the moment?

Coughlin: As a follow up to our last conversation, it’s workforce, workforce, workforce. You’re seeing this all across the industry — not just us, but the broader health care industry. COVID itself has clearly exacerbated it. 


There’s the impact of COVID and the protections you have to take when individuals have gotten it. And there’s the loss of the workforce because people are doing things like taking care of loved ones. Layered on top of that is the issue of vaccines. We’re waiting for that other shoe to drop with the regulations.

Who does the vaccinations apply to? How broadly is it going to apply? Is that going to move those workforce issues into the area of administrative staff? Workforce, I’d say, is the biggest concern I’ve heard from others.

What are some of the biggest opportunities currently for the industry?

We, as an industry, have been talking for years that we are nowhere near parity, that we continue to have problems and insurance companies continue to find ways to deny access. Now, we’ve got a Labor Department that is actively taking some enforcement actions, which we view as very positive. There’s still challenges, obviously. There’s millions of plans and hundreds of oversight of individuals, but it’s very positive that they are looking and have taken actions.

We’ve had both legislative actions requiring [insurers] to document their non-quantitative treatment limitations, which gives enforcers a new tool. And we’ve brought online our Denial-Of-Care portal. That’s a real opportunity for us to move to true parity and get this issue taken care of.

We saw in the House reconciliation package that they did include one of our industry priorities, which is giving the Department of Labor enhanced enforcement authority over parity. We’re seeing that recognition in Congress.

What is your impression, so far, of the Biden administration and how they may — or may not — be addressing pertinent behavioral health issues?

The play right now appears to be in Congress. The administration is dealing with a wide variety of problems and issues, but the Department of Labor is making behavioral health a priority. We’re hopeful that the administration is going to support that.

Verbally, they said that this is a priority for them. But I think COVID has displaced everything. Hopefully, when we get through everything with the debt limit, reconciliation, and the infrastructure bill — which is sucking all the oxygen out of Washington right now — they’ll pivot to us and focus on behavioral issues, because I think it’s one of the biggest challenges facing the country.

The IMD exclusion remains a hot button issue in behavioral health. Where does NABH stand on it?

This is where we differ from a lot of other groups. We represent the entire behavioral health care continuum, and we understand that the entire continuum is what is required. There’s been so many changes since deinstitutionalization, there’s been so many changes since the IMD exclusion went into effect. The practice of medicine has changed dramatically. And this notion that it’s “us versus them” has been one of the biggest historical problems for the behavioral industry.

We’re starting to see a recognition that we need a broader comprehensive structural reform. No other segment of health care is being treated like behavioral is being treated. You don’t throw grant dollars at cancer as the primary funding mechanism. They don’t throw it out for anything other than behavioral health.

Those folks who argue that inpatient is not a necessary component don’t fully understand the needs that individuals have. There are individuals that will always need a higher level of care than that can then be provided in the community. It’s just a fact, there’s no other way to describe it. Our approach is that we need the entire behavioral health continuum. The entire continuum has to be brought to bear, and it’s got to be all hands on deck.

We’re not arguing that community-based services do not have value, it’s an absolutely necessary component of the system, just as inpatient care is. So, why would they continue to have this notion that some segment of the industry can just be eliminated, and everything will be better? It’s just myopic.

Rather than have this fighting of inpatient versus community, as far as we’re concerned, every one of us have a role in this way in this arena. And we should be focusing on building out the entire continuum, and ensuring that individuals are aided in finding their way into the system.

How do you feel about more behavioral health providers leaning into value-based care payment models?

I agree 100% that value-based care is the trend across all of healthcare. That’s fine, as long as we’re talking and starting from an adequately-financed system.

Our [members] are focused on quality outcomes and evidence-based care. As long as the payments are adequate, we’re more than willing to move to a value-based system. We’re trying different models where we’re engaged in different programs and initiatives around the country. We’re going to be looking at that very closely as we move forward.

More behavioral care providers have been turning to telehealth since the onset of the pandemic. Has there been a difference in the tenor among NABH members, as far as how they view telehealth now compared to NABH’s last Annual Meeting in 2019?

Telehealth just two years ago was an idea that looked like it held a lot of promise. Now it is deeply embedded throughout the system. That just shows that with the right incentives or initiative — which unfortunately was COVID — the industry is very rapid to adopt it. Across the board, if you talk to members, they’ve all adopted it at very different levels, so that probably is the best case study.

Policymakers have argued for years, “Oh, we don’t know if it’ll work.” Well, guess what? COVID was not your traditional demonstration of, “Let’s report back and five years and then maybe you know we’ll try something else.” That was a broad, rapid adoption, and with anything, we’re going to have to fine tune it and make sure it’s targeted in the right ways to the right populations, in order to see who benefits.

We’re starting to see some anecdotal data that some people really like it in some age groups, and for other age groups it doesn’t work as well. We’ll continue to refine that, or it won’t last long.

Who would have thought that just in two years that this would be a positive policy idea that we’re fighting for, and saying that Medicare and commercial insurance should cover this? Universally, if you listen to policymakers, they’ll all say that this has been a great asset.

What other strides do you wish to see in behavioral health by the time the next NABH Annual Meeting rolls around?

We’d like to see progress in parity, structural reform and payment reform as a true commitment to building out this entire continuum. Telehealth has been a huge expansion that happened very quickly, and we’d like to see that be made permanent. A lot of that was and is still tied to the public health emergency declaration. We know that the Congress is looking at this very closely and looking at making a lot of this permanent. I’d like to see that happen, because hopefully, God willing, this public health emergency is not going to last much longer.

There’s this whole new area of digital health like artificial intelligence that we’re going to start looking into as well, and how that might be a viable component to add into the system later on. I think the experience we have with telehealth may actually help encourage the adoption and payment for other workarounds to help us address the workforce shortage.

We’re going to be looking at a wide variety of things to get out of the box on workforce initiatives as well. What can we do to encourage and foster interest in people going into behavioral health care? I hope that’s something that we can really start to move on in the next year.

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