Highmark Health’s Behavioral Health Director: Personalized Care, Upstream Prevention Will Define the Industry

Highmark Health’s executive medical director of behavioral health, Bradley Karlin, is looking to tackle the increase in behavioral health needs by focusing on personalizing care and upstream prevention. He’s also looking to use more data to make decisions, he told Behavioral Health Business. 

Karlin, who joined Highmark in January 2021, has a long history of working in the behavioral health field. A clinical psychologist by training, Karlin served as the national mental health director for psychotherapy and psychogeriatrics for the Department of Veterans Affairs (VA) health care system, and as vice president and chief of mental health and aging at the Education Development Center.

Pittsburgh-based Highmark Health is a health care system that encompasses insurance plans, a hospital system (Allegheny Health Network) and health care support services. The organization has an annual revenue of more than $26 billion. It has also been at the forefront of several innovative behavioral health movements. For example, last summer it became the first commercial insurer to cover prescription digital therapeutics.


BHB sat down with Karlin to discuss the future of innovation in behavioral health.

This interview has been edited for length and clarity.

BHB: How would you describe the current state of behavioral health care, and what has contributed to where we are now?

Karlin: The rates of behavioral health needs are at an all-time high. But at the same time, only 40% of individuals get care of any kind, and only 15% of individuals with serious behavioral health needs receive minimally acceptable treatment according to clinical practice guidelines.


There’s a significant opportunity to move more upstream to meet a greater number of individuals much earlier in their clinical trajectories.

In terms of how we have arrived here, I’ll mention a few contributing factors that I think are key. Behavioral health care has long been very reactive and downstream-focused. Behavioral health care is highly variable in quality. Not all psychotherapy, for example, is created equal. At the same time, we have gold-standard treatments for even the most complex and life-interfering conditions like PTSD that are highly effective, but often these are not the treatments that are available on the clinical front lines.

We do not do a good job of personalizing and right-sizing behavioral health treatments to individuals’ needs and preferences. I think that’s also an important barrier, certainly from an engagement perspective.

You have a strong interest in innovation. Could innovation help tackle these challenges? What does the future state of behavioral health care delivery look like for you?

Health economists have estimated that the degree of clinical and technological innovation we’ve experienced as a result of the pandemic over the last couple of years is equivalent to 20 to 30 years of innovation prior to the pandemic.

So what are some of those qualities or characteristics of the future state? One is being much more proactive, leveraging advanced analytics and an innovative outreach approach to reach more people and to reach people much sooner in their clinical trajectories.

For example, using claims data, EHR data or other data to identify behavioral health problems much earlier in individuals’ clinical trajectories, then outreach to them or a primary care provider well before they may even be aware they have a behavioral health problem.

Second is being much more personalized. I would argue that behavioral health has historically been among the most non-personalized industries in many respects. Referring everyone to a psychotherapist or a prescriber is missing a lot of opportunities. It doesn’t involve personalizing care. So when I talk about personalization, I also think about person fit and the right-sizing of interventions.

What else?

The future is a more upstream focus. We’ve missed opportunities for intervening with individuals with more minimal or mild behavioral health needs. We have many opportunities to prevent the course of the downstream cycle, but also, in doing so, to leverage opportunities that we now have that we didn’t have before for really utilizing lower-intensity interventions. We have more digital solutions, but only a small minority of those will move the needle. But leveraging lower-intensity interventions presents considerable opportunities to move more upstream and right-size care.

And there’s being much more quality focused. In my work at the VA, we implemented the world’s largest implementation of evidence-based psychological treatments as part of the transformation of the VA system to an evidence-based recovery-oriented system of care. We saw with veterans who received a recommended evidence-based treatment substantial improvement in their symptom severity and overall quality of life.

I’d finally point to optimizing the workforce. Everybody’s trying to solve for access right now and find more behavioral providers, which often can’t be found. We need to rethink how we provide behavioral health care.

In doing so, we must think about who the behavioral health care providers are. So that certainly includes traditional providers, licensed independent providers, but it should also include a broader workforce, like behavioral health coaches and peers.

You mentioned digital interventions. How can digital health be used? We saw a massive transformation during the pandemic, but are these solutions going to live up to their potential?

There are now as many as 20,000 behavioral health apps on the market. Much of that is noise. There are a few signals amid the sea of noise. And those signals present significant opportunities. The signals are those that include more robust clinical components that have often been subject to empirical scrutiny and randomized control trials.

In addition to having strong clinical content, they have strong characteristics and features from an engagement perspective. What’s key is marrying strong, empirically supported clinical content with strong engagement from both a functionality perspective and interactivity, and also thinking about aesthetic design and the user experience.

We’re in the gangly adolescent phase right now in digital behavioral health. There’s a lot of opportunity and a lot of opportunity that has not been realized. We’re starting to see this; we’ll continue to see this.

There’ll be much maturation and consolidation in the coming years. The best solutions will present opportunities to solve access issues, or at least partially solve issues of access, and move more upstream.

And maybe that maturation could be better for patients at the end of the day? Having to choose from 20,000 is a big task.

No question. It’s a dizzying experience for members, and in some respects, it has the unintended adverse effect of people … if only 4% to 5% of people use a solution for more than two weeks and then drop off. You know, unfortunately, that might even mean they’re less inclined to seek treatment a second time or third time.

Stigma and engagement are significant challenges with behavioral health. What are your recommendations to overcome that in the future?

Where we’ve really seen some reduction in stigma is in the area of depression. There’s been some empirical data to show this as well, and to some extent, anxiety and stress-related problems.

There’s still a pervasive stigma around substance use disorders, serious mental illness or psychosis. But garden-variety depression, garden-variety anxiety and stress-related problems, we’ve seen some improvement.

I think it’s partly a function of the universal psychological experience of the pandemic. The pandemic did not discriminate and impacted virtually everyone psychologically, and it was a normalizing experience for many.

And receiving behavioral health services through a computer screen or a cell phone normalized behavioral health care to many. There was the explosion of virtual behavioral health care. We’ve seen this within Highmark. In 2020, we saw virtual behavioral health care increase in the magnitude of about 7,000%. And then that persisted largely in 2021.

The other piece that has contributed to reducing stigma has been an opening up the conversation about mental health and psychotherapy, for example, as a result of external forces and investment, from private equity and modeling, the authenticity of celebrities.

Then there’s a huge opportunity for us to leverage identification and stratification, for example. Within Highmark, we’ve developed identification stratification models to leverage claims data to identify an individual who may have a behavioral health problem, then reach out to those individuals and provide a personal fit and right-sized intervention.

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