This article is sponsored by Rula, based on a discussion with Gabe Diop, Co-founder, Rula, and Dr. Trent Haywood, Founder, Knowality. This discussion originally took place on March 12, 2023 during the BHB VALUE Conference. The article below has been edited for length and clarity.

Behavioral Health Business: With health equity top of mind for many of the major stakeholders in the industry, how do you think about race and behavioral health?

Gabe Diop: Everyone deserves access to high-quality behavioral health care, regardless of race, gender, sexual orientation or insurance provider—be it Medicare, Medicaid, Aetna, Elevance or Kaiser. It’s important to acknowledge that access to behavioral health care can often depend on one’s skin color. Clinical data shows that approximately 38% of white individuals diagnosed with a mental health condition receive treatment, compared to 25% of Black individuals and only 22% of Hispanic individuals.

The truth is that the likelihood of receiving necessary care varies significantly based on race. This disparity isn’t just due to a shortage of diverse or culturally competent providers, or even due to lack of or insufficient insurance. A significant part of the problem is awareness.

Youth mental health, in particular, is alarming, with 9% of high school students having attempted suicide. This statistic isn’t an error; it’s a harsh reality, especially among Black youth who are twice as likely to commit suicide as their peers. Consider the challenges faced when families not only need to find a behavioral health therapist, but may also require that the therapist be someone who understands specific cultural contexts and can treat children and adolescents.

Many people may not realize the extent of this issue. Therefore, addressing the awareness gap is an essential first step. When it comes to race and behavioral health, understanding and discussing these social determinants of health is crucial.

What correlations have you seen between race and mortality?

Dr. Trent Haywood: I’ve been in the industry for a while and previously served as the Deputy Chief Medical Officer for the Centers for Medicare and Medicaid Services. During my tenure, I was responsible for implementing quality measures nationwide, because we needed to be transparent about equality levels before we could encourage action on them. We introduced all the quality measures as a first step to understanding the disparities in treatment and impact. As I was leaving, under Mark McClellan, we were challenged to link these equality metrics to what we value and to spend funds in ways we thought would be impactful.

However, a major concern was the unintended consequences of these measures. Many African American and other clinicians of color worried that without additional resources, the disparity would widen—only entities with electronic health records and extra staffing could demonstrate they were providing equitable care. This is a structural barrier, both financial and systemic, depending on the resources available at that time. I then moved to the private sector, focusing on preparing providers for value-based payment by establishing the necessary infrastructures.

Later, as the National Chief Medical Officer for Blue Cross and Blue Shield in Chicago, and then president of the Blue Cross Blue Shield Institute, we linked our efforts to social determinants of health because your zip code often predicts health outcomes more accurately than any other factor. We drilled down to individual block groups to predict outcomes based on where someone lived, uncovering stark disparities in health based on neighborhood. In Chicago, for instance, the data showed behavioral health was underdiagnosed on the south side, where more minorities live, due to other prevailing comorbidities.

In reviewing Blue Cross data, we found that conditions like diabetes or heart failure, when accompanied by a behavioral health issue, doubled the likelihood of higher morbidity and costs. This realization underscored the importance of addressing therapeutic alliance and access to care tailored to individual needs, which led to my advisory role with Rula, focusing on improving these alignments. I’ve been excited to contribute to this critical work over the past four years.

What other areas of health equity do you think are important to highlight when thinking about behavioral health specifically?

Diop: Another population I believe is important to highlight when talking about mental health equity is mothers.

I remember trying to connect with one of our advisors, Deb Adler, a while back. When I called her, she said, “I’m on the phone with my mom. I’ll call you back in a few.” Without a second thought I responded, “No problem. You can’t rush mom time.” My mom is currently staying with me in Miami, right across the bridge, and she loves the weather down here. I, like many others, understand the important roles our moms play in our lives, from childhood into adulthood. It’s crucial that we take care of our moms. One in five moms will experience a mental health condition before pregnancy or postpartum. Only 15% will receive care. Looking specifically at Black moms, three in five will experience a mental health condition or postpartum issues. Unfortunately, Black moms are 41% less likely to receive treatment than White moms, and Hispanic moms are 57% less likely to receive treatment. These disparities are significant, and while there is a shortage of providers in certain areas, that isn’t the main problem.

We also need to consider that only about 20% of moms are screened for behavioral health issues. We can definitely do better than that. It’s important to remember that this doesn’t just affect their own lives and other physical health conditions; it also impacts their children. It’s imperative that we ensure our moms are well cared for.

How do you encourage those pregnant and postpartum moms to get treatment and how do you bridge the gap that we’ve highlighted here?

Diop: I was on a call a few weeks ago with an OBGYN who mentioned that it usually takes her or her staff hours to find a provider who is, one, in-network, and two, capable of treating maternal health issues. Additionally, they might look for another specific factor, such as a provider who is African American. When I demonstrated what she, as well as other providers, could achieve with Rula – with just five clicks, she could access a wide range of providers who are both in-network and specialize in maternal health – she was astonished. The solutions are out there, which is very hopeful. Now, the challenge is bridging the awareness gap to make full use of those innovative solutions that can help us solve our most complex problems.

Have you seen any interesting outcomes when it comes to moms and overall health?

Haywood: Lately, I’ve been increasingly focused on women’s health. One of my good friends from med school in Chicago, Dr. Butler-Mooyoung, who is an obstetrician-gynecologist, spends a lot of her time on the very issue you mentioned, particularly dealing with postpartum issues. The 12 months following delivery, the postpartum period, is where we’re seeing the most significant challenges currently.

We’re thankful that payers are beginning to recognize that maternity care doesn’t end at delivery and that the subsequent 12 months are crucial. This period is where we often see issues with readmissions and outcomes. In the last two years, we’ve seen payers start to pay more attention to this postpartum period, looking to incorporate it into their payment methodologies.

As you consider value-based arrangements, ensure that the payers you work with are also focused on this critical 12-month postpartum period. We believe this focus will be key in demonstrating the real impact we aim to achieve.

With respect to collecting data and identifying health disparities, how do you suggest going that next step to make the necessary changes and impacts?

Haywood: The data has always been critical, no doubt, but we still face significant gaps in data capture, especially depending on the treatment location. Treatment at academic centers, for instance, is quite different from care at federally qualified health centers or other community-based organizations that may lack robust infrastructure.

There are many entities striving to improve this infrastructure. As highlighted, data alone, without action, isn’t truly impactful. The real question is, once we have the data, how do we implement incentives to make it meaningful? Value-based arrangements and other incentives are now beginning to make this possible, rewarding entities and providers for doing the right thing, provided it’s structured appropriately.

We must be cautious, however. If a value-based program is poorly structured, it might inadvertently harm providers by raising expectations without proper acknowledgment. Fortunately, with tools like the health equity index reward component in Medicare Advantage, incentives are aligning to reward handling difficult populations effectively, acknowledging the challenges posed by structural barriers.

I’ve spent considerable time examining ‘pharmacy deserts’ and how challenging they make treating certain populations who lack easy access to medications. Solutions like mail-order prescriptions and virtual health care are helping bridge these gaps. Similarly, at the Blue Cross Blue Shield Institute, we tackled ‘transportation deserts’ by providing rides to ensure follow-up care wasn’t missed due to lack of transportation.

Efforts also extend to integrating nutrition as a part of health care, recognizing food as medicine, especially when considering behavioral health, where a proper diet can complement treatment. It’s about more than just getting patients to the clinic; it’s about supporting them in their environments and lifestyles.

The importance of addressing these social determinants of health, which can determine 40% to 70% of health outcomes, wasn’t emphasized in medical education historically. Now, thankfully, it is gaining the attention it requires. It’s no longer sufficient for clinicians to treat patients only within the clinical setting. With partners like Rula and other stakeholders, we are now equipped to address not just the clinical needs but also the structural factors influencing patients’ health.

What do you think is needed to close some of the health equity gaps in behavioral health? What role might value-based care play there?

Diop: I always emphasize that behavioral health cannot exist in isolation; it must be integrated within the broader health care ecosystem, particularly with primary care. While there is indeed a supply issue, many aspects of this have been addressed. We also need to ensure we have the right training for providers so that more of them can treat specific areas like maternal health and children and adolescents. For example, in California alone, we have over 4,000 providers who specialize in treating children and adolescents.

We’re looking at a demographic where 23% are Hispanic, 11% are Black, and 8% are Asian, with 41 different languages spoken—just in California. If people knew they could come to Rula for care, many issues could be resolved. Reflecting on my earlier story about the OBGYN, the question remains: how can every OBGYN and primary care provider in the country know where to direct patients for the appropriate behavioral health care?

As we discuss value-based care, which is a topic among nearly all payers, we encounter various approaches: measurement-based care, measurement-informed care, evidence-based care. Many are making strides toward solutions. I fundamentally believe that to truly address value-based care, we must focus on partnerships, particularly between behavioral health and primary care.

Additionally, consider transportation challenges. I recently spoke with a payer about a joint solution with a transportation company tailored for the Medicaid population. There is no single solution or company that can tackle this alone. Solving these challenges requires collaboration among payers, health systems, governments, schools, employers, behavioral health groups, and other health care providers.

If we zoom out and think about population health, what do you think is needed to close gaps?

Haywood: It depends on the population we’re discussing, a point that I’ve seen repeatedly validated. During my tenure at Blue Cross, I had the opportunity to lead a team that created what’s known as a community health management hub, for which we received a patent. We focused on identifying the specific needs of different communities at the local level.

For instance, a well-known, nationally recognized hospital health system asked us to analyze their data concerning their own employees. What we discovered was that most of these employees were Spanish-speaking, a fact the health system had not fully recognized. They thought they had an adequate provider network, but it wasn’t equipped to serve Spanish-speaking employees effectively. This insight led them to realize they needed to recruit more Spanish-speaking clinicians to better serve their own staff, as these employees were seeking care in their own communities, not just within the English-dominant environment of the hospital.

This example underscores that one size does not fit all in population health, which is why I’m always cautious about broad-brush approaches. That said, and admitting my bias from years in the payer industry, while money isn’t everything, it’s crucial. The payment structure must at least not put you at a disadvantage. Ideally, it should incentivize those who are trying to do the right thing to do even more.

Understanding community-specific needs and aligning financial incentives to support effective interventions are key. If we manage these aspects well, we create an environment conducive to innovation, like what Rula has achieved. Otherwise, without the right financial incentives, you’re effectively asking for volunteer work, as there’s no economic motivation to tackle challenging scenarios, particularly in less affluent areas.

Editor’s note: This article has been edited for length and clarity.

To learn more about working with Rula, visit www.rula.com