I’ve softened on my no-holiday-music-before-Thanksgiving rule. The nostalgia has become too powerful to resist. Plus, I’m coming to appreciate much more the latent hope for a better world that imbues the spirit of these tunes — even if that spirit is cheaply laced into pop music industry-driven schlocky original songs or uninspired rehashes of classics.
Anyone following me on LinkedIn knows that I often break up the behavioral health posts with music appreciation posts. I’m doing something of the sort this week with the BHB+ Update. But since this is what we are delivering to our most tuned-in readers, I’m going to keep this on point and zero in on what I think are key ideas for behavioral health executives to think about.
This year, the song “Grown-Up Christmas List,” originally written by David Foster and performed in a duet with Natalie Cole, resonates more than in previous years. And it got me thinking. This section specifically stands out:
“What is this illusion called the innocence of youth? Maybe only in our blind belief can we ever find the truth.”
Perhaps my children are growing older and have finally reached a stage where they can express their thoughts clearly, and that is bringing me to experience in real-time the wonder and delight they see in the world around them. They certainly get more excited and about more things than I do now as an adult and a parent. That, I think, is kindling greater imagination in the optimist part of my mind. If I’ve expressed anything in these updates, it’s optimism for a better future.
I’m going to walk through what’s on my grown-up holiday list for the behavioral health industry. Definitionally, these are going to be fanciful. It is a Christmas wishlist after all.
Private health plans walk the talk
For years and years now, even before the pandemic, anyone seeking to be a luminary could find tons of hay to make if they talked about, advocated for, or otherwise tied mental health to their public persona. At this point, there is no question that money spent on behavioral health by and large is money well spent. And while alleviating patient suffering is itself of immeasurable moral value, the collective savings to the system are immense.
And yet, it is the expectation, not the exception, that patients and providers alike will have to face strife and torment to engage payers in the provision of behavioral health services. I’ve spoken with enough payer executives privately and heard from others in public speaking settings to know that they know their respective organizations contribute to the behavioral health industry’s problems.
To make it more specific, I wish that payers, at the very least, would make their rates worth the burden they place on their networks. Also, I wish that payers would be a driving force in behavioral health value-based care strategies.
And these companies can afford to experiment with higher and more creative rate strategies. Even beyond the actual dollars and cents, loosening up the purse strings would go a long way in addressing the public image issue that payers have with their members.
UnitedHealth Group (NYSE: UNH) hauled in $22.4 billion in net income last year, up 11% from the year before, according to its public financial filings. Profits for Elevance Health (NYSE: ELV) totaled $6 billion, $5.4 billion for The Cigna Group and $3.9 billion for the health care benefits division of CVS Health (NYSE: CVS). They are good for spending a few more dollars on behavioral health.
At the very least, I wish that payers embrace parity, as both industries widely understand the principle, not just how it is presented in statute. If not, I also wish that regulators would find either legislative solutions or political will to start slapping hands that violate the law.
GOP-controlled Washington resists the urge to cut Medicaid
The Republican Party’s traditional ethos on individual self-reliance has gradually shifted, with some members expressing increasing scrutiny about public assistance programs. However, the latest brand of conservatism has streaks of populism that might lead elected and appointed officials to consider public policy practices that look out for the common folk.
My wish is that some level of consideration for vulnerable populations prevail and the worst possible outcomes of the anti-welfare state, like gutting Medicaid matching funds or rollbacks of expansions, will be stymied. There is some reason for hope on this point. Medicaid expansion states are nearly 50-50 when it comes to majorities voting for the defeated Vice President Kamala Harris of President-Elect Donald Trump, according to the Kaiser Family Foundation.
I also hope that potentially harsher border and immigration and trade policies, which Trump sees as intermingled, will also come with either (I hope for both) regulatory streamlining for addiction treatment providers and the establishment of more universal care quality standards.
Along those lines, I wish that what deregulatory tendencies do come through will allow addiction treatment providers to overcome the NIMBY opposition to new facilities. There are plenty of reasons to be concerned about how a community’s land is used. NIMBY-ism simply isn’t constructive.
Regulators and advocates get real on inpatient, residential care settings
I think we can all agree that abuse in the health care setting is evil. Our health care community ought to be held highly accountable for the high regard and benefit that many parts of American society bestow on them. So, it is acceptable and expected that all pains be taken to ensure safe and effective care settings. However, many in the regulatory and advocacy space seemed to have gotten things mixed up along the way.
It’s my wish that all the public image damage inflicted on behavioral health providers that operate inpatient, residential or similarly congregate and isolating facilities leads to an oversight overhaul. Politicians, government officials and influencers accumulate clout when they go after these types of providers. And when that’s the only thing generated after all is said and done, we can see that actually making the world a better place wasn’t actually at the heart of that action.
In addition to an overhaul on oversight, bringing more revenue into these places will make it easier for higher staff to demand the skill and quality that they advocate these providers employ. One clear way to do that is to eliminate the so-called IMD exclusion from Medicaid. Add that as a subwish to either this or the Trump administration section. In short, Medicaid regulations established in the 1960s forbid federal funds to go to behavioral health facilities that offer residential or inpatient services and have more than 15 beds.
In parallel, I would like to see behavioral health providers found to have committed harm to take their lumps, whatever they are, and move on the better for it. It’s disgusting to see providers try to dodge accountability even if doing so is legal.
Permanent telehealth flexibilities, including for prescribing
Does Santa visit federal offices in D.C.? Maybe he could deliver a cohesive framework for the U.S. Departments of Health and Human Services and the Drug Enforcement Administration to reconcile the apparent divide between industry regulation and law enforcement.
My grandest wish is that the advocates get the DEA to create the special registration process for telehealth prescribing they have long been mandated to do and have long put off. But at this point, I will settle for making telehealth flexibility that was tested and arguably proven during the pandemic permanent. If that doesn’t happen, having the issue more or less resolved pending further political action is definitely needed to end the uncertainty around the issue.
Stronger workforce development efforts
We have long held that government entities have it in their best interest to ensure an educated and skilled citizenry. And, short of bringing more government programming and tax dollars into the equation, I don’t see any of the behavioral health industry’s workforce issues improving.
I deeply wish that some combination of several state governments, perhaps in partnership with the federal government, will create more programs that allow young people to get into the workforce or anyone looking to pivot their career to get into behavioral health-related clinical work. And since this is a wishlist, I wish that they would get paid to do it.
The need is desperate. Despite all of the investment that the private sector — for-profit and nonprofit alike — has made into expanding access to autism therapy, for example, there are still major shortages of providers throughout several markets that make that investment ineffectual.
More opportunities for student loan forgiveness, apprenticeships, earn-and-learn and second-career upskilling programs could go a long way to fixing the supply side of the workforce equation.
The private sector is already interested and investing in these kinds of programs. Again, pulling from the autism therapy sector, it’s seen as a winning strategy to invest capital that could increase care capacity to foster education programs.
Resolution to the platform-provider quality debate
I wish we could settle the debate about the role that digital therapy enablement companies play in clinical oversight and who is the true guardian of standards for the therapy space. So much of the digital discourse about the platform companies centers on the negative experiences of patients with (to put it kindly) ineffective therapists. These platforms are condemned for not having clinicians in leadership positions that can establish clinical standards to protect patients. But at the same time, therapists are constantly chirping online about having the freedom to practice as they see fit. The two concepts can eventually harmonize, but it’s a zero-sum equation: to enable more specific clinical standards, some element of clinical freedom has to be relinquished, or to enable greater freedom, some level of oversight has to be diminished.
While the difficulty of having a private practice has never been higher, looking at the services therapists use to enable those practices for greater clinical rigor seems like a mistake. We already have state and private entities that certify that a therapist is competent to do what they say they can do. Perhaps there needs to be greater scrutiny of these bodies for not ensuring that those they represent to the world as competent remain so.
