Behavioral health opportunities during the pandemic [PODCAST]

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“The dramatic uptick in mental distress, trauma, and substance use since last year has driven a corresponding rise in the use of virtual mental health therapy and psychiatric care, helping us, as a society, more effectively grapple with the fallout from the pandemic. According to one study, more than half of the people who used telehealth in May 2020 used it for a mental health concern. Virtual care has the added benefit of increased privacy and access to care for people who have difficulty getting to in-person care or end up on a waitlist for weeks to see a provider. Virtual care reduces the time commitment for therapy since it doesn’t require a commute. Overall, it’s a method that provides patients with more control over how they access mental health care. Providing treatment to those in need is no small task, but with new digital tools and more accepting attitudes, the hope is that those struggling with suicidal thoughts and other mental health challenges will feel supported and optimistic.”

Erik Vanderlip is a psychiatry and family medicine physician.

He shares his story and discusses his KevinMD article, “Suicide is never the answer, especially during the COVID-19 pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Erik Vanderlip. He is a psychiatry and family medicine physician, and he wrote the KevinMD article “Suicide is never the answer, especially during the COVID-19 pandemic.” Erik, welcome to the show.

Erik Vanderlip: Thank you. It’s a real privilege to be here. I really appreciate this opportunity.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Erik Vanderlip: Yeah, I can give you the elevator speech. As a medical student growing up in medicine, I learned that persons with schizophrenia died from heart attacks and strokes in their 40s and 50s, 20 years before the rest of the general population. That aspect just broke my heart, and so I sought training in psychiatry and family medicine to give me the skill set needed to doctor to persons with that constellation of symptoms. And in five years of dual training in family medicine and psychiatry, you start to realize that the health care system is really the rate-limiting step to people getting better, rather than your cognitive limitations or skill set.

And so I went and did extra training in public health research and health services research at the University of Washington, blending models of behavioral health and primary care. After that, I joined a medical informatics group in my home state of Oklahoma, looking at health information exchange, trying to chase big data to help us organize the delivery of care to populations. And then about that time is when a company called ZoomCare, in 2016, called me to establish their behavioral health program as part of an integrated offering with other on-demand services. I built that out, and then the past two years, I’ve lived as their chief medical officer, orchestrating all of our services for the ZoomCare network in the Pacific Northwest. We operate about 60 clinics and have about 500,000 visits a year.

Kevin Pho: So one thing you mentioned, you said that the health care system that we currently have is the rate-limiting step when it comes to getting appropriate behavioral health care. So give us an example of how that is.

Erik Vanderlip: I mean, it’s not just behavioral health care. It’s the way that we design and orchestrate access to services that is the rate-limiting step in people overcoming their illnesses. And simply put, I would be in my family medicine clinic, and I would see a person that I had seen in another instance, like on the psych unit, for their mental health, and I would say, “Come see me in family medicine.” And I’d have my 15-minute visit to try and address all their concerns, and their chief concern was their toe pain, and my main concern was the knowledge that their toe pain is not what’s going to kill them in their 40s and 50s. It was their cholesterol, their heart disease risk factors, etc.

And I knew that the meds we had them on for their mental health were contributing to their heart disease, cardiovascular disease burden. Their smoking was. But we could never get to that in the scope of the family medicine encounter because it was so clinic-based. And so all of the reforms that we have in health care are basically driven towards behavior change, getting people to engage and promote behavior change and manage their illnesses and their behaviors better to have better outcomes, because those are the main limiting steps. But our health care systems, as they’re designed and orchestrated now, are just not made for behavior change. They’re made for fixing acute methods on illness.

Kevin Pho: So what needs to be done, in your mind?

Erik Vanderlip: Well, I think, kind of radically, that we should stop trying to squish any essence of behavior change or chronic illness into the health care system as we fundamentally want today. And every effort that we try to do just piggybacks on this. I mean, we try to just squeeze diabetes management into the existing framework and infrastructure, from everything from reimbursement to brick and mortar to everything else. We need to stop, and we need to create a separate and parallel entire system of financing, funding, and services, all the way from that to really ultimately giving the power, resting power over to the person who has diabetes to make decisions for themselves on how they want to manage their care, and give them as much power to do that as possible, as much power and autonomy.

The end user with the chronic illness is the only one who really ultimately has power to effect change on it. I can tell them to take insulin, but they’re the ones who have to go do it, and then we have to enable them to be able to do that. But ultimately, they’re the ones with the power here. And so their financial incentives for care need to be aligned with everything else. And right now, use of insurance, like everything, just forced all that ability for an agent to be completely autonomous.

Kevin Pho: Now, you’re the CMO for a startup company. So tell me about that intersection between technology and health care. How can technology address some of the problems and issues that you just described?

Erik Vanderlip: Technology allows for scale, number one. It also allows for better data management so that you can target populations who are stuck in reaching recovery, in managing their own diabetes or their depression well. And so technology has a power to gather mass data and allow us to more intuitively match supply-side stuff, providers, with demand-side stuff, people who really haven’t achieved their potential yet in their health outcome. And so that’s what technology can allow us to do. It also allows for conduits of data exchange between the supply and demand side, provider and patient, so that we can have video visits or chat, or they can send us their PHQ-9 scores. All these things are really helpful. Technology mediates that process.

But the other important thing that technology has yet to really fully, I think, achieve is magnifying the supply-side chain. Up in Seattle, at the University of Washington, I worked in these collaborative care models, and by that I mean a psychiatrist, a consulting psychiatrist, in an hour can look over a panel of 50 patients with a behavioral health provider nested in a primary care clinic and give evidence-based, individualized treatment recommendations to each of those 50 persons, troubleshooting them in like a micro-population of 50. You rank-order them by their PHQ-9 score, and then you focus on those who haven’t improved yet.

And then the behavioral health specialist in the primary care setting is helping understand the individual details of the treatment plan, and then the consulting psychiatrist is saying, playing armchair quarterback, “This person needs this. This person needs that.” And that’s the magnification, because as a psychiatrist, I can’t see 50 people in an hour. Yeah, it’s not possible. But in the collaborative care models, I can effect individualized, evidence-based treatment recommendations for 50 people in an hour. And that’s the power of technology to magnify the provider and the resource that we have constrained over here, especially in behavioral health. We need like a billion more psychiatrists or something, and we’re not even talking about primary care. So I think that’s the power of technology.

And one of the opportunities with ZoomCare is that we have our own technology platform. One of the things that intrigued me about it, I think, is that if you’re going to reinvent health care, if you’re going to innovate and create a new chronic illness system that really empowers people, you can’t do it unless you have providers that you really can help hone their culture, their non-paternalism, things like that. If you’re contracting with a provider group, it’s exceptionally hard to really own that in-the-room discussion, the culture of that discussion. You can’t do it unless you have the technology in-house, and unless you have a really enterprising payer who’s willing to think differently about how we reimburse and pay for performance, it’s really hard to get all that going. You have to have all three of those pillars in place. That’s what ZoomCare had in 2016, and the majority of which it still has right now. So that’s the opportunity.

Kevin Pho: So let’s talk now about the KevinMD article. It’s titled “Suicide is never the answer, especially during the COVID-19 pandemic.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Erik Vanderlip: Well, I think earlier this year we came up with some really interesting data, and we discovered that suicide rates in 2020, in the height of the pandemic, actually lowered by about 5 percent, which is something that was quite unexpected. Every other data point that we were looking at was suggesting that depression was rising two to three times what the average rates of depression were in our population, driven by stressors in the pandemic, increasing rates of substance use, etc., loneliness, isolation. And when this came out, it was kind of quizzical, like, “What is this?” This is a data point that doesn’t jibe with what we would have expected.

And I think, regardless of that, in some ways you could look at it and say, “Wow, this is great.” But when you really dig into it, you discover suicide is still one of the leading causes of death for young adults. When you look at the data, accidental deaths, which are primarily driven by drug overdoses, which could be arguably related to illnesses of despair, loneliness, could be an indirect relationship to rising rates of depression. Maybe suicide is a lagging indicator, and this next year we’ll see higher rates of suicide as the depression, or as the pandemic, continues to pummel us over and over again.

But I think when you get into it, at first you could say, “Wow, this is great. This is like a silver lining.” But I think, double-clicking on that, you have to say it’s still not good enough, and we still have so much opportunity around suicide prevention, around managing depression and substance use disorders across the population. The recent turns in stigma around mental health and everything else have just driven more and more demand for behavioral health across our country, and frankly, probably the world. So I think there are lots of opportunities for behavioral health right now, and a lot of opportunity to help heal a wounded population.

Kevin Pho: So go into more detail about some of those opportunities for behavioral health. What exactly do you envision?

Erik Vanderlip: Well, like I mentioned, I think that with more and more people, because of a lowered stigma, raising demand for behavioral health, raising recognition that depression is a leading cause of disability, and other things, there’s just more demand than ever for behavioral health services, quality, evidence-based behavioral health services, and it’s outstripped our capacity to deliver those services. Even if you’re a great primary care provider, we can’t possibly get to all of it. And then after that, you might be able to handle some of the basics of depression, but the treatment-resistant stuff and really getting into the deeper stuff is where it can be really challenging.

And so I think we have to look hard at how we’re delivering services. There’s been a ton of venture capital and other things thrown at mental health startups and behavioral health ideas, but most of it has to do with brokering, getting people to access. But we still have a major supply chain problem. And so the real opportunity in front of us is, as I mentioned before, utilizing that technology to not just act as a conduit, and telepsych acts as a conduit between the supply and demand side, but to magnify the supply side, so that we can get great, evidence-based, high-quality treatments to persons, to prevent and target depression upstream before it becomes a hospital admission, keep people healthier, keep them in recovery, etc. So those are the opportunities in front of us, to really look at using mental health.

I think mental health in some ways is kind of the way we can reform our whole system around chronic illness. We don’t cure really anything in mental health, sadly. It’s mainly things that you have to manage over time. And as a consequence, many mental health disorders are chronic illnesses in a way. People need to manage them and be aware of them and empowered to make their own choices for how they can recognize it’s coming back and what their next steps are. So the best mental health models, the best collaborative care models, are really built on the engine of chronic illness, like we have for diabetes from the 1990s with Group Health, etc. That’s the opportunity we have: mental health leading the way towards kind of showing us how we can better manage chronic illnesses and behavior change for a population.

Kevin Pho: Now, tell us some of the barriers and challenges that are preventing virtual care and technological solutions from addressing some of the behavioral health shortage issues that you described.

Erik Vanderlip: Yeah, I mean, I’ll tell you, personally, parity for behavioral health services still remains an issue. Back in 2007, I remember being at an APA conference, an American Psychiatric Association conference, where they rang a bell and everybody cheered because the federal government had passed parity, federally mandated parity legislation. And here in 2021, we still have failed to fully implement that legislation and hold insurers accountable towards parity in behavioral health services. There are still major gaps. For instance, with certain payers, I’m not going to call them out by name, as a family physician, I will be paid three times as much for managing depression as a psychiatrist. That’s because of continued behavioral health carve-outs, etc.

So parity is one issue for behavioral health services, unnecessary quantity limits, things like that. All these stand in the way of getting access to populations, and as a CMO, I see that day in and day out. We have people who aren’t in network with us because we can’t accept the lower rates from some payers, and so they decline the visit, and we see that day in and day out. So it’s a very real, tangible thing to expanding access to behavioral health care.

But that’s only one thing. The other aspects of this are internal stigma. We need to continue to work on the stigma around behavioral health. It’s helping that major athletes and others are coming out sharing their experiences, but it’s still not enough, because at the end of the day, there’s an internal stigma to admitting that you’re struggling with something like depression, and coming around that yourself is still something that has to be combated against. So stigma is still an ongoing gap and issue with it.

And then we have to deliver good-quality services, and how we are going to do that to meet the population is still a challenge, with a limited supply of providers: Who is best suited to do that and follow up on it well? And within the field of behavioral health, there are new things like measurement-based care and other things that will allow us to do better, systematic, higher-quality care, but those haven’t been fully implemented because the field is still a little funky about really relying on something like a PHQ-9 to guide their treatment modalities.

Kevin Pho: We’re talking to Erik Vanderlip. He is a psychiatry and family medicine physician. He wrote the KevinMD article “Suicide is never the answer, especially during the COVID-19 pandemic.” Erik, what is your take-home message that you want to leave with the KevinMD audience?

Erik Vanderlip: We’re in a fascinating time in health care right now, and there’s a lot of uncertainty, but we’ve definitely hit a watershed with telehealth services. People are starting to think about accessing their doctor differently. They’re also starting to rethink their relationship with their physician, and this power differential between a physician and a patient is subtly shifting, especially around chronic illnesses. You can Dr. Google what you’ve got. You’ve had it for 15 years. Suddenly you can become as informed as your physician sometimes, in terms of what you’ve got and how you want to manage it.

And I think new health care has got to be able to embrace that exact type of thing as we move forward and really empower persons to take care of themselves. And I think mental health is a major opportunity to show the rest of health care how chronic illnesses can be hopefully managed better and safer, and provide better access to populations, and hopefully maintain or lower the cost curve in doing so.

Kevin Pho: Erik, thank you so much for sharing your time and insight, and thanks again for being on the show.

Erik Vanderlip: Yeah, well, thank you. This is a great opportunity.

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