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We dive into the urgent state of children’s mental health in America with our guest, Alex Stavros, a health care executive. With over a decade of experience in the industry, Alex sheds light on the complexities of accessing mental health treatment for children within the commercial insurance system. We’ll explore the challenges families face, the proposed policy changes aiming to strengthen mental health parity, and innovative solutions needed to address this national emergency.

Alex Stavros is a health care executive.

He discusses the KevinMD article, “To address youth mental health, we must address insurance barriers.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Alex Stavros. He’s a health care executive, and today’s KevinMD article is “To address youth mental health, we must address insurance barriers.” Alex, welcome to the show.

Alex Stavros: Thanks, Dr. Pho, great to be here. Appreciate your time.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Alex Stavros: Yeah, of course. So just a little bit about me. I grew up the son of missionaries and social workers in the slums and the outskirts of Lima. That upbringing really gave me a heart to want to give back and serve others.

Moved back to the States to become an economist. I wanted to solve world poverty. I became an economist, lived in Washington DC, worked on Capitol Hill for a bit, and learned a lot about the power of business as a force for good, and some of the inefficiencies that come with government and nonprofits as well. So I decided to use business as the platform to impact society positively.

And that journey eventually took me to youth mental health 12 years ago. And Embark, the brand name itself, I am the CEO of Embark Behavioral Health, is relatively new, but our first program served families almost 30 years ago. So we’ve been working with teens and their families on mental health issues for almost 30 years, and I’ve been lucky to be serving as the CEO of this organization for the past 12 years.

Kevin Pho: So let’s talk about your KevinMD article, which of course talks about youth mental health, we must address insurance barriers. So before leading to your article, just give us the context about what some of the statistics are and what the story is about youth mental health as it exists today.

Alex Stavros: Yeah. Youth mental health really is at crisis levels. And some people think it was due to the pandemic, but the CDC was reporting crisis levels, record levels, of anxiety, depression, and suicide amongst youth many years before the pandemic hit. The pandemic only exacerbated and exposed the issue that many of us already knew existed.

And it’s pretty startling, some of the statistics. In a number of states, teen suicide is now the number one cause of death for teenagers, and in our country it’s often number two, if not number three, but typically number two cause of death. And there are a lot of studies that pop out either from the CDC or other survey organizations that show that our youth are really struggling and hurting, from stress, from anxiety, from depression.

Fortunately, we hit record levels the previous year, sorry, but last year the CDC just reported, they usually put out their numbers at the end of each year so it came out a few months ago, for 2022 we saw a drop in those numbers for the first time after hitting record levels in the previous year. But still, it’s at least a quarter of teenagers are diagnosed with some sort of mental health issue.

And that’s alarming because there’s a lack of awareness around these issues, around what they are, how to diagnose them. There’s a lack of awareness around the services that are available to address them, and there’s a stigma around getting help.

And if you’re able to get over those awareness and stigma issues, you still have the challenge of accessing high quality care. So you could be aware, know what the issue is, not have stigma around, as a parent, finding help for your child who may be depressed or anxious, but then you can’t find any providers. Most providers are not in network, they’re private pay, and they have long wait lists.

And when we talk about providers, mostly it’s psychiatrists and therapists, very little in terms of intensive outpatient programs or therapeutic day treatment programs. So many kids just end up being admitted to hospitals, not just psychiatric hospitals but emergency rooms, where many of them aren’t really equipped to deal with mental health issues.

So it is a real crisis, not only in terms of the magnitude of the issues but also the lack of a strategy and the lack of services to address this crisis.

Kevin Pho: What are some of the key factors that contribute to the youth mental health crisis?

Alex Stavros: Great question, Dr. Pho. I get that a lot, and I think there’s a myriad of issues. And some people ask, hey, is it different, because I don’t remember this when I was a kid, and is there just not enough resilience or grit, or we just need to tell our kids just to get over it because that’s what my parents told me to do?

We really believe that the world is different today, and one of the biggest reasons the world is different is because of access to information. Starts with the internet. And you can actually look at the rates of anxiety and depression and you can map that to the prevalence of internet and the access to internet, which eventually means social media as well.

And when we talk about access to internet information, information can overwhelm a developing nervous system and a developing brain. And when we overwhelm our nervous system and brain, as you know, that ends up creating stress. And stress is at the root of almost all health issues, physical health issues, mental health issues, you name it.

In a lot of ways we think about anxiety and depression as, depression is stress around what’s happened in the past, anxiety is stress in the body around what we’re worried is going to happen in the future. And so all of this information, news about the wars and climate change and famines around the country, that’s available and the kids hear about it all the time.

And then on social media, where it used to be keeping up with the Joneses was literally keeping up with your next door neighbor, now it’s not keeping up with the Joneses, it’s Keeping Up with the Kardashians, which basically means we keep up with everybody in the world because we know what everybody’s up to.

That information starts to create stress, starts to create certain expectations that are unsaid, at a time when parents are less present and adults less present, because they’re on their phones or they’re bringing work home, they’re more stressed. And what a developing brain and a developing nervous system really needs is secure adult relationships, needs human to human contact. Most kids are engaging over social media, there’s not as much engagement at home with family. And that is what prevents us from developing that sense of self, that resiliency and grit that allows us to handle hard things and stress.

And now, at a time where there’s more stress than ever because of all the information and knowledge and pressure, we have the least amount of human connection. So that ends up being kind of your perfect storm.

Kevin Pho: Your KevinMD article is titled “To address youth mental health, we must address insurance barriers.” So talk about some of these obstacles that prevent us from treating the youth as we should.

Alex Stavros: Yeah, I think a lot of it gets back to awareness around what works, what doesn’t. This is, insurance funding and paying for these services is really new, it’s only the last few years. And so for anything that’s new there’s going to be some growing pains.

And as you know, when we talk about insurance companies, it’s very fragmented. Every state has its own licensing rules. Even if you think about, some people hear Blue Cross Blue Shield, every Blue Cross Blue Shield in every state is a different organization, some are for profit, some are nonprofit. When you think about Kaiser, Kaiser has regions and each of them are run by different network directors and clinical teams. There are very few payers that operate nationally. Very fragmented, and each one has its own processes.

So in order to start to realize and understand what types of treatments work for kids, it’s challenging. And because those payers don’t really communicate, the providers are very fragmented as well, there haven’t been a lot of providers that take insurance. So it’s really in its infancy and we need to catch up. Providers need to get more aligned, state licensing needs to get aligned in terms of how they define and license certain programs.

There’s certain states, for example, that don’t even have licensing. Texas, for example, does not have licensing for a residential treatment center for young adults for mental health, only substance use. So if you want to operate a mental health treatment center for a 19-year-old, they don’t have a license for that. And it can’t be that way. And then there’s certain states that have requirements around psychiatry for different types of care that also doesn’t really make sense.

And so the challenge is, coming together in a very fragmented field, is how do we come together and start to define levels of care that connect to our understanding of youth, the growing brain, the growing nervous system? It’s different treating a 14 year old than it is treating a 45 year old. So we can’t use the same interventions and treatments and the same programs that we would with a 45 year old that we do with a 14-year-old, where not only is there a developing brain and nervous system and sense of self, but also there’s a whole family system that has to be addressed within that.

Those programs need new CPT codes, need new definitions, need new parameters from state licensing in terms of the standards, which need to be elevated. Family treatment needs to be a part of it, required.

And so what ends up happening is, if you really know how to get the outcomes these families need, it’s more costly than typically what you see, an intensive outpatient program for a group of 45 year olds. But those rates aren’t comparable, the definitions aren’t comparable, and so then what we end up talking about with payers and providers is apples and oranges.

And so I think once we all get on the same page, we’re going to understand what really works, and then we can set new CPT codes, new rates, new standards of care, and then help launch that across the country. But right now the fragmentation is really making it hard for everybody to create the services that our youth need.

Kevin Pho: So tell us what kind of headway you have made in terms of unifying all this fragmentation so we could better address youth mental health. Tell me how you’ve moved the needle.

Alex Stavros: Yeah, so we’re talking to our payer partners all of the time. And there are certain payers that get it now, and we’re in network with those payers who get it, who understand it, who also understand the impact of not addressing youth mental health in terms of the cost to society and the cost to their particular system in terms of creating more physical health issues in the future. They know the importance of intervening, and intervening in a big way right now. And so they’ve really stepped up.

Other payers don’t understand yet, and part of it is they’re figuring out what to trust and who to trust. And so for us, a lot of it is just like a relationship at work, it takes time, and building trust is about time and evidence.

And so a lot of what we do right now is on an out of network basis. We try to do single case agreements, which as you know are basically individual in network contracts for one. And that gives us experience with the payers, gives that family member a more simple way to engage with us. And then in that process we’re sharing data and outcomes with the payers, we’re meeting with their clinical team, we’re building that relationship. Typically that happens on an in network basis. We’re challenged right now to do that on an out of network single case agreement basis, so that we can start to move in the same direction. So that partnership’s really the main thing that we’re working on. Those relationships are critical.

Kevin Pho: Is what you’re doing more on a regional level, or is there any action happening on a more national level?

Alex Stavros: Yes, all of the above. And so obviously with some payers, national conversations are very relevant. For the majority it’s not relevant, so for those payers that are regional the conversations are on a regional basis.

But part of where the genesis of this article came from, for example, is really comments that we put forward at Embark Behavioral Health, adding some teeth to the legislation, mental health parity act, that was put forward a couple decades ago. And we put some comments really supporting that, and that we need more. On a national level we need more guidance from, say, CMS to define some of this. And we believe that that’s the way to allow payers and providers to come together, is working with those in Washington DC to figure out, how do we define these standards, how do we revise these CPT codes, how do we all get on the same page and come together?

And so those national conversations are very relevant from a legislation perspective. Also national conversations with those payers that do have a national presence is what we’re doing as well.

And then regionally, we’re in 16 states, so in every single state we operate we’re working with payers, we’re building relationships with them. They’re critical in terms of this partnership, and they’re experiencing the growing pains just like everybody else is. They want the best too, they want to address this, it’s just not clear how to. It’s confusing and there’s a lot of different stories and not very many different providers. And so they’re trying their best too.

And so we’re really trying to create an organization with expertise, with legacy, where they can trust us and we can work together to find that common path to create more access to high quality services.

Kevin Pho: We’re talking to Alex Stavros. He’s a health care executive, and today’s KevinMD article is “To address youth mental health, we must address insurance barriers.” Alex, let’s end with some of your take-home messages to the KevinMD audience.

Alex Stavros: Thanks, Dr. Pho. I’ll share a little about our core purpose. At Embark, it is to create joy. And we view the lack of joy as the root of our youth mental health crisis.

And joy for us is very different than happiness. Happiness is often a fleeting emotion, a feeling, not something we choose, but it’s based on circumstances. Whereas joy is the product of a shared experience, comes about by putting others first, by finding purpose and meaning in the struggle and the pain and the suffering that we experience in life. That life isn’t about this single-minded pursuit of happiness and avoiding pain and suffering at all costs, it’s about embracing all emotions, and knowing that in those pains and struggles and difficult moments, when we’re in relationship with others and particularly serving others, we can find joy.

And when we find joy, even in those difficult times of anxiety, of depression, we can be connected to others, and that’s what makes us most human. That’s why we believe it’s critical that our organization, Embark, exists and continues to grow, so that we can continue to spread that message.

Kevin Pho: Alex, thank you so much for coming on the show, sharing your time and expertise.

Alex Stavros: Thank you, Dr. Pho.