Why is Behavioral Health So Hard to Fix?

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This episode of Vital Viewpoints on Healthcare features Dr. Gina Lasky, managing director at Health Management Associates, offering her unique perspective on the persistent challenges surrounding behavioral healthcare. Drawing from her extensive experience and research, Dr. Lasky delves into the complex reasons behind the fragmentation of our behavioral health system and the role incentives play in exacerbating this issue. This episode is for anyone exploring innovative strategies to reform the current reimbursement framework to align incentives for patient-centered outcomes to foster collaboration across disciplines to promote whole-person well-being.

Jennifer Colamonico: Welcome to HMA's vital viewpoints on healthcare, concise conversations with experts that identify practical solutions to make healthcare and human services work better. I'm your host, Jennifer Colamonico, and I'm thrilled to be your guide as we explore new ideas for solving challenges that confound our uniquely american systems. Charged with delivering health and health care in a world that has far too much information and far too little wisdom, we'll aim to keep it simple, frank conversations about what it really takes to reimagine these systems of health and healthcare. Our HMA experts know how things work and don't work, and they have viewpoints on both the problems and solutions that are born from that experience. Vital viewpoints on healthcare is not just another podcast, it's your window into the minds of those steering us toward a healthier future.

Jennifer Colamonico: Subscribe now and together we will explore the hard earned wisdom that could change the way you think about your professional challenges.

Jennifer Colamonico: Our guest today is Dr. Gina Lasky. A licensed psychologist with a remarkable background in public sector behavioral health system design and programming. Gina has been at the forefront of integrating behavioral health and primary care, evaluating organizational readiness for integration, and guiding the development of innovative collaborative care models. Gina has worked in county health systems, community behavioral health centers, state corrections agencies. She's provided direct clinical care in public hospitals, state hospitals specializing in serious mental illness, and working with individuals facing complex challenges. She's published influential work on leadership and team development in Integrated Health and is a co editor of Integrated Care, a guide to effective implementation for the American Psychiatric association. But most crucially for this conversation, Gina really brings a unique skill set to the table, a proficiency in culture change required for system transformation. She works in strategic planning, leadership models, team development, and change management, collaborating to build multisector and community based solutions to promote integration at the system level and address social determinants of health. So integrated care is really what we're going to talk about today. And Gina, first of all, thank you for being here and for being part of this conversation in our book. You are an exceptional thought leader on these issues, but you also have a really unique point of view on why fixing behavioral health is just so darn difficult. So my first question to you is, when you think about integrated care and your long career, at what point in your career did you start thinking about integrated care as a priority for your patients? At what point did you kind of connect that that was something that could be done?

Gina Lasky: Yeah, it's an interesting question, and thanks for having me. It's great to be part of the conversation so I actually had not really thought about integrated care until I took a position working for a community mental health center, where building an integrated care model for those with serious mental illness became part of my job. And to be honest, at first I wasn't sure that it was going to work, because I think, like most behavioral health trained clinicians, wanted to protect the behavioral health side of the specialty care. And I didn't understand how to blend it with primary care or medical services. And then once I started to get into it, I could see that it was definitely the right option for those with serious mental illness, but also really as a way to expand care for anyone with behavioral health through their primary care. So then I became very passionate about how to design the team side of that, how to get teams to talk to each other, cross sector, learn from each other, think about the person in front of them in a more holistic way. And then, honestly, that has become. I went from doing that at a clinical level to going back and getting a degree to think about how to combine nonprofit, government, and private sector in the same way that if you think about integration, you can think about it at the individual patient, clinical level, but you can also think about it at the system level. And so integration just kept taking on bigger and bigger terms or meaning for me and how I thought about it. And now working on system levels, it's all about reducing fragmentation and behavioral health.

Jennifer Colamonico: Yeah, it seems like, as we've talked about this over the time we've known each other, it's like they're building a bridge from two different sides. And the behavioral health side is trying to bring in more primary care, and the primary care side is trying to bring in more behavioral health. And the pieces of the bridge haven't quite connected yet. So let's get to the crux of defining the problem. If you were in an elevator and you had a couple of minutes to lay this out, you know, what is your elevator rant? What's your most kind of condensed version of why the system is so fragmented and hard to fix?

Gina Lasky: Well, I think, big picture, the reason that the system is fragmented goes back to the 1950s, when really, we decided as a country to carve out behavioral health. So mental health and substance use, and really mental health and substance use got carved out from one another, became too special. Individuals with those challenges needed to be protected. The reasons behind it had good intentions, but because of, we pulled them apart. We literally pulled apart the systems of care that were serving the same people. And then all of the funding, all of the regulation since the 1950s has been in that siloed approach. So I think that's the root cause.

Jennifer Colamonico: The funding is separate, the systems have been bifurcated. What is that, 70 something, almost 75 years of that?

Gina Lasky: Yeah. And if you look at now, in any state for behavioral health, most states have somewhere between seven and 14 state agencies funding behavioral health. So that fragmentation just kept going. So people with behavioral health who are in carceral or justice involved settings, that funding is carved out for education, behavioral health funding is carved out. So you have all these agencies with little pockets of dollars to serve the same population. And then I think that the other big piece of that elevator speech is that behavioral health was designed to serve a subset of the population, originally those with serious mental illness. And of course, as the world has changed and demand has changed, and our understanding of mental health and substance use has changed, that population is now everybody. So even how we think about the field of behavioral health has changed. And then I think, of course, the piece of integration that you keep bringing up is now we want to serve not just the individual's mind and emotional state and mental health and substance use conditions, but we want to serve the whole body and think about this whole person. And so it's just been an evolution where the field itself wants to move towards integration. Clinical models want to move towards integration. And I mean integration at the big level and the clinical level, and at the same time the funding and the regulation are still siloed. Yeah.

Jennifer Colamonico: So I want to talk about funding and incentives. You talked about all these different agencies. I mean, it kind of answers my question, which is, where are we wasting money that could be better spent elsewhere? It seems like this kind of big fragmented system, there's got to be some waste in there. Where do you think we're wasting the money being the most inefficient with our fund?

Gina Lasky: I think the most inefficiency comes from a couple of things. One is duplication of services. Again, if you have all these state agencies or entities funding different parts of the puzzle, they don't know about the other opportunities or funding streams that are happening. You also end up with really inefficient systems. So you have different networks of providers with different focuses on slices of the population all running in parallel to one another. So if you think about an individual family who's trying to get their child services, they might start in one network stream, say commercial market, and then let's say things get a lot worse and they end up in the Medicaid market. It's a different network of providers. So it's not like they just get referred over. They'd literally have to cross over this chasm between these networks into this whole new process. And then even within the public sector, there are multiple networks under different managed care entities, for example, or different state agencies have their own networks for specific services. And then that creates different credentialing processes and contracting processes. And all of that creates wasted dollars and complexity for someone to manage and navigate to get to the services that they need.

Jennifer Colamonico: How does reimbursement and incentives play into this? Where are our reimbursement structures kind of steering us wrong?

Gina Lasky: Well, I think that part of it is we still have very fragmented funding, right, as we said, between the state agencies, and you have two big funders in the behavioral health space. You have Medicaid, which is new. Mental health and substance use was not always part of the Medicaid space. So even that, it's not new new, but it is new. If we think about from the 1950s, four, that's still new. Medicaid is by far the largest funder of behavioral health. And then you have the SAMHSA non Medicaid funding that goes to states that's really serving those who don't have Medicaid or who are services that aren't covered by Medicaid. We need to figure out and be more creative about blending and braiding dollars to really be able to create those cohesive networks and more holistic care. But there are regulatory barriers to that. There are system barriers to that. So I think the incentives are still in their silos. And so as a provider, you end up getting contracted and reimbursed and incentivized by funding stream.

Jennifer Colamonico: So is that regulatory burden, or I guess not burden, but sort of that opportunity. Is that mostly at state levels, or is there because of the clinic funding and so forth?

Gina Lasky: Is that also local?

Jennifer Colamonico: How far down do you have to go in the regulatory space?

Gina Lasky: I would actually say that behavioral health has really been over regulated for decades, and that's one of the reasons that the behavioral health field has really struggled. We in many ways faced inequities as a field because of the way in which we were carved out. We were seen as separate from less valuable. I think in many ways the behavioral health feels devalued and dehumanized. The workforce talks about that. Right? It's part of the workforce crisis today, but it's absolutely been underfunded and over regulated. And the over regulation starts at the federal level and goes all the way down to the local level. So for a provider, you have regulation at every step, and then you put managed care in the mix of that too, and there's added regulation. But the reality is regulation is not bad. I think behavioral health should be very accountable for what it does. I think we should be doing a better job of showing our accountability and our desire to have quality outcomes and our demonstration of those outcomes. However, we get held accountable for process metrics because federal agencies weren't sure how to demonstrate outcomes. So there is sort of a mismatch of the regulation with where you really want the field to go. And that is one of the problems that's creating real challenges for behavioral health to get to a different space.

Jennifer Colamonico: Does that have to start at the top and sort of trickle down, or are there innovative ways to do this kind of at the state level? Where do you think the innovation is happening right now?

Gina Lasky: I think states, there are a lot of states trying to figure out how to be more innovative about policy and administrative burden creating efficiencies. You certainly see states trying to do that also states trying to figure out how to blend and breed dollars and how to create more coherent systems of care through their system design. So 1115 waivers are a good example. There's a lot of states who are restructuring behavioral health and thinking cross payer states who are really creating strategies that are really cross all payers, government, private, commercial, really thinking broadly about how to bring those to the table and reduce the complexity at the individual level and at the provider level. I think that the long term question is some of that does bump into ultimately regulatory levels or barriers at the federal level. And so there are needs to be federal level changes, state level changes, and local level changes. They all need to happen, and some of them can't. There's only so much states can do before they bump into a limitation in Medicaid or non Medicaid funding and where they have to keep collecting data that may not be useful because that's what they're asked to report.

Jennifer Colamonico: So if you had a magic wand, what's the one thing that you would fix to start? Sounds like there's lots of things, but what's the first thing you would fix to kind of get this on the right track?

Gina Lasky: That's a hard question. One thing that I would fix, well, here's the problem. It's going to sound weedy, but there's a reason why I think this is the one thing to fix right now in behavioral health and always is a good demonstration of this over regulation. We have always said that when someone comes into specialty mental health in the public sector, we have to start with this intensive assessment of what happens to them. So we go back to their childhood and ask about trauma. We go and ask about whether or not their family has been involved in the military. We ask if they're a veteran. We ask about their cultural background. We ask so much that it's about an hour and a half for someone to get into care. In that hour and a half, we do nothing to help them. Right. Providers are trying hard to figure out how to do that, but they have all this stuff they have to report on that the state requires and ultimately that the federal agencies require. And the reason for this, the background for that was to try to eliminate risk and make sure we were capturing risk for an individual and that behavioral health providers could intervene. I think it's a problem to think that behavioral health has a crystal ball and can prevent all risk. But I also think it's incredibly troublesome for access. And we have an access to care crisis in the United States for behavioral health. With demand increasing, people waiting a long time to get into care. Once they get into care, they have to wait a long time to see a therapist. We need to get much better at treating them right there, giving some relief immediately. And that is a regulatory barrier that's creating an access problem.

Jennifer Colamonico: I see why that is both weedy and also fundamental. It's sort of like not putting the patient first in the engagement from the very beginning. And is that a federal rule or.

Gina Lasky: Is that it starts at the federal level and it moves down, and providers can't get reimbursed for seeing a person and delivering services until they do that assessment. So it is the beginning for everyone. And I prepare, when I send someone into the public sector behavioral health system from my personal life, I prepare them for that intake because it is literally ripping off every single band aid and coping skill anyone has ever had in their life, and sometimes it has nothing to do with why they came in the door that day. Right. It's not client centered and it's not productive, and it's inefficient in the system. So I think that's a really good example of where we need to sort of. Our team talks about this a lot at HMA. We want to disrupt the way in which behavioral health has been designed and created, because we're not doing it right. And it's not for lack of innovation or vision from state agencies or from providers. It's this kind of challenge that you run into.

Jennifer Colamonico: Well, and you've often talked about, you talk about transformation, you've often talked about almost like destroying the current system and rebuilding. So maybe it's not the magic wand, maybe it's the sledgehammer. What would your Sledgehammer approach be to rebuild this thing in the right way?

Gina Lasky: Yeah, I mean, I love the sledgehammer. I think about it as creative destruction. But I think we need to ask the big questions. And we should be starting with people, right? We should be using a human centered design approach. What do people want? How do they want to get services? What do services look like? I mean, if you ask individuals with mental health and sud what they want, they don't want outpatient services where they see someone once a week. They want on demand support, 15 minutes, someone who's going to answer the phone when they want to try a skill or when they need help. They want someone who's going to meet them in the community and help them do things they want peers at the front door, they want a lot of things that we don't do, we don't pay for, we don't have the regulatory structures for. And I think we have to sort of start with what people want, how to create whole person, really good behavioral health services, those strong outcomes, and then build the provider system and the regulation that aligns with that. And that means high accountability. That means really demonstrating quality. It means really having good return on investment. But we could do that if we started with what people need. Yeah.

Jennifer Colamonico: Seems so obvious. Is there anything that gives you hope that we might be moving in the right direction?

Gina Lasky: Yeah. The biggest thing right now that gives me hope is that behavioral health has moved from what I call the side salad to the center of the plea. It has always been, and it's part of that inequity that I mentioned in the past. It's always been the part of the healthcare system that's to the side and it's never gotten the funding or attention yet. It's had a huge impact. And I think that impact has finally moved it to the center of the plate. And then now it's getting attention and funding and innovation. And you see innovators in all sectors. The private sector, the public provider space has a lot of innovative, there's a lot of innovative providers trying to figure out how to work around the regulation to deliver good care. And then you see states really asking good questions about how do we do this differently? How do we create cross agency, cross payer? How do we solve this multiple provider network problem and create a more seamless approach so I am hopeful because I think we were hitting a tipping point where there's no option but to really think differently about it. Yeah.

Jennifer Colamonico: Is there anything else you think that people should understand about this issue but perhaps don't?

Gina Lasky: That's a great question. I think that a lot of people don't understand the importance of having strong mental health and substance use services in all parts of our lives. We have always tended to think of it as a specialty population, that it's a subset of people. But really the reality is most of us are going to have a mental health or substance use challenge or someone we love is going to in our lifetime. And so we have to think about this as part of health. Mental health and substance use are health. They can't be separate. And we have to have a system that works as well for those kinds of challenges as we do for how we treat cancer or diabetes or thyroid or whatever you want to say. It can't be treated as something that's so separate and so unique because it's touching everyone right now.

Jennifer Colamonico: Well, we could talk about this for hours, but we will leave it there for now. And I really appreciate your time with us today. Gina, thank you so much.

Gina Lasky: Thank you. Appreciate it.

Jennifer Colamonico: Thank you for tuning in to another enlightening episode of HMA's vital viewpoints on healthcare. We hope today's discussion has sparked new insights and perspectives. To learn more about our esteemed guests, please be sure to visit slash podcast until next time. Stay informed, stay curious, and keep searching for the wisdom that will help to transform our healthcare landscape. This podcast was produced by myself, Jennifer Colamonico, along with Tiffany Mckenzie, in collaboration with our guests. The content is the property of Health Management Associates.

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Vital Viewpoints is hosted by HMA Director of Thought Leadership, Jennifer Colamonico.

Meet your featured speakers

Gina Lasky

Gina Lasky, PhD, MAPL

Managing Director, Behavioral Health
Denver, CO
Quality & Accreditation

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