Melanie Cole, MS (Host): Today, we're exploring the economic impact of behavioral health, access disparities, and strategies for integrating mental health into primary care, right here on AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole, and joining me is Dr. Doug Henry. He's the Vice President and Medical Director of Enterprise Behavioral Health at Highmark Health.

Dr. Henry, thank you so much for joining us today. This is a really great topic and there's a lot to discuss. But data has shown that people from racial or ethnic minority groups are less likely to receive preventative health care and most certainly mental health care. And across the board, these communities have faced a disproportionate health burden.

Can you speak to us a little bit about the unique challenges in terms of health care disparities where mental health is concerned?

Doug Henry, PhD: Yes, absolutely. And I appreciate the question, Melanie, and it's good to be with you. The disparity issue is most starkly illustrated by a study that I read four or five months ago. So this is a very current study and it was a simple design and it was predicated upon two voices. One, a 45-year-old male that had a Caucasian sounding voice and one, a 45-year-old male that had an African American sounding voice and they each were going through an insurance company's sort of Rolodex or provider list of behavioral health providers seeking psychotherapy. And, the Caucasian gentleman, sounding gentleman, made four calls and was not successful. On the fifth call, he secured an appointment for an initial psychotherapy visit with a provider.

The African American sounding voice after 98 calls with not securing any appointments, the project stopped at that point. And the gentleman that was doing the experiment said that he had become depressed through the process of making those 98 unsuccessful phone calls. So, there are incredible health disparities, and as we talk about access, we have to talk in terms of access for whom, and access to what, specifically?

Host: Wow. That is really an incredible study that you shared. and we're going to get into access and disparities, but let's start a little bit with the economics of behavioral health medicine in general. How does the economic burden, because we know that there is a mental health epidemic right now in this country, and underserved communities are especially heavy with that burden.

How is this burden of behavioral health issues manifesting itself across healthcare systems and communities?

Doug Henry, PhD: It manifests in many different ways. The most obvious ways are disability. Depression, anxiety are both leading causes of disability in the United States. It manifests in attrition from work or people that are unable to show up on a consistent basis to work and most strikingly, and also, subtly, the cost manifests in elevated medical spend. So not necessarily the spend that patients have on behavioral health or psychiatry per se, but on other quote unquote medical problems that are in part driven by psychiatric challenges. And so what I mean by that are the tummy aches, that have no basis after a lot of testing or, individuals that quite rightly rush to the emergency room; when they are tachycardic and sweating maybe experiencing dizziness and they have an MRI and sometimes a CT scan of the lungs to rule out a pulmonary embolism. And in reality, the challenge is that they're having a panic attack. And so in these ways, underdiagnosed, undertreated mental health disorders contribute greatly to accelerated medical spend across the United States, and there are various estimates of that. But I can tell you one simple one, and that is that individuals with a behavioral health diagnosis tend to cost three to six times as much as members without a behavioral health diagnosis, all else being equal.

So that is in very stark terms. At Highmark Health that factor is actually 3.7x. A 370 percent of the typical spend is spent on individuals with a behavioral health disorder. And the majority of that spend is not spent on behavioral health specifically, but on treating other medical comorbidities.

Host: That is so interesting. Dr. Henry, and as we look at access disparities, lack of insurance, underinsured, mental illness stigma, certainly important, language barriers. There are so many. In your opinion, Dr. Henry, how would effective integration of behavioral health into primary care impact healthcare spending overall and outcomes, both from clinical and economic perspectives?

Doug Henry, PhD: What a wonderful question that is, Melanie. And I thank you for asking it. I'm a big supporter of integration in multiple different forms. Typically we think of integration in terms of dropping a mental health clinician or a psychologist into a primary care practice where they're co-located and can serve as a member of the treatment team.

And this is a great way to approach equitable access as well as stigma reduction in that individuals are able to find free parking and not drive too far because they're going to their local pediatrician or they're going to their local primary care office and no one would be any the wiser if they were there for a sprained ankle or for treatment of a minor anxiety disorder. They're going into the same door and into the same office. The, subtle part of it that is a huge advantage is capitalizing on the positive trust in transference that individuals build with their pediatrician or with their family practitioner or their primary care practitioner.

And most people do have trust in those individuals or they swtich. And so when a primary care doctor welcomes a behavioral health professional into their office and makes them part of the team, that is giving her or his sanction and approval to that person as a high quality provider. And that really helps the patient engagement and the trust, which is very necessary for mental health treatment to be there from the beginning.

But it's important to talk about other forms of integration. In its most pure sense, integration simply means providing access to mental health services where people commonly are. And so that can include things like schools, it could include things like a workplace, and anywhere else. It could be a women's program. It could be a youth organization; but to make those services accessible where people already are, as opposed to having to fight traffic and get to an urban center and, go into a high rise, for a specialty behavioral health appointment.

Host: Well, Dr. Henry, along those lines then, as we think of access, and as you said in rural communities, the travel, parking, all of that. What role do you see telehealth playing in closing some of those gaps for primary care and combining mental health and primary care?

Doug Henry, PhD: Studies have shown consistently for 20 years, and there's been an acceleration in the studies since the beginning of the pandemic, for obvious reasons. The studies show that nothing is lost in the treatment by video as opposed to face to face. And this is true for children 10 and up, as well as adults and even elderly people.

So that's first off, a question that gets asked most commonly by both providers and by patients alike. So, the science tells us that the quality is just the same. Now, advantages of remote treatment include greater equity on average, as digital systems tend to have digital front doors, digital evaluative screenings, and therefore they have equitable opportunity for access kind of built in to the architecture of the telemedicine system.

So it could not be anything but equal access. And so in contrast to that study that I cited before, which characterized people calling on the phone, seeking a face-to-face appointment; the digital revolution has provided a greater measure of equity, particularly if the provider has paid attention and set their system up in a way that it could not be anything but equitable.

Host: We have learned a lot from the pandemic as far as healthcare and telehealth and I agree with you and it's not going anywhere and I think it's only going to expand. And as you said, Dr. Henry, I think in the mental health and behavioral health world, this is such an important aspect for people. Technical considerations notwithstanding, I think that we're getting better with that.

Now, along those lines, physicians play a big role, a critical role in addressing these public health concerns. Dr. Henry, as it relates to DEI and equitable opportunities for recovery, how can mental health professionals really contribute to this area so as not to perpetuate or even worsen health care disparities?

What would you like other providers to know about these disparities, lack of access, and making their practice a more welcoming community?

Doug Henry, PhD: What a great question again, that is Melanie. Thank you very much. You know, one of the standards today is that one's behavioral health network, if you're a payer or if you're a large provider; that your staff of therapists, psychiatrists, marriage and family counselors, et cetera reflect the diversity of the population of the community that accesses services.

And if that stable of clinicians is sufficiently diverse, people kind of pat themselves on the back and say, well, they've done well according to health disparities. And that's not good enough. It is only a necessary precondition for equitable opportunity for recovery. And that phrase is very important.

Equitable opportunity for access is one thing. Equitable opportunity for recovery is something different. And so what clinicians can do to ensure that they are providing equitable opportunity for recovery, is to measure the variable rates of recovery of different population segments that are treated; making sure that no one segment is lagging behind another.

And what I mean by that is that if on average, 70 percent of severely to moderately depressed patients can be treated to remission in six sessions or in eight weeks or less, that that is true for people of minoritized communities, including gender minorities, sexualized minorities, racially minoritized peoples.

All of those population segments need to be looked at and make sure that rates of recovery are equitable. That's the only way to avoid actually perpetuating or even contributing to health disparities.

Host: As we get ready for our final thoughts here, Dr. Henry, where do you see the future of primary care evolving to address the behavioral health needs of their communities and the communities that they serve in integrating mental health into that primary care for a full range of a medical home?

Doug Henry, PhD: I see integration already becoming commonplace. And so if you are working for an academic medical center or a hospital system, that does not have integrated behavioral health in primary care in the United States at this point in time, you truly are behind the curve. What will evolve more and more is the further integration of mental health services and professionals into many, many different subspecialties.

And what I'm talking about are that mental health therapists and professionals in psychiatry will become a routine part of oncological care, of kidney care, of gastrointestinal care, of neurological care. If you are being seen at a pain clinic, that therapy would be routine, relaxation skills, stress management skills, and actually psychological techniques to manage pain, are part of the curriculum that patients have access to.

So that is what we're going to see in the future. And I want to go back, Melanie, to talk about telemedicine for an instant. I don't mean to say that telemedicine is absolutely wonderful in every circumstance, and we do have a problem, particularly with young people in the United States who show across the board, declining social skills because of both the isolation related to the pandemic and also our video revolution where people are interacting more on social media than they are face-to-face in many cases.

And so we have to be very, very careful about ensuring that remote mental health service is safe and effective for this particular individual. And generally that cannot be achieved with children, younger than 10. So, face-to-face work is really necessary for kids. Kids that are experiencing social deficits of any kind, may benefit much more from face-to-face therapy, as could older people, adults, elderly.

So that has to be looked at very, very carefully. And the fact that telemedicine can bring service access to people in rural areas, is incredibly important and wonderful, but we need not believe that it is a panacea and that it removes the need for face-to-face treatment in certain cases.

Host: You make so many good points, Dr. Henry. And what an eye opening and compassionate plea for an overarching initiative to bring behavioral health medicine, mental health specialties within the primary care setting. And it's just such an important aspect of healthcare. I thank you so much for joining us today and sharing your incredible expertise.

To learn more or to refer apatient, please call 844-MDREFER or you can visit ahn.org.

Thank you so much for joining us on this edition of AHN MedTalks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.