How Behavioral Health Shapes Population Health: Leveraging Opportunities for Health Plans in an Age of Rising Costs and Access Challenges

If there’s a silver lining from the global turbulence of the last four years, it may be the increasing recognition of behavioral health’s pivotal role in shaping population health. As this understanding continues to gain traction, so does the investment in enhancing behavioral healthcare services.

At this year’s Population Health Management Summit, we brought together a panel of experts and clinicians from Spring Health, Highmark Health, and Moda Health. The discussion unpacked the interconnections between effective behavioral healthcare and the broader population health landscape.

We also discussed the surge in members seeking behavioral healthcare alongside escalating health costs. In response, health plan leaders are exploring avenues to enhance access to top-tier care while curbing expenses. 

Within this context, the importance of addressing behavioral health with a focus on quality care becomes clear—a critical foundation for tackling these multifaceted challenges.

Let’s continue this conversation and examine why behavioral health is integral to overall population health, assess the current landscape of healthcare costs, define quality behavioral healthcare, and explore strategies for health plans to manage rising costs.

The role of behavioral health in population health

The interconnections between population health and behavioral health are well-documented, but often overlooked. For example: 

• Two new studies show that individuals with a behavioral health condition are 40% more likely to have a cardiac condition
• The surgeon general recently stated loneliness is as dangerous as smoking a pack of cigarettes a day
• Individuals with a behavioral health condition have a life expectancy of 15 years shorter than those without

Not only does behavioral health underpin overall health, but it’s also an area with significant room for improvement regarding treatment quality, access, equity, and health costs.

The current landscape of healthcare costs

About 25% of medical spending in the U.S. is waste. The same is true for behavioral health spending.

Ineffective treatment is one of the biggest drivers of behavioral health-related spending waste. Most clinicians providing behavioral healthcare use neither evidence-based care nor measurement-based care (MBC).

Dr. Doug Henry, Highmark Health’s Vice President, notes, “When you talk about population health management and extracting more value from your clinical interventions, behavioral health is actually at the tip of the spear. It’s not that there’s no money in behavioral health, it’s actually one of the lowest-hanging fruits. It’s a subspecialty that can get a lot better.” 

Regarding population management, one of the top priorities is working toward behavioral healthcare improvements by prioritizing value-based outcomes and driving more access to quality care.

Access challenges in behavioral health

You can’t pick up popular press these days without hearing about access challenges in behavioral health. It can take weeks, if not months, for individuals to get an appointment with a mental health provider. At the same time, more people are seeking access to behavioral health, exacerbating existing provider shortages and treatment deserts.

However, there is movement on this issue.

Addressing behavioral healthcare parity with physical healthcare is perhaps the only domestic bipartisan issue in Congress at the moment. As we move toward new parity regulations, it’s helpful to consider what true access looks like and how we ended up in a position where many individuals can’t access care.

The illusion of access

Dan Thoma, Moda Health’s Director of Behavioral Health, points out the illusion of access to behavioral healthcare is everywhere. Ghost networks are common. A national network might have 30,000 therapists, with only a fraction accepting new patients. 

Even when someone can get an appointment, there are often still problems with the quality of care and whether the provider can treat the individual’s specific needs. 

For example, is there fast access to a provider with the right specialty for someone who has been diagnosed with PTSD? Does the provider have success working with individuals who have PTSD? Are they utilizing evidence-based care and measurement-based care?

Over half of psychologists report wait times of over three months, with nearly 40% describing their waitlists as extending over a year. Imagine an individual waiting months only to begin care with a provider who’s unable to treat their unique needs. 

Addressing behavioral health challenges—driving true access

Access is the greatest barrier to behavioral healthcare. The quality of care is irrelevant if an individual can’t get into care in the first place. The most effective provider network is developed with a primary goal of driving access to choice and preference.

Building and monitoring access at scale requires some structural choices. Creating a proprietary electronic health records system and a scheduling process enables all network providers to integrate their calendars directly into the platform. This gives both providers and members visibility into appointment availability, updated in real time. 

Alongside this system, Spring Health has visibility into population needs and can hire in places lacking a specific provider specialty. Having a strong data science team and investing in data science is important for creating these systems. 

It’s critical to be able to see if, for example, members in a specific location need PTSD treatment, but that zip code lacks providers who specialize in treating it. 

Equitable, culturally responsive care is another access driver

DeDe Alexander, Spring Health’s Director of Clinical Partnerships, understands the importance of equity in behavioral health treatment and access. Behavioral health conditions are experienced equally across different racial groups. 

Still, there’s been data from the Blue Cross association showing diagnosis rates in Black and Hispanic communities are far lower than in other populations. The prevalence of anxiety and depression isn’t any different, but the diagnosis rates are. 

Black individuals are less likely to receive evidence-based care, and also experience disparities once they decide to enter care and get in to see a provider. 

Taking a step back, there’s already so much stigma around accessing behavioral healthcare, which is experienced differently depending on someone’s ethnicity, language, and/or socioeconomic status. 

So, when an individual seeking care sees a list of providers who speak their primary language, look like them, and understand their lived experience, there’s a much higher probability of the person and their provider building therapeutic alliance..

Therapeutic alliance and clinical outcomes

Decades of research have shown that therapeutic alliance—the strength of the provider-patient relationship—is one the most positive predictors of outcomes across all diagnoses. However, Spring Health Chief Medical Officer Dr. Mill Brown notes this concept is still novel and usually goes untracked.

Therapeutic alliance is an indicator of whether someone is willing to stay engaged in care long enough to even have a chance to get better and receive excellent therapy or medication support.

Having a patient return is critical. The most common number of mental health sessions for someone in the U.S. is one. Often, an individual attends an intake session and then never returns. 

Spring Health measures therapeutic alliance and works to increase it to keep people engaged in care through:

• Collecting systematic feedback from patients about therapeutic alliance
• Using that data to build out monthly report cards for every provider 
• Using data to drive a provider recommendation engine 
• Underpinning the provider network with technology and a data science team

Driving clinical outcomes at scale

Implementing MBC and evidence-based care are necessary components to driving clinical outcomes at scale. Individuals get better faster, and fewer people drop out of care that’s structured this way. It’s also clinical best practice to use MBC, even though many providers aren’t doing this yet.

MBC’s seamless integration into the patient experience and clinician workflow is also key to improving clinical outcomes. MBC is about using real-time patient data to enhance the treatment process.

How improving access can lower costs

When a health plan builds a quality behavioral health solution, overall health spend decreases. 

Individuals with the most common 20 or 30 medical conditions in the U.S. who also had a behavioral health challenge incurred health costs 3-6 times higher than those without a behavioral health issue. 

Thinking about behavioral health spend as something separate from medical spend doesn’t work. Individuals are whole people whose behavioral health is part of a holistic health ecosystem.

Prevention as a key component of population health

Dan Thoma points out the importance of prevention and proactivity in population health. The norm is often to react once a health issue becomes acute, making treatment more costly and creating more suffering for the individual.

When someone goes to outpatient care, they might need a panorama of different things. So clinicians should be able to provide stepped care—the least intrusive, most preferred level of care intensity. 

Therapy isn’t necessary for everyone. Lower levels of acuity, such as subclinical distress or episodic anxiety, might be treated through behavioral health coaching, a low-cost treatment. In this scenario, clinicians or care navigators can step up care for people with higher acuity.

Expanding the tent to cover shadow needs

This is a key dynamic in behavioral health: after someone experiences the onset of a behavioral health symptom, it takes an average of 11 years for that person to seek care. In other words, there’s a whole population of people who aren’t getting care, but need it and don’t appear in the claims data. 

Claims data alone doesn’t fully capture the complete picture of behavioral health needs within a population. By reducing stigma and improving access, the number of people accessing cost-effective outpatient behavioral healthcare increases, while utilization for more expensive emergency departments and inpatient utilization decreases. 

As we imagine possible futures for behavioral health and population health, it’s critical to expand the tent of who enters care by driving more access and better quality.

Learn how your health plan can challenge the myth that affordability and access to behavioral healthcare are incompatible,  especially in the midst of escalating healthcare costs and increased demand.