COVID-19 has created a perfect storm for behavioral health. Our society has experienced enormous social and economic stress, pushing more people into depressive, obsessive and anxious states, and worsening the conditions of those who already struggled with mental health.
At the same time, access to behavioral healthcare—which had already been limited due to resource shortages and stigma—is even more limited.
There are a number of reasons why the nation, and world, should expect a morbidity crisis in the aftermath of COVID—and behavioral health will be a key part of the solution. That’s why payers and providers, perhaps more than anyone else, should be accelerating their efforts to address behavioral health issues.
Money is flowing, but where is it going?
Capital markets have already identified the need for behavioral health in response to the pandemic, and have ramped their investment in products and services which aim to expand access through telemedicine or automated interventions. By the time we hit the midpoint of 2020, investors had already put more money into behavioral health than in any previous year.
What remains to be seen, however, is whether the investment dollars actually reach the people who need help and translate into increased access and better outcomes. Are healthcare sponsors buying digital solutions? Are consumers actually using them?
The answer to the first question is yes. Sponsors have been purchasing digital solutions for several years now. However, much of the purchasing activity has occurred in the self-insured employer space, where employers have relied on behavioral health solutions to fulfill operational as well as healthcare objectives. Not only can behavioral health solutions lead to reductions in medical cost, but they may also lead to improvements in workforce performance indicators, such as employee attrition and absenteeism.
In a pre-COVID world, where unemployment sat below 4% and benefits packages were relatively rich, employers played a meaningful role in narrowing the access gap.
However, we are now six months into the pandemic, and over 50 million people have filed for unemployment. These individuals are enduring the sort of trauma that can trigger a mental health episode and at the same time, may have lost their employer-sponsored healthcare coverage and associated healthcare services. As a result, there is a significant coverage gap that, if ignored, could lead to an unprecedented mental health crisis and a resurgence of substance abuse behavior that had begun to plateau.
Now, there are plenty of direct-to-consumer options in the market (anyone else seen Michael Phelps promoting TalkSpace?), so theoretically, the average consumer could self-serve.
However, the reality of the problem is that it’s systemic and we cannot assume that this crisis will be solved in the consumer market. To achieve the level of completeness that is required, we’ll need to see payers and providers accelerate their sponsorship of behavioralhealth.
Payer and provider involvement, pre-COVID
It’s important to point out that payers and providers haven’t been sitting on the sidelines. Prior to the pandemic, they were each at various stages of piloting and deploying digital behavioral health services.
Among payers, the business case has essentially always been there. For members with one or more chronic condition, the introduction of a mental health complication significantly impacts the total cost of care. For example, a commercial member with diabetes and a non-severe mental health condition costs 50% more per month than an equivalent member without a mental health condition. And diabetics with serious mental health or substance-use-disorder cost over 100% more.
Things get even more dire as you look at Medicare and Medicaid populations. Overlay all of this with the shortage of mental health professionals in most markets and the digital space becomes increasingly appealing, if not necessary, in creating adequate supply.
However, some payers have been hesitant to adopt. While there is now a body of clinical evidence that’s found that many digital offerings are just as, if not more, efficacious than their face-to-face counterparts, and while additional economic studies show that they are effective in bringing down medical cost, it’s taken many years for these findings to yield the level of consensus required for general acceptance. Slower payers may have waited for the body of evidence to materialize and for other payers to “beta test.”
In addition, from payer to payer, there are varying degrees of willingness to enter care delivery, especially when it comes to mental health. Some payers have simply been uncomfortable with the notion of competing with their provider network, while others are reluctant to assume the risk associated with sponsoring care delivery, especially for a population that is inherently higher risk.
From the provider perspective, health systems that have moved forward with digital behavioral health solutions have done so to optimize care delivery—they’ve used digital behavior health solutions to create virtual capacity, allowing them to deliver care to patients in the most appropriate setting (i.e. referring lower acuity patients to digital environments and reserving face-to-face appointments for higher acuity patients).
They have not, however, viewed digital behavior health solutions as a means for boosting reimbursement. Many digital therapeutics simply aren’t covered under existing billing codes, meaning health systems can’t bill for the virtual care that they are sponsoring.
As a result, what we’ve seen is that employers have been relatively enthusiastic, payers are following, and providers are adopting on a case by case basis. However, if we look back at what we’ve seen with COVID and project what’s to come, there’s good reason for payers and providers to catch up to where employers have been.
Consumers demand digital options, while our healthcare system prepares for heightened morbidity
In a matter of weeks this spring, digital care went from "early adoption" to "general acceptance" as people were forced to choose between continuing care in digital environments or skipping care altogether. And while the choice is no longer so stark, consumers have warmed enough to digital care that they will expect to have a virtual option where possible. As a result, the lack of digital options may cause members to switch health systems or, if possible, health plans.
And from a bottom-line perspective, digital behavioral health may be essential for managing the costs associated with an increasingly morbid population.
We are still in the early innings of COVID-19, and there is much more that we will learn about the disease and its impact on our health. However, one issue that is emerging as a chief concern for payers and providers is the effect of the disease on the morbidity of our population.
With people deferring diagnostics and therapies as a result of the shutdown or loss of employer coverage, the number of people considered morbid is likely to increase and the severity of morbid conditions that already existed is likely to worsen.
In addition, as I write this article, there are 6 million confirmed COVID survivors in the U.S., with millions more unconfirmed. While most COVID survivors had mild cases or were even asymptomatic, hundreds of thousands of people have had severe cases that were serious enough to require hospitalizations.
It is unclear what life after COVID looks like for these survivors, but we are seeing evidence that some will experience long-term effects of the disease, such as loss of lung function, chronic fatigue and post-traumatic stress. As a result, we should expect that, in the years that follow COVID, we are more morbid and medically complex than we were before, and that keeping us healthy will be more expensive.
This is obviously problematic for payers, but it is also a problem for providers when you consider the fact that they are unlikely to be fully compensated for the additional complexity that they will be managing. The chronic and morbid conditions that are likely to worsen (diabetes, chronic kidney disease, hypertension, obesity, COPD) are already health system loss leaders.
Increases in prevalence or complexity will not only be devastating to our families and communities, but they will be financially unsustainable for health systems that have already been hit hard financially by COVID.
Overlay the increased morbidity with a higher prevalence of behavioral health conditions and a less favorable payer mix, and health systems will need to make mental health access a top priority, if for no reason other than to defend their complex populations from additional complexity. It is for this reason that the moment for broad-based provider adoption of digital behavior health has arrived.
By the time we see evidence of a post-COVID morbidity crisis, it may be too late to reverse course.
Instead, we should assume our population will come out of COVID less healthy and more morbid. We should further assume our morbidity will be worsened by anxiety, depression, or other mood disorders. We should be encouraged that patients are open to addressing mental health conditions in digital environments and accept the body of evidence that supports the efficacy of digital solutions.
And payers and providers should accelerate the development and deployment of digital behavioral health strategies so that everyone who needs it has access to mental health services.
Ellen Herlacher is principal at LRVHealth where she collaborates with the firm’s strategic investors including providers, payers and select vendors to identify and nurture early-stage startups solving the industry’s biggest challenges.