Changing views on mental and substance use disorders: An interview with Patrick Kennedy

DISCLAIMER: The views and opinions expressed are those of the interviewee(s) and are not necessarily those of McKinsey and Company.

Foreword: Thank you for tuning in to our McKinsey on Healthcare podcast interview with Patrick Kennedy, former congressman and founder of the Kennedy Forum. Of note, the original podcast was recorded prior to the recent impact of the COVID-19 pandemic. Yet, we’ve been able to add questions from a brief phone interview on April 8th to the end of this podcast. The topic of behavioral health remains critically relevant. It is inevitable that the global pandemic, compounded by financial crisis, will have a material impact on the behavioral health of society.

As such, it has never been more important to safeguard the behavioral health of our families and the resilience of our communities. Through this conversation with Patrick Kennedy, we hope to highlight what measures stakeholders across the healthcare system can take to ensure needed support for people with mental and substance use disorders.

Following is an edited transcript:

Erica Coe: I am honored to be speaking with Patrick Kennedy, former congressman and the founder of the Kennedy Forum. It’s so great to be talking with you. Today we’re going to be focusing on mental health. We know that this is top of mind for companies trying to move the needle for those facing mental health challenges.

It’s a really big topic. In fact, it’s one of the focus areas for our Center for Societal Benefit through Healthcare. Research shows that one in two individuals in the [United States] will experience a mental or substance use disorder in their lifetime.

The numbers involved are, of course, enormous and so are the implications for society. We know this topic is of personal relevance to you. And especially through some of the work you’ve done at the Kennedy Forum, you’ve focused on how mental health needs to be part of that overall health in the workplace. I’d love to understand why the focus on employers?

Patrick Kennedy: Well, thank you, Erica. I thank McKinsey for putting a spotlight on this issue and using their platform to really take some of these subjects out to a much broader audience. We really do need to focus on employers because that’s where the people are.

The work that I did on the Mental Health Parity and Addiction Equity Act, which we passed in 2008, it’s basically saying we don’t want these illnesses discriminated against in the form of more limited access to care and higher thresholds for medical management determination.

It’s just wrong that we’ve denied people access to treatment for so long. And then we wonder why it’s such a systemic issue in our society. And employers are really in the middle of it because it’s not just the criminal justice system, it’s not just the homeless populations.

It’s our newest generation of workers, who are coming in, who are suffering. According to all indicators, with much higher levels of depression and anxiety. This is a phenomenon now that needs the leadership of employers. Because they dictate what the policies are in the workplace in terms of employer benefits. Employee benefits, EAPs—employee assistance programs—as well as, how the payers’ structure what the kind of care is that will be considered primary care, which will mean that it’s not going to impede an employee from gaining access to that treatment because of really high deductibles, and copays, and the like.

It’s all in aligning the financial incentives. The most salient issue is we know good mental health has a huge ROI [return on investment]. That ROI can be defined in numerous ways: lower absentee rates, much higher productivity rates, hence lower presenteeism. Much less comorbidities in terms of disability.

But ultimately, it’s only going to happen if you structure the value proposition and the risk proposition by payers in a way that doesn’t have to be defined in such a narrow window of time the way most insurance companies evaluate ROI.

And that’s what really precludes us as a healthcare system from investing in what has all kinds of ancillary benefits to the employer community, which they ought to be insisting that their third-party administrators really focus on. But the third-party administrators do not take into their value proposition: the lower disability, the lower presenteeism, and the lower absenteeism.

That’s not part of their metric. And because it’s not, they do not evaluate towards it. And hence, they’re not giving employers the kind of product that the employers should demand. That’s only going to happen if companies lay this out, at the C-suite level, and say, “You’ve never thought of it in these ways. But perhaps it’s important for you to start to think about this.”

Erica: That’s a really important framing and I love your point that employers [are] where the people are, and this is one way to really make a difference. Picking up on your notion of discrimination and what might be leading some of those barriers of people accessing care [and] getting quality care. How much of this do you think comes to just lack of understanding or a mental health literacy?

Patrick: So, we need a toolkit as policy makers, as advocates, as politicians. There’s just no voice for these issues, and it’s principally because people still feel the shadow of judgment and shame when someone says that they have a “mental health issue.” It still feels very viscerally like it’s a personal moral failing on the part of people who suffer from it.

So even with the changes in stigma, we’re still digging out of a big hole. That is the biggest barrier and it’s meant that no one’s upped their game, because no one has demanded greater accountability.

You had better be on your toes when the American Cancer Society comes calling, if you’re a politician. If you’re AIDS Action Network, you had better be on your toes because the advocacy is unparalleled. It’s backed up with money and voting lists and town hall support. But with this community, because we’ve been so anemic, people haven’t needed to really worry about them being that good at what they do.

And by the way, that’s compounded by the fact that they’re not paid. So, it’s a vicious cycle. They’re not paid because they’re not very good and they’re not very good because they’re not well paid. My view is cancer, we’ve changed in the course of the past several decades because we threw a lot of money at it. And for a long time, we never made great strides, but in the last two decades, we’ve made enormous strides. And it shows what happens if you have the will.

Now we have to have the will to do something and not be so obsessed right away with getting results. Because the results will come, but we have to have the mission that has to be what brings us to this space. Because if we have the mission, all of this will work out; if we start to micromanage this, we’re going to lose the bigger picture. The bigger picture is none of us wants the current system. The current system isn’t serving people with serious mental illness and people will all kinds of mental health challenges.

Erica: Building on that mission point, what do you think is needed to encourage more a culture of compassion rather than condemnation?

Patrick: Well, I think that this does affect every single person in this country. There isn’t a family that can’t tell a story about how it has impacted them. It’s incredibly personal and painful, in my own family to think about the numerous ways that my mom’s alcoholism and depression affected all of us. And my dad’s post-traumatic stress and drinking affected all of us. And you know, what really affected us was the shame that came from them suffering in these ways.

My grandmother on my mom’s side died alone as someone with alcoholism. And she was divorced from my grandfather, no one spoke to her, she was isolated. And that’s because shame did that. If we had intervened earlier in all of these illnesses, if we can treat it in a normalized way, so that everyone expects to get the questionnaire like they do for stroke and cancer and everything else. So, you know, what’s your family history? What’s your risk, in other words? Then we know how to triage people and risk [assess] them so that doctors will know how to better treat those people.

We’ve talked about an epidemic of opioids, but there’s a whole slew of additional medications that are written that are not good if people have an underlying addiction or a mental illness in many cases.

So, the system is not aligned, and we have to do a lot to align the system where we train providers to really train in a level of expertise for a particular type of diagnoses, so that we can really get personalized medicine brought to this field like we expected in cancer and in other diseases.

So much to do. But as big as it seems to try to take on all of this, it’s not a heavy lift if you know where you’re going and if you know what you need to do to get there. And we have the facility today because of computing and our knowledge of global budgets and ability to do all of this new formatting of how healthcare could be incorporated as a holistic thing.

We have a great opportunity to reset this whole template. And it’s not overwhelming, it really can make an enormous difference and bring enormous satisfaction for this new generation to know that in the course of just a few years, we can reduce the suicide rate dramatically.

We can reduce the overdose rate dramatically and we can get around the bigger issues of addiction generally, which are unaddressed in our society. Alcoholism, which is really not even touched in any of the public policies we’ve discussed.

Erica: You raise the good point that there have been advances in other conditions and other places of health that have not yet made it to behavioral health. I’m curious, how do you see the role of technology, as one example in raising the bar, in terms of education and awareness [and the] quality of care we’re able to deliver on mental health?

Patrick: You know, the great game changer for us in treating mental illnesses, which includes addiction and chronic disease, is that technology today, really gives this space a chance to allow someone who’s struggling or living in recovery a chance to have a full-time physician on call through their phone. A full-time monitor of how they’re doing, a full-time reminder, and alert for any of the risks that they are facing because of the way technology can pick up voice modulation [to] determine depression level. It can check on the rapidity of certain words being used. How social media is being accessed, lots of cued language, even their geo-access, if they are staying in the same place for long periods of time.

There are so many things that can be brought together in terms of [a] biomarker that can help people with these illnesses get a handle on exactly where their risk is and give them the tools, real time, so it’s not like they have to wait till next Thursday morning at 10:30 to go and see their therapist to get help.

They can access helplines. They can access peer supports. This is a real game changer for this space. You know, what we really need to do is build more informed people in recovery to be their own best advocate. I know as an asthmatic, I am empowered because no one knows what my risks are for an asthma attack better than I do. And that’s true frankly for my addiction. But what I now have as a result of technology are additional tools that can validate where my risk profile is and start to allow me to calibrate what it is that I need to do in order to move in a more positive direction and away from a place of risk.

So, that’s one area of technology. Obviously, we need more communication in general throughout the medical system and the broader healthcare system. What’s never been included in the, quote, “EMR” [Electronic medical record] is, “What’s going on in the community?” What someone’s social determinants of health look like, in terms of their access to housing, employment, transportation, [and] food. These things can impact health as much as anything. And yet, we do not have peer support, social workers, and the like who can be real assets for someone in their healthcare in the community plugged into the medical system. That’s going to be a game changer for the healthcare system to really see those para-professionals as integral in the delivery of healthcare for especially high-risk populations.

If we can just get the reimbursement to be aligned with what it will mean in terms of reduction and total cost of care and start to put those risk models in place and talk about whole health and put this, you know, framework together. As I said, we can map this out. We have done great things as a society, we have achieved incredible feats. The notion that this is beyond our ability, it just flies in the face of all the evidence in our history. So why is it that we’re taking so long to do what we need to do to tackle this problem?

The thing that we’re fighting that’s the biggest barrier is this sense of inertia and this defeatism that this is too big a problem to tackle. If you had some smart, aggressive people roll up their sleeves and say, “No, no, folks, we can manage this.” Boy, that’ll really open up possibility. Because here, we need hope. We need someone to just say this is totally doable.

Erica: And to your point, this really should be a priority on every CEO’s agenda and the only way to move from a current state of systems not being aligned to a future state where you really have those aligned financial incentives and recognition. Would love to hear from you how the employer is the nexus of some of that with their relationships with payers and providers and other organizations.

Patrick: Employers have to recognize that this is a big battle for them. Because if they don’t create a culture in the workplace where everyone takes their mental health seriously, where they’re supported, where they’re made to feel as part of, which of course, addresses that whole sense of isolation which is so toxic for people who struggle, who want to keep it a secret. But that this is a leadership initiative by the CEO that spreads throughout the whole company. By the way, specifically, determines what the EAP, the employee assistance programs, look like and what the design and benefits look like.

But it’s more than just dotting the I’s and crossing the T’s. It’s emblematic of the recognition that we’re living in a different era now. And if you want your high-valued employees to stay, to be productive, to want to work there, these are things that are no longer, “soft” but are really “hard” and can be measured against. It’s not just the build the gym, or the yoga, or the meditation room. If that’s not coupled with a vision that is saying, these are things that are part of our overall effort to try to meet your needs. And by the way, if there are additional things that we need to do, we’re going to do them, as opposed to them being put out there as, “Well, I guess we got to check the box on this stuff.”

A lot of places of employment have all of this, but it still feels pretty lonely. And I think that is an intangible and it can be extinguished if there’s a culture in place. And that cultural change needs to be led by the CEO.

Erica: I think it’s a great and powerful point that you raise that in order to really mobilize this range of stakeholders—whether it be investors, philanthropy, government, payers, providers, [and] in a sense, the employer—needs to be at the table making that demand and raising this issue.

When you think about the role that employers in terms of human service providers are playing, how do you view mental health literacy as helping with those, whether it be healthcare, law enforcement, [or] teachers who are working with some of the more vulnerable populations?

Patrick: So, as I said, we are digging ourselves out of a hole that we’ve been digging for decades and generations, frankly. Where the perception of these illnesses and the people who suffer from them is so ingrained that we don’t even realize our biases. We’re still stuck in a lot of these and it’s not out of any malice. But it’s hard to not react in the way you’re programmed to react, to look at people who are sleeping in the streets or look at people who are acting in an annoying and aggravating way, because they’re in a mental health crisis. So, we all need to get better literacy.

That’s at all sectors of society. You know, we love to compartmentalize, “It’s education here, it’s healthcare over here, it’s criminal justice over here, it’s the workplace over here.” The bottom line is: It’s everybody. You’re not seeing these illnesses confined to any demographic group, professional group, [or] socioeconomic class, anywhere.

So, we have to have a general increase in our literacy. But yes, when it comes to specific areas, first responders should probably be on the top of our list of people that we start training because they are the ones who interact. As a result of our neglect of people with these illnesses, they end up becoming criminal justice issues as opposed to healthcare issues.

So, they definitely need to be cared for. Huge biases [exist] within the healthcare system against people with mental illness and addiction. They are not treated with dignity and respect in many instances. And yet, of course, a lot of that’s compounded by that there’s no resources for them to access. Which really makes those who are in the medical system feel like they’re in a rut because there’s nowhere they can turn. It’s a lot, but it’s not complicated.

We need to include the family. They’re going to all be impacted by any one of their family members who is ill. And that’s going to spill over in any number of costs that society incurs. This is something that we often think of in an individual way. And these illnesses manifest—in a community and a family. We’ve really never done white papers on that. But if we really want to get to population health and societal health and intergenerational health; if we want to reduce this epidemic of suicide amongst young people, we had better start now.

This is not going to get better overnight. And the best chance is to start now, we’ll see this pay long-term dividends for our country in lower criminal justice, lower healthcare costs, lower costs in the workplace, and lower societal costs. But we just have to map this all out.

Erica: I think that the importance of the long-term view especially when thinking about value is really important. And just to your point, too, that you can’t be thinking about mental health in isolation. That we know that there is a really strong intersection of individuals with chronic physical conditions that have higher rates of mental health issues. Also, individuals with unmet social needs that have higher rates of mental health and how this just needs to be top of mind for everybody.

Stepping back a bit, I’m wondering if you could have everyone spending 30 minutes to just do something to improve their mental health literacy and understanding, [to] start to get a step closer to that compassion that you spoke about, what would that be?

Patrick: Think about two or three people in their life that are struggling in some way or another that could benefit from them reaching out and just calling. I guess even texting or emailing, but there’s no substitute to a voice on the phone.

I just think that’s a game changer because when you do that, you enter the spiritual realm, which is helping another and having your own burdens seem a lot lighter after you’ve reached out to someone else and you’ve entered their world and what’s going on with them. That’s the solution.

It’s the most paradoxical thing that you’re helped by helping others. It’s the heart of what I work on in 12-step recovery and it’s the most rewarding thing. And it’s what will give me the best chance of remaining sober. There’s nothing that will substitute for intensive work with others. Nothing. And, I’ve been around the block. There’s no manmade solution that can solve this. This is the most challenging, insidious thing. And it’s what makes people feel very overwhelmed by these illnesses.

And I would say even though I emphasized the medical and employee assistance programs, all of that, because they’re all very important, I believe the spiritual element is at the core of successful treatment for people suffering from these illnesses.

Erica: That human connection and trust is so important.

On a final note, and building off of your earlier theme of hope of the fact that we should as a society be in a position to actually tackle and achieve this, what would you say we’re actually doing right now to help crack the code on improving mental health literacy and actually making progress in this area?

Patrick: When we passed parity and we did the ACA, we set into motion a whole series of chain reactions. Among those chain reactions is this desire to create value-based purchasing and underwriting, which really starts to put providers into a whole new mode of thinking about how to keep their patients healthy as opposed to just checking the box every time they come in and they need sick care.

And that’s so helpful because frankly, with mental health, that’s the secret sauce. For overall total cost-to-care, management is addressing something that’s never been touched, which is underlying comorbidities: depression, anxiety. So, I would say that’s very, very exciting and is happening now. I think that the real goal for us is pay for what gives us the biggest punch. Investing in social determinants, investing in mental health, and total well-being, that’s going to keep people independent and leading a higher quality of life.

And reducing the number of times they go to the ER or keeping them more compliant with all of their healthcare needs, so there’ll be much more adherence to other medical protocols. I mean, it is just positive all the way through. And rather than me saying you’ve got to cover mental health, which is what we did through the parity law, it’s a lot more effective if payers say, “We’ll make more money if we reduce total cost to care. And guess what? Mental health is the key to doing it.”

You know, that’s a nice thing that we’re seeing, how the market forces are aligning to make our message salient. We’ve been advocating, advocating, advocating, but there’s nothing like that interest in the payer world and the provider world to start focusing on this as the new frontier of our time.

The brain, frankly, is the last medical frontier. If you were to think about an existential crisis for our country, aside from the environment, and our political process, it would be the fact that if we don’t do something about Alzheimer’s, if we don’t do something about autism, if we don’t do something about addiction—they’re all brain-related. If we don’t have a moon shot to map the brain, understand the circuitry, use all of the technology, understand all the systems analysis from genetics to proteomics, to metabolomics, to phenomics, and start to do that tough work that we have the capacity to do today, we’re only going to see healthcare costs continue to sky rocket.

And we’re not going to see the healthcare system really deliver on health for our people if we don’t tackle this last frontier of medicine and that’s brain health and treating brain illnesses.

Erica: We have an unprecedented situation before us with the COVID-19 pandemic unfolding. What do you think we can learn from past crises in terms of anticipated impact on behavioral health or how we can best respond?

Patrick: I think there are a lot of parallels between COVID-19 and the curve of suicide and overdose that we’re going to undoubtedly see as a result of COVID-19.

I think the metaphor of Hurricane Katrina applies tragically to this situation. When we knew before Hurricane Katrina even hit that the levees surrounding New Orleans would not withstand the storm surge of a major hurricane, we did nothing about it. And when the Hurricane Katrina hit, we now know what happened.

We do not have the levees to sustain the enormous need that’s going to come as a result of COVID-19. We need to prepare ourselves now in the way that we weren’t prepared for COVID-19. Because the demand on our mental health system is going to be unparalleled. I really see this COVID-19 less a virus, in its totality [more] a turning point in the way we respond to a public health emergency.

[It] is not only a viral pandemic, but really a pandemic of mental health and addiction. [It] is going to follow this COVID-19. In a sense, you cannot separate the virus from the enormous devastation and tragedy that this virus is causing all Americans in one form or another. Either through a loss of a loved one, a loss of a job, a fading away of a career or a business, [or] economic insecurity. It’s unknowable, all of the trauma and how that’s going to manifest itself in higher rates of disability, anxiety, and depression. Ultimately possibly suicide and overdose.

We as a nation are not prepared to meet the enormity of the demand that’s going to come in the wake of COVID-19. In a real sense, the next curve that we’ll try to have to flatten is the curve of suicide and of overdose, which for too long we’ve neglected; but which we will not be able to turn away from after COVID-19 because the pronounced effect of COVID-19 on our mental health and addiction system will be such that it’ll demand our nation’s full attention.

Erica: What do you see as a shift in society to address behavioral health disorders as a result of the COVID-19 pandemic?

Patrick: I see COVID-19 as being a turning point in the attitudes towards those suffering from mental illness and addiction. I think we’re going to see COVID-19 really obliterate the impact of stigma in our country. In a real sense, everybody is going to suffer from a mental health challenge in the wake of COVID-19.

In a real sense, everyone will be sensitized to these issues in a way that they can no longer place them as someone else’s problems or someone else’s challenges. Because in a real way, all of these mental health and addiction issues are going to be present in every single person’s life. In their own personal life or that of their family. No one is going to escape the mental health impact of COVID-19.

Erica: Patrick, thank you so much for your time today. For the thought-provoking discussion and for your challenge for us to prioritize mental health as a nation and for each of us to up our game. We really appreciate all that you do.

Patrick: Thank you, Erica, it’s great to be with you.