Strong minds, strong futures: Behavioral health for the next generation

| Podcast

In this episode of the McKinsey on Healthcare podcast, Erica Coe and Kana Enomoto, who co-lead McKinsey’s Center for Societal Benefit through Healthcare speak to experts Victor Armstrong, Megan Jones Bell, Johanna Bergan and Andrew Dreyfus to discuss successful interventions to address behavioral health and health-related basic needs as well as well as tactical actions that governments, healthcare leaders, and other actors can take to deploy these solutions.

Erica Hutchins Coe: My name is Erica Hutchins Coe. I am a partner with McKinsey based out of our Atlanta office. I’ve been with our healthcare practice for a number of years. And along with my colleague, Kana, I co-lead our Center for Societal Benefit through Healthcare.

What we’re here to talk about is addressing healthcare needs early and holistically through integrative, preventive care for children, adolescents, young adults, and families in ways that will be critical to really unlocking healthy lifespan opportunities. With that, I will hand it off to you, Kana.

Kana Enomoto: Thanks, Erica. I appreciate it. So, I am Kana Enomoto. I’m a senior expert in McKinsey’s DC office and very privileged to co-lead the Center for Societal Benefit together with Erica. I’m going to start off by asking each panelist to tell you a little bit about themselves. So, Johanna, would you mind kicking us off?

Johanna Bergan: I’m Johanna Bergan and I lead the Youth MOVE National Team. MOVE standing for Motivating Others through Voices and Experience and that’s what we do. We’re a youth-run program, chapter-based organization that looks to harness the voices of young people who have lived experience in our country’s child- and youth-serving systems.

We center our work in mental health and also work in child welfare, juvenile justice, and the education system. And our goal is to uplift the power of young people’s lived experience in creating systems change, particularly in creating systems that work better for our young people.

Andrew Dreyfus: Hi, I’m Andrew Dreyfus. I’m the CEO of Blue Cross Blue Shield of Massachusetts. Thank you to McKinsey and our hosts for including me today. I’ve worked on mental health from both in the public sector and in the private sector. And our health plan thinks a lot about how do we care better for our members with both mental health and substance use disorder conditions, and how to make that a part of the broader healthcare movement.

Megan Jones Bell: And, hi, I’m Megan Jones Bell. Thank you, McKinsey, Erica, Kana, and the rest of the organizers. I am a clinical psychologist by training. Lived experiences got me into that business in the first place. And devoted the first chapter of my career to designing and evaluating digital mental health interventions really across the age continuum, but with a large focus on youth.

I realized that nothing I developed in academia was actually getting into the hands of the people for whom I was designing it. So, I decided to start a company. [It] was one of the first coached mental health offerings. [It has since] been absorbed into a number of other digital apps. And now, I’m the chief strategy and science officer of Headspace, which is the world’s leading mindfulness app.

Victor Armstrong: Hi, my name is Victor Armstrong and I am the director of the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. And I have been in this role for all of six months. So, I came in right in the midst of the COVID pandemic. But I come to this work after spending about the last eight years working in the hospital systems.

And I’ve worked for a large hospital system in Charlotte, North Carolina, Atrium Health, where I was vice president of behavioral health. And of late, I’m really focused a lot on some of the disproportionate impact of health disparities on communities of color. So, this conversation today is very relevant to me.

Kana: What role can public institutions play in addressing behavioral health needs and health-related basic needs in youth and families?

Victor: I think that we need to think about the changes that we would make programmatically but also culturally and philosophically.

I think that some of the things that we can do programmatically would involve how we can better integrate care. But I think where there needs to be changes, philosophically and culturally, is that we may need to rethink what integration means.

We’ve done some work on, within our systems, on integrating behavioral health into primary care, and primary care into behavioral health. I think where we still have challenges are how do we integrate behavioral health into a community setting. And I think that’s where public institutions can play a role because we can pilot, we can build programs, that would allow us the opportunity to really build services that take into account not just the behavioral health needs and the physical needs, but also how do we weave in the social determinants of health.

How do we look at integrating behavioral health into the faith-based community, into the YMCAs, [and] into communities where people live and congregate? So, I think that’s one of the things that we can focus on. As we’re answering this question, I think we also have to look at the lessons that we’ve learned from the COVID-19 pandemic.

And we have seen not only the disproportionate impact on communities of color, but I think we’ve also seen in the way that we’ve tried to respond to that impact, at least in North Carolina. One of the things that we have learned is that we did not necessarily have a provider network that was equipped to speak to a lot of the needs of some of the historically marginalized communities and historically marginalized populations.

What we’ve seen, historically, is a couple of things. I think in large part because we have not focused on these historically marginalized communities and putting resources in those communities. Yet, statistically we access behavioral health services at about half the rate of white people. And we are less likely to initiate services. We’re more likely to terminate services prematurely. And I think there are things that we can look at to address those things. You know, one of the issues being, where are the outpatient services located? Where are the resources located?

If we don’t have resources and programs in the communities where people can access them, they’re less likely to engage in services in their communities. And they’re more likely to have the introduction into the behavioral health system being in the back of a police car or in an acute care emergency department. Neither of which are going to be conducive to get outcomes, and neither of which are going to build good relationships with mental health.

I’d also say that I think one of the things that we can do programmatically, also, is looking at the use of advanced medical homes. I think advanced medical homes can play a critical role in ensuring that children and families are screened and treated for behavioral, physical health, and for social determinants of health. So, I think there are things that we can do with that, particularly building those resources into prepaid health plans.

And I think also there are things that we need to do differently around kids with complex needs. I think, again, if we’re looking at health disparity and if we’re looking at equal access for all, one of the things that troubles me is that when we look at youth in this country, African-American kids make up about 17 percent of the youth in this country, but about 40 percent of the kids in the juvenile justice system, and about 45 percent of the kids in the foster care system. So, we need to build in ways of reaching those kids earlier, before they get pushed into the system.

If I had to point to a couple of things that we can do and some things that we’re looking at in North Carolina, one of them is we’ve been doing what we call a fostering health initiative, and it’s a partnership between primary care, the department of social services, and behavioral health where kids, who are entering the foster care system, are assigned a health home and it requires doing a series of health screenings within the first 30 days.

Mental health first aid is something that we know works. And there are kits for how we can bring that to the school system. So, that’s another thing we’re looking at. And then finally, some of the consultation services that we’re providing for our pediatricians to be able to have psychologists and psychiatrists that can consult with them and then also some of the work we’re doing around our behavior health and juvenile justice partnerships throughout the state.

Erica: And Andrew, in Massachusetts, you all have done some really inspiring actions recently in terms of child psychiatrist access and other support for children. Do you want to share a few comments on how you have thought about that important imperative that Victor teed up?

Andrew: Sure. It’s interesting because there’s a lot of parallels between some of the initiatives that Victor’s trying to do on the public side that we’re trying to do on the private side. So, I’ll just give you a little context that, about a decade ago, we made a decision at Blue Cross Blue Shield of Massachusetts to try to kind of take mental health and substance use disorder treatment kind of out of the shadows and put it in the mainstream of care.

The first thing we did is we stopped doing what many health plans still do which is they outsource or carve out mental health services to private companies. We carved it in. We took it in and hired a number of mental health clinicians from psychiatrists to social workers to work alongside our other physicians and nurses inside the company to make sure that care for our members was as integrated as possible.

The next thing we did is we looked at the benefits we were offering. And so, first, what we did is we made sure that all the clinicians who accepted our value-based payment model, our global payment model, included behavioral or mental health in that. And what we saw immediately was, when they started to accept some financial and clinical risk for the care they were offering, they started to integrate social workers and psychologists right into the primary care setting, and that was a really important advance.

We then, rather than constructing a limited network of mental health clinicians, we opened it up to basically any willing mental health clinician in the state. And so, we have a very, very broad network. And then, you know, we started hearing complaints about administrative barriers. And so, we eliminated most of those, partly so, because many of our mental health clinicians are solo practitioners—they’re in a small practice without much administrative support.

We wanted to try to kind of radically simplify their experience of working with a health plan. So, the only paperwork they really had to provide is to send us a bill. These changes resulted in adding about 2,000 clinicians to our network over the past few years. And we’ve seen a really significant uptick in mental health services by our members who saw over 2018, a 43 percent increase in the care our members were receiving.

And that did increase spending. But we also saw a 40 percent reduction in spending outside of the network. And that seemed to be another positive development. At the same time, we were working on the addiction side, too. We dropped copays for things like methadone and Narcan and we eliminated prior authorization for Suboxone treatment.

We really believe that reducing the barriers to access to care for both mental health and substance use disorder is not just the right thing to do, but it actually may reduce overall medical spending. But despite some of the positive things we’d done, it wasn’t enough and we knew there were still gaps in the system.

So, about a year ago, and this is pre-COVID, I assembled our mental health team and other reimbursement leaders in the company. [I asked,] “What more can we do?” And one of the big gaps we knew was that a lot of kids in the Commonwealth of Massachusetts weren’t getting access to child psychiatry services or at least not access to care that would be paid for by insurance. And many child psychiatrists were simply only accepting private pay for their services.

And so, what we did is we dramatically increased, and this is a recent development, the fees they were paying for child psychiatry services to, again, bring that back into the mainstream and not require families who are in much distress, if they’re needing to consult a psychiatrist, have to hunt for a solution. We started as some others have done, during the COVID epidemic, to pay for telemedicine visits for mental health at the same rate that we pay for in-office visits. And we’ve announced that we’re going to continue that indefinitely for the future, and not just for telemedicine visits, but also for telephonic visits.

We’re investing in a new company called Brightline (that I hope you’ll hear a lot about) that is opening offices both in the San Francisco area and in the Boston area to provide coordinated, integrated services to families with mental health problems.

We expanded access to a program called Learn to Live, which some of you may know is a cognitive behavioral therapy-oriented online program for mild anxiety, depression, [and] substance use. And we’re also finally investing very heavily in something called the collaborative peer model which I think is similar to what Victor was talking about, where we pay higher fees to primary care practices that integrate mental health services into the practice, often with a psychiatrist supervising it.

Too often, someone might get screened for a mental health diagnosis in a primary care office, and then maybe they’re handed a piece of paper with a scrawled number for a social worker. [That’s] very different than walking down the hall and saying you can make an appointment right now to see the social worker or the psychologist in our practice.

And so, you know, some people asked then how can we afford to do this, to expand so [many] services to people with mental health and substance use. Think our response is we can’t afford not to do it, that given the need and given how widespread mental health and substance use is, we wanted to be a plan that responded to the needs of our members and our employer customers who are asking us to provide better mental healthcare for their employees.

A holistic approach to addressing the US behavioral health crisis in the face of the global COVID-19 pandemic

A holistic approach for the US behavioral health crisis during the COVID-19 pandemic

Erica: Great. I would turn to the other panelists to see if Megan or Johanna, if either of you all have any reactions to what both Andrew and Victor have raised, particularly about access to care, especially around diverse and complex groups?

Johanna: Yeah, I love that both Victor and Andrew brought up access and so quickly in their discussions. We live in a world where mental health and substance abuse challenges [still carry] quite a bit of stigma and discrimination. And those are the invisible barriers for accessing care on top of some that we just spoke about in terms of being able to access telehealth or being able to know how to navigate the system or identify those services.

I think we hear from young people, and my own experience as well, that [the] ideal would be (just as you said, Victor) to bring the services to where we already are. So, instead of accessing behavioral healthcare being this journey to a foreign land where you’ve never been before, rather making it a system that supports us in the community. I think that would support what we’re hearing from youth.

Megan: And I think what has been a barrier is that many of the technologies that we have available for behavioral health have not been designed specifically for youth. They’ve been kind of adapted down for children and younger people, which is not really the appropriate way of designing an intervention. And then, you know, they’ve also not been designed for diverse populations. We, over recent months, have seen a rise in the number of meditation apps designed by, and for, people of color.

I think, and if you’re targeting populations who don’t feel seen by the traditional healthcare system, they don’t trust it, they don’t see themselves reflected in it. That particularly when we’re trying to close that divide with technology, we really need to be designing those interventions with those people in mind.

Victor: To me, that is an extremely important point and I think that’s, in part, what we need to shift the way that we think about things culturally and philosophically. Even with technology, we think about the programmatic piece of it. Let’s create technology, make technology more accessible to underserved communities, and we will automatically get them to utilize the resource.

But early data shows that we still have that gap, still in historically marginalized populations utilizing services. And we often hear that people of color won’t access services or that Black men, in particular, don’t want therapy.

And so for a lot of people of color, they’ll go to their faith-based organizations first because that’s where things are palatable to them. And if you have treatment modalities that are not really culturally sensitive, you’re not going to get people of color engaged. And I think that’s part of the reason that it makes so much more sense, too, to actually take the resources into the community. Because the more that you do things on their turf, you’re more likely to have in addition to evidence-based and evidence-informed practices, you’re going to have community-informed practices.

Kana: You raised an important point. I mean, we need to get services to where people are. But we also need to have a sufficient workforce. And Andrew’s trying to get at that by bringing more people in network. But even at that, I imagine there are still challenges.

You know, you got 2,000 more providers in network but do we have enough? And do we have enough workforce that reflects the diversity of the folks that we’re trying to serve, or have this specialized expertise?

Andrew: I guess I would say a couple things. First of all, you’re right. We need more specialized services and we need to dramatically diversify the clinicians who are serving the public. You know, one of the things we looked at in the child psychiatry problem, I mean, there are 400 child psychiatrists in Massachusetts.

And I think we may have one of the highest (if not the highest) per capita number of child psychiatrists in the country. And we had 140 of them in our network. Hopefully many more will join now. But we’re not going to ever produce enough child psychiatrists to treat all the kids and adolescents who need help.

So, we’re probably going to have to rely on other forms of clinicians—psychologists, social workers, mental health counselors. We’re going to have to help pediatricians do more. We, with others, developed a program in our commonwealth for pediatricians, and [they] essentially call a line and get a child psychiatrist or a child psychologist on the phone for a consult. So, they can handle some of the more moderate cases in their own office. We’re going to have to come up with both payment models and delivery mechanisms that better serve kids.

And on the issue of diversity, we just have to continue to expand the number and kind of people who are serving the public because we just have insufficient diversity. We know that, in many cases, people want to talk with someone who looks and sounds like them and has their same background. And there are cultural barriers, language barriers, and other barriers that persist in our healthcare system.

Victor: I would add to that, I look at it as kind of what’s the long-term approach and what’s the short-term approach. The long-term, we do need to be growing a more diverse workforce. On the short-term, I think one of the things that we have to do is we have to look more also at the value of using non-traditional collaboration. So, how do we collaborate with the faith-based community? Because the family’s going to go to them anyway. And how do we utilize more lived experience? I know here in North Carolina, we have something like 4,500 certified peer support specialists and about 1,500 of them are employed. So, that’s a workforce that’s out there that we need to figure out a better way of utilizing them and creating a way to pay them, because they bring a value to a treatment team.

And then the final thing I’ll say is we’re now looking at, as we are awarding contracts, how do we look differently at them. How do we make sure that before we award a contract or an RFP [request for proposal] or an RFA [request for application] that we’ve done our due diligence to try to make sure we’re interviewing providers of color?

Because what we were hearing anecdotally was that part of the reason we don’t have more providers of color in the network is because, well, we couldn’t find them or they didn’t meet the criteria. So, we’re looking now at, even if that’s the case, how do we prepare them better? How do we groom them [and] educate them on how to respond to RFPs and RFAs so that when we’re awarding contracts to provider organizations, we can make sure that we’re utilizing historically underutilized businesses in our network.

Megan: I wanted to build on Victor’s point about peer support because I think if you look at the evidence on global mental health, there’s very encouraging results showing that peer support combined with, you know, an evidence-based intervention ideally delivered over text message, so that you’re not using data plans that don’t exist, can really be effective, particularly for lower-acuity conditions or better yet, intervening upstream.

Johanna: I wanted to jump in here about peer support and particularly about the emerging youth peer support workforce. For me, to be a part of supporting the development, our contribution to a new service or support within the system has been this beautiful connectivity of the work that we do as an organization to include youth voice in systems change and our own lived experiences.

I was living a journey that included multiple diagnoses and I could’ve let anxiety and depression and mania become my life. And instead, I was afforded a path that allowed it to fuel my passion. And now, I get to do this work every day. And we’re seeing so many exciting things happen when young people are able to see that they could have a future in a helping field.

And oftentimes, young people—particularly in our public systems—aren’t given a pathway to show people like them doing work in the mental health field. And so, the youth peer workforce is really just creating this entirely new pathway. And at the same time, while we’re potentially making a very large contribution to a workforce shortage, we’re also providing this hope model for young people who may be sort of steered away from accessing services and support.

When instead of a clinician providing you very formal, medical model, construct things, you have someone who looks and talks like you, maybe at a coffee shop or a basketball court, encouraging you to say, hey, stick with this, like, this team’s got your back—that’s just a far more welcoming invitation for young people. And I think back to the point about access earlier, particularly youth-to-youth peer support can be that invitation. Like, come along and access support with me there’s a positive way out of this journey, is just incredibly powerful.

Andrew: Thanks, Johanna. So, what I was just going to add is that we’ve actually had some interesting developments in this in the treatment of substance use disorders. One has been the emergence of recovery coaches, which are another form of peer support but they’re not licensed clinicians. But we’ve started a program where we’re paying for, reimbursing for, recovery coaches as part of a team, and hoping that they may become a new kind of category of licensed professionals that we can use, and provide that important peer support. As Victor said, it’s not just how you look, but it’s, like, have you been there and lived experience I have.

The other thing we did is we have tried to reach in a little earlier and we’ve been funding something called the Drug Story Theater which is kind of older adolescents talking, through theater, with middle-school students about their experience with addiction and mental health problems. And I visited some of these programs, and the kids are just rapt.

Erica: That’s great. I love the rich and lively dialogue particularly around peer support, given all the potential there. I’m curious just from this group’s reaction, thinking about the path forward here, what do you think needs to happen for something as important as peer support to be able to scale?

Andrew: One of the reasons we invested in a demonstration project is to, in fact, produce some evidence that will help persuade people. You know, you can watch a kind of similar parallel work that’s been going on in the area of autism treatment with applied behavioral analysis where that was something that was really mostly dealt with in the education system.

A new intervention came along. We had people who knew how to do it, who weren’t licensed therapists. A lot of parents were getting legislation filed in different states requiring health plans like ours to cover it. And you had to almost create a new kind of profession, a new kind of category of a licensed professional, in order for us to be able to pay it under our kind of laws and contracts.

We’re part of an organization called RIZE Massachusetts. And it’s spelled R-I-Z-E for zero stigma and zero deaths. But really trying to see what we can do to reduce stigma, because until we do that, not everyone’s going to be as brave as Johanna was in dealing with her illness and then talking about it afterwards.

We all have mental health diagnoses in our families. Almost all of us have substance use disorder in our families. We have to start talking more openly about it so it becomes part of the mainstream. And again, as I said in the beginning, take it out of the shadows.

Erica: Thank you. Megan, I wanted to turn to you with one question, too. Building on this theme of access and the role that digital behavioral health may have, the importance of access to evidence-based services in particular, would love to hear your perspective on what might need to happen to increase to evidence-based services.

Megan: I love, Erica, the qualification of evidence-based services because that’s something I spend a lot of time thinking about is, you know, the opportunity that we have with digital behavioral health technology is to close that access gap. I think in part that is a bit conditional on the digital divide being adequately addressed which is why I think while that’s a work in progress making sure that we’re, you know, developing the simplest technology that is the most ubiquitous as a delivery mechanism so that we can get around those cost barriers.

But I think this, as healthcare shifts to be more values based, as there are incentives for being able to demonstrate, and be held accountable for outcomes, you know, my hope is that that creates pressure around the digital ecosystem that drives the developers of these technologies to really evaluate with real-world evidence because it’s quite easy to collect and analyze this data in real time.

It’s kind of one of the unique advantages of digital health intervention. But I think that there needs to be the right pressures and incentives around this ecosystem to really ensure that it is, you know, not only informed by evidence but what they’re actually doing is held accountable to outcomes.

I think, you know, particularly in youth mental health, that this is a way that we can leverage technology for good. Whether we like it or not, social media technology screen time is going to be here to stay. And while we can try to teach digital media literacy in schools, we also need to start working with the technology industry at large to ensure that we are kind of creating safe spaces online. We’re designing and embedding tools within these digital ecosystems or social media sites that give people opportunities to create healthy social norms.

We’ve done a project like that with SNAP where we integrated pieces of Headspace into a mini that was designed to let friends share emotional support, cheer each other on, [or] meditate together. Particularly for children, we need to design kids-focused digital behavioral health tools that use the technology as a jumping-off point for in-person interaction.

I’m working with a company right now called OK Play where it’s really about co-play. It’s teaching parents techniques that they can go take into play, when they are feeling burned out from being on a screen or you know, a large part of child psychology is teaching parents the skills that they can bring into their interactions with children.

Erica: This has been such a rich back and forth. Kana and I thought we’d take a shot to summarize some of the great points that have come out of this. Kana, I’ll hand it to you.

Kana: So, I appreciate the group talking about how we really need to focus on addressing the needs of diverse populations, not only where they are, but what they need, and who they’re looking to for help. We want to build the workforce including engaging peers and also reimbursing our providers with some parity or in a way that adequately reimburses for the value that they’re bringing to our system.

We need to build the science. You know, make sure we’re promoting evidence-based practices, aligning our incentives, combating stigma, increasing literacy, and, most of all, I think Johanna, you said it very nicely, we need to share hope. So, I think this has been a fantastic conversation. We thank all of our panelists.

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

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