by Emily Wengel07-11-2017
Behavioral health is increasingly getting the attention it deserves due to recent legislation and declining stigma, although challenges still exist. Why is behavioral health a topic payors and providers should pay attention to? $172B is spent annually on behavioral health, with the majority of the spend coming from depression. Not only does behavioral health account for high costs, physical chronic disease patients with behavioral health comorbidities have significantly more expenditures than those without.
In this article, we will review:
- Challenges in behavioral health and how digital health can overcome these changes
- Key success factors in choosing a digital health solution
Behavioral Health Challenges & Potential Solutions
Healthbox conducted secondary research and spoke to academics and providers in the space to identify some key challenges and potential solutions in the behavioral health space. We found that the challenges could be segmented into three key areas, as illustrated below:
Challenge: Access is one of the primary issues in behavioral health. While the Mental Health Parity Act, which dictates that insurers treat behavioral health conditions the same as physical conditions, may present opportunities for increased access, there is a shortage of behavioral health specialists, especially in rural areas. Furthermore, while declining, stigma may prevent individuals from seeking and continuing care.
Potential Solutions: Telemedicine (teletherapy, telepsychiatry, and asynchronous communication) is best positioned for improving access to behavioral health specialists. Some digital health solutions, such as Ieso Digital Health, suggest that a real-time text chat feature may actually enable patients to open up more freely about their problems, as compared with face-to-face therapy. Other companies, such as Teladoc Behavioral Health, Regroup Therapy, and Genoa Telepsychiatry provide access to specialists via phone and video conference.
Samir Malik, SVP and general manager at Genoa Telepsychiatry noted that the access they provide is crucial given that many of their patients were previously not seeing a psychiatrist or facing wait times greater than a month to get treatment. Citing data from their patient population, Samir highlighted that “once we start treatment, 90% of our patients come back for follow up visits. This amounts to tens of thousands of appointments through telepsychiatry in bringing care to those who would have no access otherwise.”
Challenge: Even after the access problem is mitigated, there are several issues in delivering care to behavioral health patients. One of the biggest challenges is one of patient engagement, due in part to the underlying psychopathology, which can lead to problems focusing and adhering to medication. Further, another major issue is the lack of coordination between primary care providers (PCPs) and behavioral health specialists, which is a major problem for patients with chronic diseases.
Potential Solutions: A number of apps exist to help in the treatment of behavioral health conditions. Some solutions, such as Karify Health based out of the Netherlands, provide educational modules and exercises to supplement in-person care. Other companies, such as SilverCloud Health, based in the UK but with a growing presence in the US, offer computerized cognitive behavioral therapy (CCBT), a technology which enables the patient to challenge their negative thoughts without the help of a provider. Ken Cahill, CEO at SilverCloud elaborates on the success of their platform: “Originating from over a decade of academic research, we developed SilverCloud Health’s platform and programs across behavioral and co-morbid chronic healthcare. SilverCloud Health has shown high levels of engagement, demonstrated results via randomized control trials (RCT) and currently has 15 large scale clinical trials in progress.”
Finally, to overcome issues coordinating care across providers, collaborative care models, such as those provided by Quartet Health, have been shown to improve outcomes and reduce costs in large integrated healthcare systems.
Challenge: It is challenging to identify and segment patients for behavioral health interventions, especially for patients with physical chronic illnesses. Furthermore, behavioral health issues are unique in that there are not as many measurable “vital signs” in the space, unlike physical illnesses. However, evidence has shown that implementing measurement based care (MBC) using symptom rating scales such as the PHQ-9 for depression have lead to improved outcomes.
Potential Solutions: A number of companies are using analytics to identify and measure improvements in care, such as Owl Insights. Another example of a company tackling this problem is AbleTo, which uses screening and assessment tools to identify physical chronic disease patients with behavioral health issues, and providing a targeted intervention for those issues.
AbleTo addresses the challenge of identifying and engaging patients by providing “evidence-based behavioral health treatment and scaling that care using a technology platform that allows our network of therapists to screen patients, triage and deliver treatment, coordinate care, and capture structured data to ensure quality and outcomes measurement,” explains Rob Rebak, CEO of AbleTo. He continues, “We also use data and analytics to proactively find people in need, engage them, and ensure we are delivering care to the right population to drive medical cost savings for our health plan and employer customers.”
Key Success Factors in Choosing Digital Health Solutions
There is no shortage of digital health technologies. As indicated above, digital health solutions show promise in addressing some of the needs in behavioral health but “it has been a challenge to develop behavioral intervention technologies that are usable, useful, and adaptable to the needs of individual patients, that fit into the workflow of providers in care systems, and that can be made available to people when they are ready to engage in behavior change,” says David Mohr, Director Center for Behavioral Interventional Technologies (CBITs) and Professor at Northwestern. Some of the researchers we spoke with highlighted key themes to help address these challenges:
- Access: Selecting solutions that will extend care and access to remote and vulnerable populations
- Treatment: Patient centric design and integration into clinical workflows
- Triage: Customizable approach based on disease type and severity and ability for the clinician to be alerted to potential deterioration
Elaborating on the need for a customizable approach, Dr. Evan Goulding, a practicing psychiatrist and researcher focusing on bipolar disorder at Northwestern notes that even patients across populations may vary by motivation levels, which may impact adoption. He says: "When you have savvy patients who are motivated, it's relatively straightforward to provide them with tools and techniques, digital or otherwise, to manage their health. On the contrary, those patients who are less motivated may be less likely to adopt those tools." Therefore, the Healthbox team believes there are opportunities to customize solutions based on level of motivation (in addition to disease type and severity) -- and therefore there could be higher impact to those patients that are more highly motivated.
These concepts are also illustrated in the graphic below:
 SAMHSA, 2014
 ⁵ US Spending on Personal Health Care and Public Health, 1996-2013. JAMA. 2016;316(24):2627-2646.