With 2023 in full swing, JPM officially in the rear-view mirror, and Davos underway, we were reflecting on highlights from 2022 and were pulled back to our time at HLTH in November.
Our own Chief Innovation Officer, Shirley Bergin, moderated a discussion as part of Solome Tibebu’s, Going Digital: Behavioral Health Tech programming, which explored “How Health Plans are Scaling Mental Health Innovation from the Outside In.” Joining Shirley for this important conversation were esteemed behavioral health leaders Dr. Cara McNulty from CVS Health‘s Aetna, Eva Borden from Cigna’s Evernorth, and Suzanne Kunis from Horizon Blue Cross Blue Shield of New Jersey.
The conversation was so nuanced and rich, in fact, that Shirley was only able to cover half of the questions she was hoping to, so we decided to share Part II of their discussion on our blog. Cara, Eva and Suzanne were game to continue sharing their wisdom, so we took full advantage of the opportunity! (If you missed the conversation at HLTH, here’s an article that covers a bit of the goodness for context.)
Their insights range from observations about today’s mental health landscape, to sharing how companies decipher quality solutions in a crowded field, to ways the industry is working to ensure that underserved populations have the access and unique care they need, to sharing how tech solutions can begin to meet the need for scalable tools for mental health evaluation and care. We hope this Q&A and the insights from these amazing leaders contribute to a successful 2023!
What are the top 3 things each prospective digital health company must demonstrate in the first meeting to advance in your consideration? What should they avoid doing?
Cara McNulty, DPA: Here is what we look for when meeting with a new digital health company:
Eva Borden: We take many items into consideration when evaluating prospective digital health companies for our customers. Particularly, we want to make sure that the company can clearly and effectively articulate the digital solution’s value via metrics and outcomes. The company should also be able to showcase the engagement approach and experience through a demo and be able to show us its roadmap for the future, including product expansions and enhancements. All of that information allows us to really understand how the product will benefit our customers.
Companies must share data and outcomes in order to demonstrate the value they will bring to our customers.
Suzanne Kunis: A digital health company only gets through our door if they are evidence-based and clinically-proven, have a commitment to measuring efficacy embedded in their operating model, and are a mission-driven organization. They’ll find that door quickly closing if we sense that it’s an organization driven largely by profit rather than mission, they rely on the buzzwords or tech of the moment rather than evidence or are not 100% and unfailingly honest about where they are in their journey. Nothing ends the discussion faster than losing my trust – I can work with an idea that looks promising, but that is going to be a very different scale than a market-tested concept that has proven effective in a real-world clinical setting. If it sounds too good to be true, it is generally either not good, not true, or both!
What should companies know when considering their ability and readiness to integrate within your environment?
Cara McNulty, DPA: It is very important that companies come prepared for intense security, especially around protected health information (PHI) and data protection protocols.
Eva Borden: Our partnerships with digital health companies have resulted in quality, innovative health care solutions for our customers and clients. We’ve been able to expand access to specialized care solutions resulting in improved health outcomes and lower health costs.
When digital health companies want to work with us, there are some key details they should consider. First, we work in a highly regulated and data-sensitive environment that companies must be able to accommodate. In many cases, customization may be required to fit within our environment.
Also, we value a flexible and creative partnership mindset to be able to solve technical problems in an iterative manner. Companies must be set up to have the ability to test, learn, and make adjustments along the way. In addition, we expect our digital health partners to be able to accommodate growth.
With these key considerations in mind, we can partner with digital health companies to ensure individuals have access to the world-class solutions they are used to accessing through Evernorth.
Where do you think the market’s current approaches to addressing behavioral health are falling short, and where might digital solutions help?
Cara McNulty, DPA: Right now, the industry is still building resources to adequately and accurately infuse data-driven and sustainable methods of measuring quality and demonstrating outcomes.
We are seeing several new digital platforms that connect people to varying levels of care and offer ancillary support like peer-to-peer connection, Cognitive Behavioral Therapy [CBT], educational mental health content, and personalization tools. The depth of personalization is something that continues to be improved through better use of data, consistent and integrated ways of developing and measuring quality, and outcomes reporting to demonstrate ROI.
Eva Borden: Many Americans struggle with mental health – whether it’s stress, depression, anxiety, or more acute conditions – and these issues have only been exacerbated by the COVID-19 pandemic. In our current post-pandemic environment, the demand for behavioral health resources continues to grow, our solutions must offer personalized support. We are continuously working to identify and address the behavioral health needs of our communities. Listening to the needs of our customers, clients, and provider continuously support our ability to deliver innovative care and solutions.
Digital solutions play a large role as one option for obtaining care. Early engagement, faster access to high-quality behavioral health care, and personalized, holistic support that addresses an individual’s unique mental health journey can all be accomplished through the integration of digital care offerings into a comprehensive suite of offerings so that the intervention can be tailored to individual needs.
Suzanne Kunis: The vast majority of solutions out there today, even those with great utilization uptake, exist in isolation, as point solutions, and not within a framework or integrated system that treats a person holistically rather than as a set of discrete diagnoses. That is the biggest change needed. Evidence-based virtual and digital solutions can increase access and reduce barriers to care like transportation and stigma. But, all virtual and digital solutions are not created equal – and those that are not supported with evidence demonstrating clinical impact can create more harm than good.
What are the challenges to measuring outcomes in behavioral health? And how can digital health help address these challenges while improving measurement?
Cara McNulty, DPA: Mental health can be, unfortunately, a particularly difficult area to measure quality. And for the measures we can track, the data exchange can be difficult due to the technology and the regulatory environment that limits the exchange for certain diagnoses. As a result, we need to expand our capabilities to highlight providers – including digital resources and services – that provide both positive clinical outcomes and member experience.
For example, we are a funder of Shatterproof, which has a free, first-of-its-kind tool that connects those in need of treatment for addiction with high-quality and appropriate treatment. Shatterproof evaluates addiction treatment facilities' use of evidence-based best practices, allows patients to see and provide feedback on their experience, and offers an easy-to-use online interface to allow those in need and their loved ones to search for and compare facilities using criteria such as location, services offered and insurance provider so they can connect with appropriate treatment.
Eva Borden: Behavioral outpatient care is a vital tool that helps a person explore symptoms that may lead to mental health distress, so they can enact new thought patterns and learn coping skills. These critical skills can help people feel better – and reduce avoidable medical services over time.
However, treatments are often personalized and don’t necessarily have the same type of standard metrics or quality measures that we see across the medical field. We are making progress, such as Evernorth’s recent collaboration with the Behavioral Health Center of Excellence, to develop quality performance metrics to drive improvements in treatment for autism spectrum disorder.
For patients with low-acuity conditions, or who are looking for more preventative measures to help stop the onset of more severe conditions, we can track their use of behavioral health tools and compare to their medical and pharmacy claims to determine whether behavioral treatments that are preventative are having an impact. These are the kind of measurements that we can readily use now while other types of metrics are developed.
In fact, we’ve done this. In 2021, we found that individuals with a diagnosed behavioral health condition who received behavioral health treatment in an outpatient setting, such as a psychologist’s office or virtual visits, had fewer emergency department visits and inpatient hospitalizations, decreasing health care costs by up to $1,377 in one year and up to $3,109 over two years.
Suzanne Kunis: Change is hard, and any time you try to do something outside of the box, there will be unforeseen blips - but knock-on wood, nothing has been unsurmountable – we’ve been able to successfully launch relationships with lots of different organizations and have received great feedback from our members who are using these different services. What’s been most important for us is that we’ve developed really collaborative relationships with all of the new organizations that we’ve partnered with – we put them through the wringer in terms of due diligence, and it ends up paying off because once we’re ready to launch – we trust each other. We look for solutions who are evidence-based with leadership that are mission-driven and in it for the right reasons. We approach these relationships in a collaborative way in terms of aligned incentives, clinical outcomes, etc., so that we are all on one team – we want what’s best for our members, and they want what’s best for our members – that way if there are blips, we figure them out together.
How does the impact of mental health on physical health factor into ROI when evaluating behavioral health solutions – especially when considering comorbidities?
Cara McNulty, DPA: It’s critical. Individuals don’t approach their health by thinking, “today, I’m going to improve my physical health, and tomorrow I’ll focus on my mental health.” They just want to improve their overall health, and the solutions we provide need to align with that perspective and account for whole-body health.
And we need to go even further than just mental and physical health. The more we can address social determinants of health – for example, legal and financial issues, or child and elder care responsibilities that can impact one’s health – the more strides we’ll make in improving overall health.
Eva Borden: We know that behavioral and physical health are intrinsically connected – each is needed for a person to truly achieve whole-person health. This is very much true for individuals with comorbidities. For example, we know if an individual is dealing with low back pain, there’s a strong likelihood that the individual could also develop depression.
Another example that we recently studied is how a cancer diagnosis impacts someone’s mental health. According to data from the Evernorth Research Institute, oncology patients who do not get behavioral outpatient treatment are 2x more likely to have avoidable emergency room visits, averaging plan sponsors anywhere from $173 to $243 per member, per year higher than those who do seek outpatient behavioral care. To help address the psychological impact of cancer, Evernorth has incorporated distress screening within its oncology case management program. We believe that actively addressing problems of distress will help in reducing physical and emotional suffering, improving the quality of life, treatment adherence, and, ultimately, health outcomes.
Suzanne Kunis: There is significant evidence that integration leads to overall better outcomes across a person’s entire health however, in many cases with new solutions it is very challenging to prove ROI in a shorter period of time. We often evaluate VOI (value on investment), including enhancing access, enhancing member experience, improving availability of evidence-based services, reducing stigma, etc. vs. formal ROI. We also know in many instances that many startups will never be able to prove a formal ROI – there are many different solutions and providers and organizations touching and supporting the same member, and it becomes almost impossible to pinpoint which organization actually caused the improvement in some cases.
How are you prioritizing populations and conditions and ensuring the needs are met across the range of needs?
Cara McNulty, DPA: Given that mental health needs continue to rise across all demographics, we need to start by ensuring we have resources and treatment options available across the mental health continuum to ensure that anyone who needs care has options that are best for them.
The needs are different, though, across each population. A caregiver for an aging parent, a young adult in college, and a mom of young kids all have different mental health concerns and needs. So, navigation is incredibly important to ensure we work with each individual to match them to the resource or treatment that best meets their needs. Education is critical here too, as we need to help communities understand that the resources and types of providers available to improve mental health have really expanded.
But we have prioritized certain conditions and populations. For example, given that suicide is a leading cause of death, we set a goal to reduce suicide attempts by 20% among Aetna members by the year 2025. We’ve made significant progress in adult members, but still need to make progress amongst adolescents. As a result, we are doubling down on efforts to prevent suicide in teens with a youth-specific strategy.
Eva Borden: Over the last year, we forged new partnerships with providers to enhance access and service for customers, and we've expanded our national network by 14% with a priority on adding providers positioned to support the unique needs of customers.
For example, we expanded the number of in-network providers with expertise in addressing cultural or ethnic issues by nearly 20%. We also continue to expand the clinical breadth of our network increasing the number of providers who can help our customers who have more acute care needs.
Suzanne Kunis: We have woven together a curated ecosystem of evidence-based solutions across all populations. We continue to speak and meet with new solutions almost daily in an effort to solve different strategic priorities. At the top of our list for 2022 was expansion of evidence-based solutions for children, adolescents, and their families, and we are so pleased that we were able to identify and select a number of organizations to join our network in this space.
How are you tailoring innovation to address the needs of the diverse members you serve? With a growing focus on digital solutions, how are you ensuring populations that are less technologically savvy are not left behind?
Cara McNulty, DPA: Digital resources and telemedicine have been great tools to expand access to mental health care, especially to underserved communities. We’re also building out our infrastructure to help match individuals to a provider that not only meets their clinical needs but looks like them as well, if that is a priority.
Digital tools, though, need to continue to be just one part of our overall set of solutions. They aren’t for everyone and for every mental health condition. To truly improve the mental health of our communities, we need to provide a range of options, and continue to navigate those in need to the treatment that is best for them, whether that’s in-person, digital, or a mix of both.
Eva Borden: We are finding innovative ways to engage customers where it is convenient for them, focused on creating more behavioral moments – whether it’s a quick text back and forth with a coach or accessing a meditation on demand when one feels stressed. We want to ensure all customers have the type of care that will support them on their behavioral health journey. Through continued enhancement of our digital capabilities, we will improve our ability to match customers with the care that best meets their needs.
We are committed to creating a provider network with proficiency in providing culturally sensitive treatment like we have done through our partnership with Hurdle. Customers fill out a short survey and get paired with a provider who best meets their needs.
In addition, real-time assessments and support administered telephonically are an important part of the behavioral health landscape. We actively listen to our customers, use tone and empathy to support them, and guide them to virtual or in-person care based on customer’s preferences and needs. Our continued support ensures they are connected to the right resources. This concierge service focuses on getting immediate needs met and driving towards appropriate care, and staying connected until all their needs are met.
We tailor our services to meet the needs of our customers, whether that is through virtual care, brick-and-mortar providers, or telephonic support. We are committed to meeting our customers where they are.
Suzanne Kunis: We know that there is no one size fits all approach to mental health – just like any other chronic condition. As a result, we’ve developed and launched this curated ecosystem as a supplement to our traditional brick-and-mortar network, while continuing to expand that footprint. We absolutely understand and agree that digital and virtual solutions are not right for everyone, and as a result, we continue to offer and expand brick & mortar solutions, as well as evaluate new models like in-home or in-community care.
Are digital solutions the answer for everyone? How should they be balanced with traditional, in-person options?
Cara McNulty, DPA: Mental health concerns have been on the rise across all demographics for the last several years, and digital tools and telemedicine have been great tools to help meet the need. In fact, about 6-in-10 people agree that society has become more comfortable using these resources to improve mental health since the start of the pandemic. We’ve seen these trends in our own data as well – with about 60% of outpatient visits now conducted via telemedicine compared to less than one percent prior to COVID.
But that doesn’t mean digital resources are for everyone, perhaps due to their comfort level, their condition, or other reasons. Our goal is to view mental health across a continuum – from daily stress to anxiety and depression up through serious mental illness and suicide – and to ensure we have a variety of resources and treatment options for each point on the continuum to help individuals improve and maintain their mental health in a manner that is most appropriate for them.
That’s why, for example, therapists that are available through CVS Health MinuteClinics in select states meet with patients either in person or virtually. We want to ensure individuals can seek care in a manner that makes them most comfortable.
Eva Borden: Digital solutions play an important role in how we help people access behavioral health care, but they should work in partnership with more traditional options, especially for individuals with acute conditions. Virtual care helps individuals overcome many obstacles to accessing care – it’s convenient for those who can’t take time off work or don’t have behavioral health care options in their local area, it’s private as it can be done in your home, and you can access a range of different types of care from coaching to talk therapy and psychiatry.
For many of us, there’s still a need for in-person visits. For some individuals, it’s more comfortable to be in the same room as a provider. For those with more acute conditions, being in person allows a provider to see first-hand how an individual is doing. In addition, therapies like play therapy for kids, when done in person, allow for an easier, more natural connection between the provider and patient.
Digital solutions will continue to play a large role in the accessibility of health care – both behavioral and medical – but knowing what’s best for an individual’s health outcomes should be determined by both the patient and provider.
Suzanne Kunis: Digital and virtual solutions are not for everybody for a variety of reasons, just like in-person therapy is not for everybody for a variety of reasons. What is most important from our perspective is that the clinical framework of the program is evidence-based and measured in an effort to achieve and prove clinical outcomes. We believe each member should have the ability to select the modality of care that works best for their particular needs and circumstances – and that obviously has the potential to change over the course of their lifetime.