Have we learned anything so far in the pandemic?

Tune in next week to hear experts discuss lessons learned around behavioral health in California – I will be moderating!

As pressures from the public health pandemic and the economic crisis continue to increase, the importance of access to behavioral health services and the connection to the safety net will be critical. At the 2020 Northern California State of Reform Virtual Health Policy Conference the session, “Behavioral health and the pandemic: What we’ve learned,” will review the data, survey policy options, and discuss strategies for California moving forward.

Kelly Pfeifer, MD, Deputy Director of Behavioral Health at DHCS, and Le Ondra Clark Harvey, PhD, Director of Policy and Legislative Affairs at the California Council of Community Behavioral Health Agencies, will offer their insights. Randall Hager, Director of Government Affairs at the California Psychiatric Association, will also speak on the panel, and Brenda Gleason, President of M2 Health Care Consulting, will moderate the discussion. #behavioralhealth

Mental Health in the Era of COVID-19

Mental health care is a deeply personal issue for me. My experience in trying to help friends and family navigate the deeply flawed and broken U.S. health care system is a key part of what drives me to work on access and cost issues for patients, and reimbursement issues for providers.

Mental health conditions are much more common than we might think. According to the National Institute of Mental Health:

• 1 in 25 people in the U.S. – about 11 million people – experience a serious mental illness that significantly limits a major life activity such as working or caring for family members;
• 1 in 5 people – about 47 million people – experience a mental health condition, for example, ADHD, anxiety, bipolar disorder, or depression, at some point in their lifetime.

But we have not built a system that acknowledges, destigmatizes, or serves patients who experience mental health conditions.

Nearly 10 years ago, Támara Hill, a licensed therapist and certified trauma professional in private practice, wrote A Failed Mental Health System: The Top 5 Failures, which are:

“1) Poor access to financial support/high insurance costs

2) No direction after a psychiatric diagnosis

3) Feeling overlooked, alone, uncertain, and confused

4) Lack of knowledge about the mental health system in general

5) State laws and treatment policies that interfere with appropriate and timely treatment.”

Not much has changed, even with full implementation of the Affordable Care Act. Access to care, in particular, continues to be a problem. Before the coronavirus pandemic, even though most people with any mental illness under age 65 had some sort of health insurance, less than 10% had received any kind of inpatient treatment. For the 1 in 5 people experiencing a mental health condition (not considered a serious mental illness), less than 30% received outpatient mental health treatment, according to the Kaiser Family Foundation.

The Mental Health Consequences of COVID-19

The mental health consequences of COVID-19 are widespread and affect nearly everyone. Of course, they don’t affect everyone equally or in the same way. Further, we don’t really know the extent of what people are experiencing and what mental health care needs people will have in the future.

From a systems point of view, it seems obvious to say, but we need to make changes immediately to boost access to services and treatment, including destigmatizing the need for care, lowering costs and other barriers to patients, and improving reimbursement for all types of providers who can provide mental health care. Telehealth might be a great place to start!

Systemic changes also need to consider how communities can support mental health care, not just how large hospitals or integrated provider groups can provide medical treatments. Dr. Sandro Galea, Dean of the Boston University School of Public Health, made several suggestions recently in a co-authored piece focused on prevention and early intervention approaches to address mental health needs during and after the coronavirus pandemic, including offering stepped care, “training nontraditional groups to provide psychological first aid, and helping teach the lay public to check in with one another and provide support.”

Love, Care, and Concern

From a personal perspective, we might consider whether there is some action that can be taken immediately. Most of us are able, at least some of the time, to send a note, make a call, make a donation, or simply act compassionately toward another human in our path. Offering love, care, and concern will not fix all of the systemic problems of mental health care payment and delivery in the U.S. I am committed to continue working on these issues in my role as a policy advisor.

But in the meantime, I am also committed to continue to offer love, care and support to others. If you can, please join me.

Note: For useful information and resources related to Mental Health and COVID-19, please see:

Mental Health America

Mental Health Coalition

There’s No Clarity Forthcoming

We analyze state COVID19-related orders and materials every day for clients.

We were asked recently if we thought there would be a checklist large, national non-retail businesses could follow to ensure the health and safety of their workers.

Our response was quick: there is no clarity forthcoming. You will need to make your own plan.

There are quite a few frameworks, roadmaps, plans and guidelines being published by states and other government entities, even if some are not official. Two of the most detailed, thoughtful and useful are Utah Leads Together and the Washington’s “New Normal” planning documents, in my opinion.

One big problem, however, is all of the guidelines say something different.

Today, the Information Technology Industry Council, which represents some of the biggest employers in the U.S., wrote a letter asking for governments to “coalesce around a single set of guidelines that are comprehensive, reduce the risk of a patchwork response, and make it easier for all employers to identify and follow health-protective guidance specific to COVID-19.”

In this case, #BigWillNotWin. There is no coordination or coalescing or clarity forthcoming. What’s your plan?

Big Will Win, If We Let It

As the coronavirus pandemic unfolds, so far it appears #BigWillWin in health care (in other areas too, but we focus on health policy at M2!).

For example, spending on primary care in the U.S. is comparatively low, accounting for 5 to 7% of total U.S. spending, and primary care practitioners are among the lowest paid specialties. The combination of already low payment and patients’ inability to use telehealth as a substitute for face-to-face visits has meant nearly half of primary care practices in an April survey said they are experiencing “financial strains threatening practice closures.”

But Walmart Health is expanding, as “physician practices face cash crunch.” Teladoc saw a 50% week over week coronavirus surge in March, even though it already provides access to 50,000+ medical experts for more than 36 million patients.

More broadly, private equity was spending record amounts buying U.S. health care entities even before the pandemic, and 2019 marked the first time “employed physicians outnumber[ed] self-employed physicians.”

As a policy matter, #BigWillWin in health care if we let it, but are we thinking enough about whether that’s a good idea?

Telehealth – What Are We Not Thinking Enough About?

In 1962, Elroy Jetson had a telehealth visit from his home.

In 2019, 10% of people in the U.S. had used telehealth at least once. As of April 2020, surveys show 20% of people in the U.S. have had a telehealth visit. Telehealth is definitely having a moment. It isn’t hard to find articles saying the rapid uptake of telehealth because of current coronavirus distancing requirements will cause a lasting shift toward online care. If federal and state regulatory changes stay in place, reimbursement for providers is stable and cost-sharing for patients is reasonable, telehealth may very well be used by more and more people in the coming years.

What Are We Not Thinking Enough About?

1) Systemic inequities make widespread telehealth adoption difficult at best

Athena Cross, in The Technological Divide and Inequities in Health, explains, “as the health care system runs toward technological innovation, it is important not only to note the digital divide, but also the historical injustice in health that may inhibit adoption and participation by our most vulnerable and marginalized communities.”

We like to think that everyone has access to health care, and telehealth means a patient is simply having a video call with their existing health care provider. That isn’t what is happening right now. (Later this week we will write more on how #BigWillWin…)

2) Telehealth works better for some services than others

Childhood vaccine orders are down significantly, and diagnostics used to screen and monitor cancer (such as Pap smears and colonoscopies) have dropped dramatically these past few months, as these services are nearly impossible to deliver virtually. On the other hand, claims data is showing more than 50% of mental health visits were delivered via telehealth in the last week of March.

3) Telehealth today is favoring infrastructure over communities

A core promise of telehealth is improved access. But we are not thinking enough about how communities – not just patients, but also community providers and organizations, may be left behind if large corporations hire contract health practitioners who live hundreds or thousands of miles away to deliver “care” at the press of a button. How might local communities be worse off if there is no health care provider in their area? Or if health care providers don’t have race or ethnicity or culture or language or geography, etc. in common with the patients they are serving?

Will the “solution” of telehealth leave people better off? It seems we need to do significantly more thinking and balancing of priorities before we make massive policy and reimbursement changes to support this modality.

It’s National Entrepreneurship Week. Here’s how to be an entrepreneur wherever you are.

The word entrepreneur may bring a certain definition to mind, but it doesn’t have to. The most obvious definition of an entrepreneur, and the one used by economists for counting purposes, is a person who starts a business venture. This definition is fairly narrow as the chart from The Kauffman Foundation below shows.

Not counted in these numbers, for example, are “sidepreneurs,” those people who are trying out an idea that could be a business while they are otherwise employed. In 2005, I was lucky enough to have an employer that allowed me to start my side idea, and M2 Health Care Consulting was born! Turns out, this is becoming a very popular approach.

According to The American Express 2019 State of Women-Owned Businesses Report, the growth rate of sidepreneurs over the past five years is much higher than entrepreneur growth rates generally (see chart below). Notably, this method seems to be very popular with women, and even more so with women of color. While women generally are starting businesses at higher rates than men, the growth rate of black women entrepreneurs between 2014 and 2019 is 50% compared to 9% of all businesses, and the growth rate of black women sidepreneurs in the same time period is 99% compared to 32% of all businesses.

You can use the entrepreneur mindset anywhere

As a proud entrepreneur, I have learned by both succeeding and failing as a business owner. But the concept of entrepreneurship goes well beyond business. The word, as derived from the French, means a person who organizes and manages a task or set of tasks, usually with considerable initiative and risk.

From this perspective, any chance to oversee a meeting, manage a project or start something new at your organization, is an opportunity to be an entrepreneur. So how do you do it? Here are four tips for facing the risk of failure and increasing the likelihood of success when starting something new.

1. Love uncertainty
When you are asked to lead a new project, one of the hardest parts to manage is the uncertainty. Where do you start? What comes first? Who should be included? How do you make it all work? Use the entrepreneur mindset and love uncertainty. No matter how effective you are at managing and organizing, surprises will happen. A key team member will call in sick. A budget will get slashed. Try to think of uncertainty as something exciting, not scary. A challenge to be met, not a warning sign of failure.

2. Plan thoroughly
I have both sales people and entrepreneurs in my family. From a young age I heard them say, “Plan the work, work the plan.” While I didn’t understand the phrase at first, I felt like someone had taught me a magic trick when I put it to use in real life. The essence of entrepreneurship is organizing and managing. To do both of those things well, it is imperative to create a written plan. With steps. And a timeline! Then use that plan to guide your days, weeks, and months. When you complete a step, take note. Was it completed on time? Did it require sub-tasks? Was it dependent on the step before it? Learn from your plan and your working of the plan. The more thorough you are, the more opportunities you have to learn, improve and succeed.

3. Listen carefully
It is the rare successful project that never interacts with another human. Running a business, a non-profit, or a project all require working with people in one way or another. The better you are at listening carefully to your customers, funders, co-workers, and anyone else with a stake in your success, the more likely it is that the project will succeed. When a customer says the product doesn’t work well, listen carefully. What was their experience? Was it unique? Can you fix it? When a co-worker expresses concern about a deadline for the project you are running, listen carefully. Are they trying to tell you they need more time? Warning you about a pitfall you didn’t anticipate? Try not to take things too personally. Listen carefully and assume other people want to help the project or business succeed, not that they want you to fail.

4. Recover quickly
We all fail at something eventually. But there is a difference between failing and learning. To fail is to stop, but to learn, is to keep going. Take the information or lesson from the failure and recover quickly. Get back up. Try again. Don’t take it too personally. You are not a failure. You had a failure. Use the entrepreneur mindset to see that failure as a learning opportunity. Then recover yourself and get back at it!

An entrepreneur isn’t only a person who starts a new business. It is any person who uses a certain mindset to face the risk of failure head-on. So go ahead, be an entrepreneur wherever you are!

Data, Charts, and Policymaking – Is there a Relationship?

In a , we noted some recent studies with international price comparisons for health care.

Now let’s connect some of that data with the policy possibilities.

First, consider two policy proposals currently under consideration that would address international price differences for pharmaceuticals:

1) Using an International Pricing Index (IPI) in Medicare, “to bring down drug prices and cut down on foreign freeriding” and

2) Allowing states to import pharmaceuticals from other countries (which Colorado, Florida, Maine, and Vermont have now passed laws to pursue).

These policy proposals may seem obvious when you look at just one chart, such as the one on the left below published by the International Federation of Health Plans in December 2019 (posted by the Health Care Cost Institute). However, the 2017 Comparative Price Report of International Variation in Medical and Drug Prices shows U.S. prices for ALL medical services are also almost always higher than in comparison countries (see chart on the right below).

Similarly, for the most common reason for a hospital inpatient stay, childbirth, health care prices are higher in the U.S. than elsewhere in the world.

The data represented in just these few charts show that in practically every instance, health care prices are higher in the U.S. than the rest of the world. So yes, it is possible to create policies that would set U.S. prices based on world prices, not only for drugs, but also for all medical services. But such an approach raises a myriad of operational questions, and of course, raises the core question of whether such a policy would even work.

What do we mean by asking whether the policy would “work?”

If what a patient pays is the issue, importing health care prices from other countries is unlikely to have any meaningful effect.

Using childbirth as an example, a recent study published by Health Affairs shows the mean cost for delivery care in the U.S. remained relatively stable between 2008 and 2015. However, “the average proportion of costs paid by patients went up over time (from 12.3 percent in 2008 to 19.6 percent in 2015).”

Further, the required out-of-pocket spending for maternity care was mostly in the form of a deductible, and the amount of deductible, depending on the type of health insurance, rose by 40-50% over the time period studied, as shown in the chart below.

Comparing U.S. medical prices to international prices is one way to view the problem of health care costs and points to certain policy proposals (for example, cutting administration costs, as we’ve mentioned previously), but it doesn’t directly address the pain of paying that patients are feeling.

Instead, when policymakers examine health care cost proposals, they should define what “works” as something that would actually help patients pay less for the care they need.