Living Health: Building the Future of Behavioral Health

• By:  Don Bertschman
• Posted:  September 27, 2022
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Highmark Health’s ambitious Living Health strategy pulls together payers, providers, tech innovators, and community organizations to build a new health ecosystem and take on the industry’s most daunting challenges. If you want a nice, easy leadership job, this would probably not be a good fit.

Dr. Bradley Karlin knew exactly what he was getting into when he signed on as Highmark Health’s executive medical director, Enterprise Behavioral Health. He had led ambitious and challenging projects of his own — including one of the nation’s largest mental health care change initiatives at the Department of Veterans Affairs.

He says he joined Highmark Health largely because he believes it is positioned to be one of the leaders in transforming how behavioral health care is delivered, assessed, and financed. He took time to discuss the enterprise behavioral health strategy he and his team have implemented, and how it intersects with Living Health.

Clinical and financial transformation

Don Bertschman: Starting with your work at the VA, you have led large-scale transformations in mental health care for nearly 20 years. Before we get to Highmark Health’s efforts, what systemic challenges, nationally, make all this “transformation” necessary?

Dr. Bradley Karlin: Challenges in access, engagement, and quality, combined with outdated financing models, contribute to high rates of unmet need and substantial unrealized opportunity. These challenges predated, but were significantly exacerbated by, the pandemic.

Only about 40% of those in need of behavioral health treatment receive care due to stigma, lack of accessible providers, financial and other barriers. We see a significant lag time to treatment — in some studies 10 or more years after initial symptoms. Of people receiving care, many studies show that a startlingly low percentage receive what is considered minimally adequate treatment. Add the impacts of COVID-19, and we are in an unprecedented time of need and opportunity for behavioral health care that requires fundamentally rethinking both delivery and financing.

I often say that behavioral health care has a quality problem, but it’s not because there aren’t treatments that work. It’s because we have a research-to-practice divide that is larger than in almost any other health care context — treatments proven to be effective don't make it to the clinical frontlines as often as they should.

A focus of the VA transformation was to adopt a more active, evidence-based, recovery-oriented approach. This included the national implementation of more than 15 evidence-based psychological treatments and training more than 11,000 VA mental health staff. This journey, the nation’s largest implementation effort of its type, led to significant positive outcomes for veterans, providers, and the system. Passionate about exporting this to other systems, I led similar work as part of the leadership team of EDC, a global health and education consulting firm.

My experiences and those of my colleagues and team members have demonstrated that transformation is possible. It becomes imperative when you take a holistic view of health, as the Living Health strategy does, because behavioral health care quality is essential to overall health.

Don Bertschman: What are the advantages of pursuing transformation through an enterprise-level strategy?

Dr. Bradley Karlin: There is a unique opportunity to align clinical and financial transformation within a blended health organization like Highmark Health. The multidisciplinary perspective and collaboration — payer and provider, but also aligning product, home and community care, enterprise analytics, the technology business, Living Health partnerships, and other areas — enable us to achieve a more systemic, integrated, and holistic change than would be possible at most organizations. We truly push each other to rethink the whole picture — who, what, when, where, and how — keeping whole health and what is possible at the forefront. This is fundamental to the vision Dr. Farah set for Living Health — behavioral health is very much at the center.

Don Bertschman: Can you talk more about how that “whole picture” approach plays out?

Dr. Bradley Karlin: Sure. It can be tempting to think about improving behavioral health care primarily in terms of access challenges, with the solution being “we need more providers.” For us, “who” isn’t just how many providers, it’s rethinking and optimizing the whole team, including leveraging coaches and peers in appropriate situations and freeing up and empowering clinical staff to work at the top of their license.

“What” goes back to quality — let’s make sure our “what” is evidence-based, Grade A recommended treatments backed by measurement.

“When” — as with the entire Living Health model, we want to move behavioral health care upstream, meet people earlier in their journeys, and deliver personalized, right-sized interventions.

With “how” and “where,” we want to leverage digital solutions and telehealth, and also think about how to better integrate behavioral health into not just primary care but home and community care, emergency, and other non-traditional settings. All of this helps with the access challenge, but it’s a very holistic approach to improving personalization, engagement, and outcomes in the delivery of behavioral health care.

I’ll emphasize two related points about why there is an enterprise-level strategy and organization. First, we are focused on integrating leadership, starting with the provider system and health plan, but really across the entire enterprise. This is essential for ensuring success and impact at scale. We want behavioral health to become everyone's business.

But beyond just changing the clinical paradigm, a key to success, and another reason for the enterprise-led approach, is that clinical transformation requires business transformation. That’s a key element in our enterprise behavioral health strategy. To achieve and sustain change, we must reform outdated financing models that do not incentivize high-quality care, and move to innovative value-based models that incentivize, reimburse, and align health plan benefits with the better future state we want to create. That includes elevating behavioral health to be on par with physical health. For example, right now, most U.S. health plans classify behavioral health as a specialty condition, so copays and cost-sharing are often higher than for primary care.

Enterprise behavioral health strategy

Don Bertschman: At a high level, what are the enterprise behavioral health strategy’s key priorities?

Dr. Bradley Karlin: We can break it down into six areas. First is reducing stigma and increasing engagement, including through direct-to-consumer outreach and engagement campaigns and being thoughtful about how we message around behavioral health.

Second, we’re moving from the prevailing downstream, reactive model that focuses on treating diseases and disorders, to an upstream, proactive model. Leveraging technological innovations and predictive analytics, we want to identify and address a potential problem in some cases even before a patient or provider might know there is one.

Third, our strategy is to transform from a siloed, fragmented care model to one that's truly integrated, where behavioral health is embedded in physical health care and overall health. As I said, this includes integration of behavioral health care into non-traditional settings, such as primary care and home and community-based care settings. It is also about integrating behavioral health principles into one’s overall health and daily experiences. We frame it as thinking of behavioral health as both a column and a row. The column, behavioral health conditions, is what most people think of, such as treating depression, anxiety, substance use disorder, and so on. But behavioral health is also about health behaviors — this is the row opportunity — like adhering to medication, sleep, lifestyle choices, or managing chronic pain. Attending to health behaviors must be interwoven, because they are part of a person’s health experience and impact overall outcomes.

Fourth, we are replacing the variable quality and “one-size-fits-most” approach that has long characterized behavioral health care with a model focused on the delivery of evidence-based, personalized, precision treatments where care and technology solutions are tailored to individual needs and preferences, and supported by ongoing measurement to make adjustments as necessary. Quality and precision are vital to achieving the promise of behavioral health care.

Fifth, we are moving from often inefficient and labor-intensive models of delivery to an optimized workforce that matches the right skills with the right purpose at the right time. For example, within a personalized care model, behavioral health coaches can address mild needs and support lower-intensity interventions, allowing licensed providers to devote more time to care that requires their expertise.

Sixth, as I mentioned, we are developing innovative business and payment models that better incentivize quality and wellness.

Living Health: Personalized, proactive behavioral health care

Don Bertschman: The enterprise behavioral health strategy parallels many goals of Living Health. Can you talk more about that overlap, and specifically how Living Health’s integrated platform, being developed with Google Cloud, will help advance the transformation goals you laid out?

Dr. Bradley Karlin: We are endeavoring toward the day when behavioral health care is highly personalized, precision-based, and proactive — so support, digital solutions, treatment, the entire experience is tailored to an individual’s needs and preferences. This is very much in line with the Living Health strategy and the development of a dynamic platform powered by advanced analytics that will help this come to life and make the experience much more integrated and seamless. Combine EHR and health plan claims data with information from validated symptom measures and answers to preference-based questions and you get exciting opportunities to develop a precise personalization and recommendation system.

Moving health interventions even more upstream is the exciting opportunity of digital phenotyping, leveraging AI and machine learning innovations for earlier detection and treatment. Sensing technology incorporated into cell phones and wearable devices, and data from interactions with providers or case managers, can be used to detect specific signals or phenotypes and then quantify behavioral health problems and their severity. This allows for detection of a problem before even anyone may be aware, and for better guidance of clinical decision-making.

In addition, the Living Health platform will serve as the “connective tissue” between different solutions and points of care, which presents opportunities for better integration across multiple conditions and promoting whole health. When you consider that many individuals do not have only depression, anxiety, or a substance use problem, but experience these conditions alongside comorbidities like diabetes or hypertension, it is imperative that we have integrated solutions that empower and heal the whole person.

Transforming the paradigm for patients, providers, and the industry

Don Bertschman: The Living Health model centers on the individual and clinician. Can you talk more about how an integrated platform benefits clinicians in terms of behavioral health issues?

Dr. Bradley Karlin: The ways in which the integrated platform will benefit the clinician are numerous, including: earlier identification; ongoing measurement for guiding clinical decision-making; next-best-action and step-up/step-down decisions within the stepped care model; and enhanced and simplified communication, navigation, and care coordination, not only between an individual and clinician, but with a person’s entire care team.

The use of proactive identification and outreach fueled by advanced analytics, personalization, and navigation capabilities within the highly integrated and customized experience will solve two of the most vexing behavioral health challenges facing primary care and other clinicians. The first challenge it will address is how to identify and connect with patients earlier to reduce those multi-year time lags from symptom onset to treatment. The second challenge is where and how to refer and navigate patients with behavioral health needs to treatment — specifically treatments that are person-fit and right-sized to maximize engagement and outcomes. The Living Health platform also presents a significant opportunity to integrate and tie together solutions for behavioral health with non-behavioral health needs and conditions.

Don Bertschman: Technology can help improve health outcomes in the ways you mentioned, but I want to return to what you said about the quality issue in behavioral health care and the work you led to improve quality and outcomes with VA and other large systems. Where does that fit into the big picture at Highmark Health?

Dr. Bradley Karlin: Not all behavioral health care is created equal. Often, what happens behind one therapy room door is very different from what’s behind another. Research shows that, in the overwhelming number of cases, treatments provided on the clinical frontlines are not gold-standard, evidence-based treatments. In fact, some estimates are that only 15% of patients receive minimally acceptable treatment, much less evidence-based treatment.

One component of driving high-quality care is therefore increasing the delivery of evidence-based treatments — both psychological and psychopharmacological. This includes specific evidence-based psychotherapies that include active ingredients for cognitive, behavioral, and social change. Another part of high-quality behavioral health care is delivering measurement-based care — using patient-reported outcomes to monitor response and guide clinical decision-making, including changing treatment approaches when a patient is not responding.

We are working to advance both of these highly recommended practices through the development of a high-performing, technology- and data-enabled behavioral health network. As part of this effort, we recently launched a Center of Excellence in Evidence-Based Psychological Treatments to establish enhanced capacity to deliver specialized evidence-based treatments not highly available in the community. We are also working to develop a high-performance behavioral health network, as well as innovative payment models to incentivize quality, measurement, and value.

Don Bertschman: Can you talk more about the clinical care model for transforming behavioral health care?

Dr. Bradley Karlin: Clinical transformation of behavioral health care at Highmark Health is rooted in the stepped care model, which involves meeting patients where they are based on their need and preferences and stepping them up or stepping them down as needs and preferences change. It is a model for providing more effective and personalized behavioral health care. It is also a model that includes important emphasis on moving upstream and utilizing innovative engagement strategies and lower-intensity interventions — to reduce that time lag, averaging 8 to 10 years in some studies, from onset of symptoms to treatment. This model, often written about in aspirational terms, is one that Highmark Health, as a blended health organization, is uniquely positioned to achieve as part of the Living Health strategy.

Visualize the model as a series of steps in an ascending staircase from left to right. Center to left represents progressively milder needs that can be served with earlier, lower-intensity interventions like the digitally-enhanced program and behavioral health coaching we’re piloting. Center to right involves moderate to severe behavioral health needs that require clinical care and specialized treatment capabilities. We are working to develop or expand differentiated and complementary capabilities within each step of the care continuum.

Don Bertschman: Having led large-scale transformations in behavioral health care, would you say that the pandemic has opened up a level of opportunity for broader change?

Dr. Bradley Karlin: This is a unique moment for behavioral health, an industry that has been in crisis and ripe for innovation and transformation since well before the global pandemic. The last two years exposed and exacerbated the crisis — but also brought much-needed external focus and attention to the sector.

In my close to three decades in the field, there has never been so much need and so much opportunity. To share one powerful data point, health economists have estimated that the technological advances seen with respect to virtual and digital behavioral health over the past couple years is the equivalent of 20-30 years prior to the pandemic. We must now harness this innovation and opportunity for transformation to design new models, modalities, and approaches in the right way. We are witnessing a potential renaissance of sorts for the field, one that requires leadership and sophistication in vision and implementation.

The journey we are on to transform the clinical and business paradigm of behavioral health care as part of the Living Health model presents exciting opportunities to help reshape how behavioral health care is delivered across a broader care continuum.