World Mental Health Day is on October 10th and this year’s theme is Mental Health in an Unequal World. There has been considerable momentum over the last few years in eliminating traditional access barriers to care as well as addressing stigma. However, there is still much work to be done, as made increasingly evident by the mental health crisis that has emerged as a result of COVID-19. Beyond issues of access and stigma which remain top of mind, additional emphasis must be placed on defining success and the quality of mental health therapy.
Q&A with Michael Boroff, Crossover Health’s Mental Health Program Manager
What took you into mental health and healthcare in general?
My values have always been based on service and wanting to reduce suffering in the world. There are just so many struggles that people endure. Throughout my career, I’ve sought inspiration from the people who have been impactful in my own life and who have helped me navigate difficult times. This led me to explore roles in multiple systems, from education and criminal justice to homelessness. Eventually, I found myself at a larger healthcare corporation working as a therapist.
The common thread amongst all of the systems in which I worked is that they are broken. I didn’t observe any proactive efforts being made to address the underlying issues, which left me feeling really frustrated. While I still love doing therapy and seeing Crossover members, increasingly, I’m really focused on systemic change. I’m honing in on how we can right the wrongs that exist in mental health and healthcare and do it in a better way.
Where have you seen progress in mental healthcare over the years?
There has been significant progress on the access front, especially with the addition of virtual care offerings. It’s important to get people who are struggling with their mental health through the door as quickly as possible, so that they remain engaged in getting help. When we speak about access, it’s also necessary to think about equitable access, as not all communities face the same barriers to care. We’re starting to see people from more diverse backgrounds and geographies seek out mental health support, which is a good sign of progress.
Where is there still room for improvement?
Mental health is siloed off and treated as something separate from the rest of healthcare and it’s baffling to me because mental health issues don’t occur in a vacuum. Physical health issues contribute to mental health issues and vice versa, and when team members aren’t working together to address the whole person, care is going to suffer as a result.
Genuine integrated care is essential. Success in large part depends on a team-based approach. At Crossover, even the design of the health centers fosters organic collaboration with the entire care team—including the mental health therapist, the primary care physician, the health coach, and the physical medicine team. I don’t know where else that happens in our industry, but I firmly believe it’s essential to great care.
What most excites you about your role?
As an organization, we are proactively thinking about not just how we can improve healthcare, but how we can actually reinvent it so that it yields optimal outcomes for people. We often ask ourselves what a good healthcare system would look like if we were going to build it from scratch. The opportunity to innovate from the ground up, especially in a healthcare system where cost and value are not aligned, continues to be very appealing to me. When I accepted the role, I knew that Crossover offered a unique opportunity to make real change, whereas I felt I had little to no power to shift systems in the places where I worked previously.
What about the profusion of digital mental health apps we’ve seen hit the market over the past few years. Whether self-driven or provider-driven, what is the real opportunity?
We’re seeing this proliferation of digital mental health solutions and just billions of dollars in venture capital money going there. The American Psychiatry Association has estimated that there are now 10,000 mental health apps available for download. They help the mental health conversations, but when it comes to results, they’re siloed and fragmented.
There are so many apps now that do so many different things, but most of them still don’t have the evidence to suggest they’re effective and for whom. When you look at research on what makes mental health care effective, the biggest common factor is the relationship with the provider. That’s still trying to be solved for in these kinds of digital solutions, especially when there isn’t a human point of contact involved.
Crossover’s Chief Medical Officer, Stephen Ezeji-Okoye, MD, has talked about the biopsychosocial model of care. Have you seen anything like that in the marketplace?
There are places where mental health is integrated into primary care, but only to a certain degree. It’s common in Veterans’ Administration settings, where Stephen spent several years, and in some community mental health settings and larger healthcare companies. But even in these instances, mental health is often restricted to a three session treatment program, after which patients are referred out, so it’s limited in the scope of what can be treated.
I haven’t seen anybody do what we do. For example, let’s say I have a patient who’s depressed and for whom physical activity would be helpful. If that patient were to tell me they can’t partake in physical activity because they have pain in their knees, the Crossover model would enable me to engage one of our physical therapists on the spot. In other cases, for people who struggle with diet or sleep, we have health coaches who can step in to offer care right away, not eight weeks down the road after symptoms have worsened.
Same with prescription medications. Amongst our mental health patients, about 35% are on some kind of a psych med for depression, anxiety, or sleep. The prescriber in our system is often the patients’ primary care doctor who sits right across the table from me during breaks. So, if a mutual patient of ours is not taking their medicine as prescribed due to side effects, our data collection system lets me know that, and I can connect with the primary care doctor in a timely fashion. Within a matter of minutes, that primary care doctor is reaching out to the patient to troubleshoot. Lots of systems try to do that, but we do it really well. And I think that’s huge.
How does this degree of integration lead to better outcomes for patients?
The earlier we can see someone, the easier it is to treat them. When care is delayed, their symptoms can worsen over time, which makes treatment more difficult. With our biopsychosocial approach, a primary care doctor, a health coach, and/or a physical therapist works with a mental health therapist right in the office. Sometimes we can even have the therapist come into the room and do a warm handoff so there is no gap in care at all.
Does the mental health sector suffer from the same reliance on utilization metrics as the rest of the healthcare industry?
I think it’s even worse in the mental health sector. For so many employers, the laser focus on catching up by providing mental health access followed by driving mental health utilization has left little to no time spent on the education around what positive results look like. Access is important, but it’s also crucial to think about the quality of care being delivered and whether people are getting better.
Is there a resistance to data in mental health?
I think in mental health, there’s this tension between science and art. There are still many mental health professionals who are resistant to measurement-based care, where they have to quantify symptoms and improvement. It’s a place where mental healthcare has lagged. At Crossover, we know if we’re not measuring for improved outcomes, the odds of the patient getting better are far less. This can’t be optional for mental healthcare. It just needs to be what we do. We have great research that shows that when therapists track symptoms and therapeutic alliance data regularly, and use it to inform a dialogue with their patients to personalize treatment, the outcomes are way better. For our members, it’s helpful to be able to show them the results of the work they’re doing, and how far they’ve come along in their treatment journeys.
Is there a patient volume issue in mental health that needs to be addressed?
Yes absolutely. In mental health generally, we see people who are in therapy forever. They start and they’re just in it for years and years, and providers are incentivized to maintain this—it’s a natural consequence of any fee-for-service model.
This exacerbates our national provider shortage. I was at a conference recently and heard about a secret shopper survey completed on a major health payer. The surveyors called 500 therapists on the panel, and 75% of them were not accepting new patients while 18% did not have any appointments available for at least a month. The outcome is that 93% of those 500 providers had no open appointments at all or no openings for a month or more. Imagine that you’re struggling with depression and just want to get in and talk to somebody but there’s no one available. This hurdle can be a big disincentive for those struggling with mental health.
A whole shift has to happen within our mental healthcare field. We must start thinking about therapy differently and about how we can better encourage vulnerability, autonomy, independence, and resiliency, so that our patients with conditions like anxiety and depression aren’t dependent on us and their regular visits. At Crossover, we don’t count success in visit volume; we define success as when our members are healthier and we’ve taught them the skills they need, including how to develop their own support systems.
Crossover’s mental health outcomes are much higher than industry standard. What things are you measuring which support that?
In addition to PHQ and GAD scores which many rely on, we go a couple steps further. For one, we use Tridiuum, a mental health outcomes tool that’s much more sophisticated. Tridiuum measures depression and anxiety, suicidality, and alcohol and drug use. It also measures functioning and subjective emotional wellbeing. This is important because you can have somebody who gives you low depression and anxiety scores, so in theory they should be doing okay, but they tell you they feel terrible. Tridiuum lets us measure that discrepancy. It also measures prescription medication adherence for psychiatric meds. Do patients have a prescription? Are they taking it as they’re supposed to, and if not, why?
Explain to us the concept of therapeutic alliance and how that contributes to better outcomes.
As a therapist, what I find most valuable are the therapeutic alliance scores. The majority of our core services now use a therapeutic alliance or “goodness of fit” measure that allows us to track the relationship between the provider and the patient. No surprise, when the relationship is strong, the outcomes are better and this is something you have to measure. Patients in every session are asked to respond to simple questions: “Did I talk about what was most important to me? Did I feel understood and respected? Do I agree with my treatment plan?” It empowers our members to give their therapists feedback and the therapists to tailor treatment accordingly to ensure optimal outcomes.
COVID has of course driven both an increase in virtual care, and a shift to a hybrid care model. How does that impact the care your team is delivering, and how would you like to see it evolve?
First and foremost, what is foundational to our mental healthcare delivery is centering the experience around the relationship and the trust that results. That starts with meeting people where they are. Some prefer a virtual environment as their first step, others want to meet in person. Beyond the vital relationships and member support, what I would love to see is technology that assists our therapists in being their best professional selves. What can we arm them with that helps them drive outcomes, reduce burnout, and feel effective in their work?
Michael Boroff, Psy.D., is a clinical psychologist and the Mental Health Program Manager for Crossover Health. He oversees the mental health program across the country and works within Crossover’s integrated, team-based care model, to establish trusted relationships with his patients and their extended care teams to achieve optimal outcomes for his patients.