New White House Health Initiative

Patrick J. Kennedy (00:00):

... a great deal to say, because as many of you know, just last week, President Trump issued an executive order on tackling addiction in this country. I don't think it was any accident that that order was issued, because for those of you who followed a little bit of my cousin, Bobby's, campaign in the presidential election, he made addiction really a forefront of his whole campaign. If you haven't, just Google the YouTube RFK Making America Facing Addiction, and it's all in there.

(00:39)
I was so impressed, because I had never seen a presidential candidate devote so much of their time on the road to this issue. And Bobby crisscrossed the country and met with many of the people that you and I know, the kind of thought leaders in addiction treatment, those that are really advocating for better prevention, and finally, what's often left out of this equation, those who are supporting recovery. Because we, in this country, have an acute care system, that continues to treat people, that never supports them in terms of their longer term recovery, and even though this is a chronic illness, we often treat it as an acute episodic illness as opposed to the chronic illness that it is.

(01:32)
What was really impressive to me in that documentary and the words the Secretary has had since then is the frame that he's putting around this issue, because he and I both understand what it is to be in recovery, and we know that it's a biopsychosocial illness. What we've neglected in our treatment paradigm in this country is the psychosocial, but principally the social. We have done a terrific job on the biological, we know what to prescribe. Thank God, we've got some not only great treatments in the past, but ones that are coming on board that show great promise. But if you don't combine the mental health and the social health, it's like a three-legged stool. The stool's going to fall down.

(02:27)
And what I read into the President's executive order the other day is a commitment to start connecting the dots. All of us in our movement know that we're so fragmented. All of us as advocates advocate for one little diagnosis or one piece of the treatment continuum. We never take a holistic approach, and furthermore, we never connect all the different government agencies that touch someone with these illnesses. We relegate them to one system, and that's the healthcare system. And we've forgotten that these people work and operate within all the housing, and tragically and too often the case, in the criminal justice system and the human services system and so forth. And what we've never done as a country is think about the true cost of these illnesses across the government, we only look at the cost to the medical spend alone. And until we take a broader aperture of this, we're never going to wrap our arms around all the needs that someone has, such that we can provide them the support that's going to give them the best chance at long-term recovery.

(03:46)
Now, in this audience, I see many friends who are there for Amy and I. Furthermore, let me acknowledge my wife, Amy Kennedy, is over here in the back. Amy and I co-founded The Kennedy Forum shortly after I left Congress, and the main goal of The Kennedy Forum was to really push for the full enforcement of the Mental Health Parity and Addiction Equity Act and to end the double standard in our healthcare system that treated the body but neglected the mind, that treated the physical but neglected the mental. It's hard to believe that that has been the case throughout our history, and frankly, we still need to fight that battle.

(04:36)
But as you know, we at The Kennedy Forum have also taken on the alignment for progress, and in the alignment for progress, we're not only advocating for more access, meaning payers reimburse for care, but we're also advocating for outcomes. God forbid we would ever want to pay for something that actually has better outcomes. And so, the idea is the alignment. We have to align the reimbursement to pay for the treatments that actually show the greatest results, not rocket science here, but certainly a paradigm shifter if you think about our field, because all we do today is pay for services. Did you make your therapy? Check. Did you make your... Check. We don't check how people are actually doing in their lives. Are they stable? Have they been able to hold down a job? Do they have housing? Are they reconnected with their family and friends? Are they in the community? These are things that have never been done in our system, and one hope that I have, through Secretary Kennedy's whole initiative, is that we can start to connect all of these dots that have been left aside in the whole approach.

(05:47)
But the alignment for progress today is getting new life, and it's getting new life through the action for progress, because we, at The Kennedy Forum, have put great policies forward, and we needed to curate those policies, but at the end of the day, we need to also implement those policies. And I am so grateful that I met an old friend who I reconnected with in Tom Koutsoumpas and found out that he has done at his firm, Healthsperien, exactly what we want in mental health and addiction. He revolutionized the end of life care to ensure that we had a bundled payment model that pays for outcomes for the whole person, and frankly, for those of us who are advocating for addiction and mental illness treatment, we want a bundle payment model. And Tom and his A team at Healthsperien have wrapped themselves around our initiative at the Center for Behavioral Health at Healthsperien. Many of you have been partners for us in that effort, but I just can't thank Tom enough.

(07:05)
And I'll just conclude with this. Many of you may wonder, what am I doing up here with someone that I share in common very little with politically? And I'll just answer that by telling you a story. In the years since I left Congress, I took up the fight against commercialized marijuana, and I fought sports betting and the problems with gambling in this country, both of which are new addiction-for-profit industries that are really compromising the health and wellbeing of our fellow Americans. And guess what? Fox News used to love having me on, they used to love having me on because I was like a Democrat that talked against marijuana. They said, "We've got to have that guy on here." So I went on all the time.

(07:58)
What always surprised me is when I got off Fox News, and of course I would check my phone for messages, my phone lit up, and it was all my fellows in recovery. And I'm thinking to myself, "That many people in recovery are watching Fox News?" So it was a real awakening for me that we really can't be divisive in this issue, we have to be unified, because as much as we have our political disagreements, this is an issue that affects every single American, as the Secretary has said, and I really appreciate the fact that he has taken his role as HHS secretary to put this on the spotlight. And so, with that, I'm going to have my friend, Tom Koutsoumpas, invite the Secretary to have a fireside chat around all of these issues and the new initiatives that have just recently been announced. Thank you so much, Tom.

Tom Koutsoumpas (09:02):

Well, Patrick, before we have the Secretary on, I just want to say one thing. First of all, welcome to all of you. We're all here because of your leadership. So I think we want to give Patrick an extraordinary round of applause. He has brought all of this together for us to focus on and make a difference.

(09:22)
And now, we're going to welcome the Secretary of Health and Human Services to the stage. Welcome, Secretary Kennedy. Secretary. Thank you.

Robert F. Kennedy, Jr. (09:39):

Good to see you.

Tom Koutsoumpas (09:40):

Good to see you. Well, thank you so much for being with us at our launch for Action for Progress. This is such an important issue. As you and I have talked and you've said so many times, mental health, behavioral health addiction is really one of the most critically important issues in our healthcare today, and it affects families throughout the country, all parts of families, mothers, fathers, sisters, brothers. It really is so extraordinarily important. And I know how important it is to you, and so we're so grateful for you to spend the time with us today, but also, I think, to hear from you about why it's important and where we're going with the exciting new announcements that you made just recently around the executive order and the focus that you're taking to address these issues. Talk to us about that.

Robert F. Kennedy, Jr. (10:29):

I mean, it's a raw financial issue. It can be reduced to a raw financial issue. It costs about $92 billion here in direct costs, about 890 billion a year in indirect costs and lost productivity and costs to our healthcare system, and just collateral damage and all the collateral illnesses. One of the things Patrick and I were talking about backstage is the intensity of use by drug addicts and alcoholics of the healthcare system. They're in the emergency room all the time. They're also imposing costs on our justice system. They're imposing costs on our foster care system. They over-utilize every aspect of the government, and you get them into treatment and all that stops and they stop...

(11:27)
Patrick was telling me that he went to 17 rehabs, but he was in the emergency room once a week with everything from kidney infections to contusions on his face from falling, and that in the 15 years that he's been sober, he's never been to an emergency room. I see that, we all know that that's what happens to addicts, they're negative producers. Like I said, in economic terms, they're drags on the whole system. But also, just for the morale of our country. What we're facing now in this country is we have the worst health outcomes in the history of the world. We have the highest chronic disease burden of any country in the world. We pay the highest cost, two to three times what Europeans pay for healthcare. And we've lost six years to Europe in terms of our lifespan over the past two decades. We've got the highest infant mortality rate in the developed world, the highest maternal mortality rate in the developed world. And then, our cancer rates, we're having an epidemic of colorectal cancer now among children. In 10 to 14-year-old children in the last decade, colorectal cancer has grown by 500%.

Tom Koutsoumpas (12:57):

Wow.

Robert F. Kennedy, Jr. (12:58):

We have a healthcare crisis, but we also have a mental health crisis, and that's a crisis of loneliness, it's a crisis of despair, of fragmentation, of atomization, of just disconnection from community, and it's being amplified by social media, by cell phones. But also, people, when they're disconnected, turn to drugs. They look for something outside of them to fill that lonely hole inside of them. And so, you're seeing record numbers of addictions now. The highest cause of death is overdose in Americans under 45 years old. And we can't fix that by treating the addiction alone, we have to treat the causes of it. We have to work on prevention, we have to intervene early, but we have to figure out ways to reconnect, particularly our children, with community.

(14:02)
Addiction is about isolation. It's a disease of isolation. Addicts end up alone. They burn their relationships, they lose their jobs, they end up in rooms or jails or institutions or dead. And the ultimate solution to that is reconnecting people to community. And we have to look at how do we do that, that strategy is about how do we do that. Patrick talked about outcome directed strategies, and that's what we need to focus on. The fragmentation is occurring in response to... There's no coordination between all of the needs and the institutions that could help with this problem, housing and law enforcement and healthcare and mental healthcare, there's no coordination and it's a fee-based service system.

(15:04)
So people, just like the medical system, people have an economic incentive to make sure you don't get well, and that's not saying caregivers don't want you to be well. Of course, they do. But the system itself is designed to keep you sick. Every time you relapse, the rehab makes more money and the costs go up, and the insurance companies... You think the insurance companies are going to lose money every time you go, but they're looking at the entire cost, because they collect friction from those costs. Would Lloyd's of London rather have one boat sink a year or 100 boats sink a year? They'd rather have a hundred, because then everybody is buying the insurance and the cost of the pie goes up and they're collecting friction on it.

(16:01)
Everybody along the way is making money on fee-based services, and ultimately, what we have to do at HHS over the next three years is do everything we can to switch the model at CMMI and CMS and HRSA and SAMHSA to coordinate response so that somebody is in charge of that addict, somebody is accountable as he moves through the system, and to move to outcome-based services, where people have an incentive to make sure you don't relapse, that there's a strong economic incentive, you get paid one price, you're treating that individual, then you follow that individual for three years and you're responsible for all the costs, that will bring down the costs, because then people will look. We have lots of evidence-based treatments.,We know what works, but we're not doing it well because nobody has an incentive to do that, and so there's no accountability.

Tom Koutsoumpas (17:03):

And we were talking earlier as well, Secretary, about the disconnect between the mental health and the physical health, and as you've just described, the opportunity to make sure that all of that is incorporated in as people are cared for so it's not just separated. But how does the mental health affect the physical health, and so that there's actually an integration of services?

Robert F. Kennedy, Jr. (17:23):

Yeah. I mean, we need to integrate services and that's... The Great American Recovery Act is an effort to begin that transition. The STREETS program, for example, well, it's based partially on the program that was modeled in the Netherlands, where we go out, we bring together law enforcement, we bring together mental health, we bring together counselors, we bring together housing, and we intervene early. We try to get to that addict or people with mental health problems as soon as possible. We find them on the street, we move them from crisis to detox, to treatment, to housing, to employment, and ultimately to reconnecting to communities and to self-sufficiency.

Tom Koutsoumpas (18:20):

Well, as you can imagine, everyone here is very excited about the Great American Recovery Initiative, and so hearing more about it and understanding how you're taking this on and moving it forward is really extraordinarily important and very exciting to all of us who are concerned about these issues. You had talked about the STREETS program, tell us a little more about STREETS. And then, sober housing, I think, is also a very important part of this that I know you're very committed to as well.

Robert F. Kennedy, Jr. (18:46):

I mean, the STREETS program begins with a $100 million program that's going to be distributed to eight regional pilot programs where we will coordinate the government. Insurance companies don't have any... Your life with them is very short-lived, you move from one to the other.They're looking at the cost over one year, and we need to extend the periphery of that horizon so that somebody is looking over the cost over three years and the entire cost. Right now, the fiduciary for addicts is CMS. CMS only is looking at the cost savings to the healthcare system, that's all they're concerned about, and nobody's looking at the broader cost savings, for example, law enforcement. We're bringing all of these agencies together. We're going to do a study that looks at the entire cost of the addict over the lifetime of the addiction so that we can demonstrate savings over time to justify the cost of this program.

(20:03)
The STREETS program, as I said, it's a $100 million program. It builds on a $45 million program that we gave this year for sober housing. And I'm working with Scott Turner at HUD to revolutionize sober housing. I am a really strong believer in sober housing. I think we need to not just treat the addict and then put him back into the environment that was making him sick, or contributing, let me put it this way, contributing to his sick illness. We need to give him some stability, or her some stability, and from there, they can get employment, they can develop relationships, they can develop independence, and then they can move on. But you need to give them that. Without sober housing, treatment is going to fail.

Tom Koutsoumpas (20:55):

Yeah. Well, this is a whole new approach as you're describing, which is also so tremendously important, and the difference between other programs from the past and where we're going into the future under your leadership, it really is a very important and exciting part of this. We'd also talked a little bit about integrating some faith-based initiatives within this whole arena to help address these issues. Talk a little bit about your thoughts about that and how that plays a part of this.

Robert F. Kennedy, Jr. (21:24):

Well, faith-based initiatives work, they're scientifically proven to work, and they do that by, again, by reconnecting us to a community, by expanding the relationships that the addict has. As I pointed out, addiction is a disease of isolation, you cut off those relationships. And God talks to human beings through many vectors, through each other, through organized religions, through the great books of those religions, through wise people and the prophets and through nature, and nowhere with such texture and grace and joy as through other human beings. And when we cut off our relationships with other human beings, we lose that access to the divine, and that is a healing power.

(22:16)
We are in a spiritual malaise in this country, and we need to give people access to all different ways of reconnecting with something that is higher than themselves. I'm reminded of Bill Wilson, who is the founder of the 12 Step Movement, he was in a program before he launched AA, which was called the Oxford Group, and the Oxford Group had eight steps, from which the 12 steps of AA are taken, and those eight steps were intended to induce a spiritual awakening.

Robert F. Kennedy, Jr. (23:00):

And Bill Wilson had that spiritual awakening, and his compulsion to drink, which he'd been fighting for 40 years, suddenly just went away, just miraculously. And he could not imagine that he would ever take a drink again. And then during that six-month period when he was sober, he put together a deal to buy the primary vendors for the Goodyear and Firestone Tire Companies. And the deal was going to make him a millionaire and set him up for life. This was the height of the Great Depression, 1932. And he went out to Akron to ink the deal and somebody else had gone in and stolen the deal from him. And he had put all of his finances in that deal and he was crushed.

(23:48)
He was standing in the lobby of the Mayflower Hotel in Akron and all of a sudden all of that compulsion to drink came back to him full force. And he was 20 feet away from the lounge and he could hear the ice clinking in the glasses and he could hear the laughter of the patrons and it was screaming at him to come in and get a drink.

(24:10)
And on his way to the lounge, he had the central revelation of the 12-step programs, which is he realized the only way that he was going to stay sober is if he helped another alcoholic. And he went, instead of going into the lounge, he went into a phone booth and he got the Yellow Pages and he looked up preachers, Salvation Army, sanitariums and hospitals, looking for a hopeless alcoholic that he could talk to.

(24:39)
And he eventually found Bob Smith, Dr. Bob Smith, who had tried everything to quit drinking. And he was able to persuade Bob Smith to meet with him. And when Bob Smith came into the meeting, he said, "You got 15 minutes," because he'd heard it all. He never heard it from another alcoholic. And they ended up talking all night. And that was the first 12-step meeting. And they both decided the next day, the only way they're going to stay sober is to find another alcoholic. So they went to the hospital and they found a guy who was literally handcuffed to a bed and he was the third member.

(25:18)
And it was that this realization that the only way that the spiritual awakening works, but it's just a daily reprieve. And if it's not renewed every day through service to other people, service to other alcoholics, then you'll lose it. And so the 12-step programs teach you, build that muscle of you've got to do something to serve another human being every day of your life. And that's how you teach people to reintegrate in the community because they get that spiritual and emotional return from service that they then become addicted to, and they begin building relationships and friendships and a sense of community and stability in their lives. And it gives them a purpose in their lives. And that's how you cause, that's how you precipitate a spiritual revitalization, a spiritual renaissance, reaching out to addicts on the street and then giving them stable lives and teaching them ways to be of service every day.

Tom Koutsoumpas (26:30):

It's extraordinary. Well, this also is... We have, as a nation, have a crisis around social isolation and loneliness. And I think that adds, as you've just described, to these issues around addiction, et cetera, that are so prevalent, but the opportunity to reach out as you've described it is extraordinary and yet so simple to do.

Robert F. Kennedy, Jr. (26:53):

I don't think it's simple. I get-

Tom Koutsoumpas (26:57):

Simple in terms of making the effort.

Robert F. Kennedy, Jr. (26:59):

I get very intimidated from talking to Patrick.

Tom Koutsoumpas (27:01):

Yeah, right.

Robert F. Kennedy, Jr. (27:02):

[Inaudible 00:27:02] encyclopedia. There's always ideas about how to do it-

Tom Koutsoumpas (27:04):

Simple in that you need to make that effort. Yeah.

Robert F. Kennedy, Jr. (27:06):

... but they all involve doing these... It seems like you've got to change everything the federal government has been doing forever. And I think that's what we [inaudible 00:27:17].

Tom Koutsoumpas (27:17):

Which I think you're able to do.

Robert F. Kennedy, Jr. (27:22):

We can do that. There's a tremendous amount of low-hanging fruit.

Tom Koutsoumpas (27:27):

Yes, yes.

Robert F. Kennedy, Jr. (27:29):

But I'm hoping that when I leave this job in three years, that we will have changed the trajectory and changed public attitudes toward the treatment of addiction and at least developed a lot of models in the states for outcome-based care and for integrated care so that we have something to build on.

Tom Koutsoumpas (27:54):

Yes, yes. And that's happening so much, as you know, in the physical health arena. So paying for value, incorporating all those aspects.

Robert F. Kennedy, Jr. (28:02):

Yeah. It's that's what we're trying to do across-

Tom Koutsoumpas (28:03):

Yes.

Robert F. Kennedy, Jr. (28:04):

... CMS and we have an amazing team. Dr. Oz is really extraordinary and he's completely committed to this as everybody is. Marty Makary and Jay Bhattacharya and all the people who work there are committed to that model.

Tom Koutsoumpas (28:22):

Yes. Well, and the outcomes then will be quite different than they are today where you're just paying for a service.

Robert F. Kennedy, Jr. (28:28):

Yeah. And that's just a death spiral for us.

Tom Koutsoumpas (28:31):

Death spiral. Yeah. Yeah.

Robert F. Kennedy, Jr. (28:34):

We have to figure out ways to reconnect our children to a national purpose and to communities and to a sense of purpose in their lives and create bridges to bring people together again across all these atomized landscapes.

Tom Koutsoumpas (28:52):

Right. One of the challenges I think that we all face as well is the workforce. The opportunity to provide these services depends on a robust workforce. What are things we can do to support developing a better, a more comprehensive workforce? Because right now we have a lot of shortages and problems that really prevent us from doing certain things [inaudible 00:29:15]-

Robert F. Kennedy, Jr. (29:15):

You mean in caregiver-

Tom Koutsoumpas (29:17):

Yes.

Robert F. Kennedy, Jr. (29:17):

... for addiction specifically?

Tom Koutsoumpas (29:19):

Yes.

Robert F. Kennedy, Jr. (29:21):

I mean, that's part of the funding that we're putting in and we're putting in hundreds of billions of dollars and a lot of it, about 500 billion will go to the states in block grants. And a lot of that is workforce retention, building a workforce. That's one of the things that we've got to make an investment, an enormous investment in.

Tom Koutsoumpas (29:50):

Yes. And I know we've talked about this before, but I know personal stories are so important with respect to these issues because people relate and I know your personal journey has been so extraordinarily important. Could you talk a little bit more about how that's affected where you're thinking and sort of what direction we're going in as a result of what you've experienced personally? Because I know that has really shaped your approach and your values.

Robert F. Kennedy, Jr. (30:17):

Yeah. I mean, I was a heroin addict for 14 years, beginning in my early teens, and I've been 43 years in recovery. And these 12-step programs saved my life. It provides all the gravities around which all of my life is oriented, my family, my friendships, the work that I do. I mean, I go to meetings every day. I don't have time to go to meetings. I've got 75,000 employees and I've got a big job and a lot of people are relying on me and I really don't have time to do it, but I go anyway, no matter what. And when I first came into the program in September of 1983, my first meeting, I asked the guy, "How long do you have to keep coming to these meetings?" He said, "Just keep coming until you like it."

Tom Koutsoumpas (31:20):

Until you like it?

Robert F. Kennedy, Jr. (31:21):

Yeah. And I've been coming 43 years, but I still don't like going to meetings. There's always someplace I'd rather be. I'd rather stay in bed with my wife. I go to an early morning meeting, but I go every day because when I go, the rest of my life works. And for me, it's like brushing my teeth. I don't look forward to brushing my teeth. I don't enjoy the sensation. I do it every day because I don't want to live with the consequence of what happens when I don't do it. And I need to maintain that spiritual center.

(31:58)
Everything that I've done in my life that I've done out of personal ambition or aspirations or an inquisitive impulse or materialism has been wormwood and bile and everything that I've done that is consequential or enduring has come from that spiritual center.

(32:21)
And we're all hybrid beings. We're half spiritual and half biological. And a lot of times our biological being doesn't have the best judgment and the challenge is how do you walk with one foot in the spiritual world and one in the biological world? And the answer to that is that you have to be disciplined about keeping yourself spiritually fit. And so I make a big effort to do that in my own life, but it also gives me an understanding about what that takes for an addict who's out there, who's hopeless, who's irritated, discontent, who's lost all of their touch with their own humanity, and how do you bring them back into society and how do you give them a chance to fulfill their God-given potential and give them a sense of purpose in their lives? And it begins with these little steps of giving them the opportunity to be useful to other human beings.

Tom Koutsoumpas (33:42):

Right. The other area that you've mentioned oftentimes is the importance of prevention, working to make sure that we can prevent these things from developing into the crisis points and crisis response as well. Any thoughts about-

Robert F. Kennedy, Jr. (34:00):

Yeah. I mean, this is just like in physical medicine, the longer you wait, the more expensive and the more insurmountable. We know the kids who are going to become addicts. It's pretty easy to identify them early in life. They're acting out, they're having contact with the criminal justice system, they're getting thrown out of schools, they're getting in fights. And you see these things happening and we need to start doing the interventions then, when there's still neuroplasticity in their brains before they've internalized the pathology and locked themselves into behaviors that are very, very difficult to break later on. Well, we can break them early if we identify them early.

Tom Koutsoumpas (34:52):

Yes.

Robert F. Kennedy, Jr. (34:53):

And that's one of the aspirations of the street programs, to find people as early as possible, but also we're taking a number of other steps to make sure to identify kids in foster care who need help and provide them with help before they have encounters with, again, with the criminal justice system, with hospitals-

Tom Koutsoumpas (35:19):

Sure.

Robert F. Kennedy, Jr. (35:19):

... with medical care, et cetera.

Tom Koutsoumpas (35:21):

Right. So as you look ahead, Secretary, thinking about the future, in five years in America, what progress do you hope you'll see as a result of this work? How do you see that progress moving forward for our country?

Robert F. Kennedy, Jr. (35:40):

Well, I'm hoping that we've at least by then gotten a series of models around the country and in states and cities of things that work so that we know how to do them. We know how to bring the insurance companies in.

Tom Koutsoumpas (35:57):

Yes.

Robert F. Kennedy, Jr. (35:58):

We know how to do early intervention. We know how to unify the response across all the different agencies and we know how to... We've developed ways of following the addict for several years and having somebody take ownership of that addict and say, "Okay, if I pay you as a rehab, I'm not going to pay you a daily rate so that the guy relapses in two months and you get paid again. I'm going to pay you one cash disbursement for him for a year, or for two years, or three years."

Tom Koutsoumpas (36:43):

Yes. And really manage the care.

Robert F. Kennedy, Jr. (36:45):

Right. "And you manage all the care."

Tom Koutsoumpas (36:47):

Yes.

Robert F. Kennedy, Jr. (36:48):

"You're responsible for that individual. So if he shows up on your doorstep again, you're going to lose money."

Tom Koutsoumpas (36:53):

Right. Right.

Robert F. Kennedy, Jr. (36:54):

And that gives the economic incentive, the financials incentive to that rehab to do everything in their power to make sure that that addict does not return. And when you align the economic incentives with the healthcare outcomes that we're looking for, behavior will change. And that is what we need to do. And that misalignment is pervasive throughout the healthcare system in this country, and it's why we're paying so much for healthcare because people are not getting paid to make patients well.

(37:33)
Everybody in the system, the insurers, the hospitals, the doctors, the pharmaceutical companies, are all making money by keeping us sick. And those economic incentives filter down and they change human behavior. The easiest way to change behavior is to rationalize the financial incentives. Once you do that, everything else is just going to follow naturally. People are going to be incentivized to identify the interventions that actually work and to implement them. And the companies that don't do that are going to go out of business and the companies that do are going to stay in business and flourish.

(38:21)
All the things that we're chattering about, nothing's going to work unless we realign those incentives. It's absolutely critical that we do that. So we all have our thinking caps on every day about, how do we do that? How do we do models for this? How do we rationalize the economic incentives so that they're aligned with good healthcare policy and good health?

Tom Koutsoumpas (38:48):

Yeah. Well, I think everyone in this room, and certainly the work we're doing for Action for Progress under Patrick's leadership is really focusing and aligned with exactly what you're saying. So we are really grateful to you for your leadership and grateful that you're moving forward with all of these initiatives that we can work with you on and be supportive of and really transform the mental health addiction care that we provide in this country. It really is an exciting opportunity.

Robert F. Kennedy, Jr. (39:17):

Thank you very much, Tom.

Tom Koutsoumpas (39:18):

We're about out of time. I just want to say one personal thing at the end. The secretary and I have known each other for, I don't know, most of our lives actually, since we were kids.

Robert F. Kennedy, Jr. (39:26):

At least 50 years.

Tom Koutsoumpas (39:27):

At least 50 years. When I was talking about doing this, my colleague said two things, "Don't call him Bobby and don't start talking about Hickory Hill and Hyannis Port stories." So we stayed away from all of that. But what we didn't talk about and we touched on was I think the thing that I find most inspiring by this whole discussion, Secretary, is, one, your passion and commitment to transforming the system and providing that leadership. But also if you think about those who are suffering today, right now, struggling the way that you did in the past and looking at sort of that time to where you are today as the Secretary of Health, influencing the health of millions of Americans, the inspiration and hope that that provides is beyond described... description. So thank you for all you're doing and we look forward to working with you into the future to achieve these extraordinarily important goals that you've aligned. [inaudible 00:40:29].

Robert F. Kennedy, Jr. (40:29):

Thank you very much, Tom, and thank all of you.

Tom Koutsoumpas (40:30):

Let's give the secretary a round of applause. You're the best.

Robert F. Kennedy, Jr. (40:33):

Thank you.

Tom Koutsoumpas (40:33):

Give me a hug, man. Thank you.

Robert F. Kennedy, Jr. (40:33):

Thank you all.

Tom Koutsoumpas (40:45):

Well, that was really an inspiring conversation. Important for all of us to think about the future, where we're going, and how we need to get there together in our action for progress. So I'm also now pleased to bring on stage CMS administrator, Dr. Mehmet Oz, and Dr. John Sherin, professor of psychiatry at UCLA and USC, and the former director of the LA County Department of Mental Health. So with that, welcome to the stage, and I'm going to turn it over to you guys. Thank you, John. Thank you, Dr. Oz. Thank you.

Dr. John Sherin (41:25):

Hello, sir. Great to be here. I came from LA, 75, 80 degrees, five foot surf. But for you, I would do that. Really, really great to see the new commitments coming from the administration, particularly around addictions, the inclusion of spirituality and other non-clinical elements, as well as a focus on AOT, a very important program. I ran mental health, as you just heard, for LA County, which is the largest mental health system locally in the country. And what I'll say is that I had great bosses, I had a great team, great community, wonderful clients, but the needs and the bureaucracy itself were overwhelming. It was a very process-oriented experience. And I know from listening to you and knowing you a little bit, that this is one of the things that really you want to transform, to liberate the front lines of our country to care for those people in need.

Dr. Mehmet Oz (42:28):

We use the word liberated. I think it's the right way to think about it. We could unlock tremendous potential and we can do it in a couple ways. The secretary, who you're blessed to spend some time with, is a remarkable leader who has put MAHA on the agenda, not just in political campaigns, but intrinsically, it's what we think about now at Health Human Services. And the reason that's important is if you define MAHA the way I do, which is making it easier for Americans to be healthy, and I think that's reflective of what so much of the secretary spoke to you about and has been espousing, and you recognize that those are realities that need to be addressed so that everyone feels they can be on the playing field of life. A lot of moms are telling us that they feel it is harder for them to raise their children healthy than it was for their mothers to raise them. But that's probably chronically the case. Everyone always thinks it was easier for the prior generation and their parents had it easy.

(43:25)
But demonstrably, objectively, there are challenges to raising healthy people today that we have to get our arms around. And that has much more to do with us taking brave action on some controversial topics, which have sometimes moneyed interests that oppose them. And that takes a brave person, so I applaud the secretary for that. He's been a great leader, and I know that's going to take place. It may take a while, but that's definitely going to take place.

(43:53)
But then within the system of how we pay for healthcare in America, we have remarkable levers that we do not use as effectively as we could. And one of the... I went to business school when I was in medical school. I didn't go there and invest my portfolio. I went there for one reason. I knew money drove decisions in medicine. I was curious how it did it. And the graduate course is what I'm in now. It's the best job I've ever had, by the way. It's not just because of the secretary, but it's remarkably talented people come in the government, at least in this administration, and they're not coming there to watch stuff. They don't want to keep the trains running on time. They want to actually fix the problems that many of you appreciate. That's why you're here today. And so the structural abnormalities that hinder our ability to drive value into the healthcare system have been hindered.

(44:39)
But let me come back to this word liberate that you used, because it may be the most important point that we'll both talk about. If we want to unlock the value of Americans, we have to keep them healthy. But what does that translate to in money? You are all aware of the national debt and how every year we're losing trillions more and the interest rates more than the defense budget, all that stuff. But let me just put a number that's a bit more helpful, make you optimistic.

(45:06)
The average American retires at age 61. Obviously Medicare doesn't even hit you until 65. So they're retiring before they're getting their Medicare benefits, before Social Security fully kicks in. If we could get the average American, because they feel healthy, they're vital, they're strong, they have agency over their future, they start working a year earlier, right out of high school, or work a year later, not retire, or work better during their lifetime because they're healthy, it would generate about $3 trillion, $3 trillion to the US economy. That would more than remove the debt. It would provide us unbelievable strength because the taxes on that $3 trillion would allow us to keep Medicare Part A solvent to make a trust fund. It would allow us to make Social Security healthier, tremendous downstream benefits. But to do that, you actually have to invest in making sure people want to work the extra year.

Dr. Mehmet Oz (46:00):

And a major reason people don't take the steps that make objective sense for them or want to leave their jobs early are mental health issues, the purpose of this conference. And we have all kinds of laws and rules that treat mental health conditions, like they're chronic illnesses that makes them eligible for payment and the like, but what we're going to talk about today goes beyond that. Why is it that it's so hard to deal with mental health challenges in America?

Dr. John Sherin (46:24):

Yeah, these are great points. One of the things that I've always led with is the importance of purpose, and we have a population with folks, as you're saying, who have an opportunity and capacity to deliver more work, and why are we not leveraging that? And why are we not leveraging that in the health and human service space? And I would even say particularly in the behavioral health space, as Secretary Kennedy always points out, sponsors, mentors, coaches. In the military community, battle buddies are a critical component not just to navigate, but to provide kinship and help people with their day-to-day lives, and that's not something that we, in the healthcare system, and I say this as a clinician, really give enough attention. The solutions are not all clinical, and the non-clinical arena is very, very important and we ought to be looking for that as an employment initiative as well.

Dr. Mehmet Oz (47:23):

20 years ago with my wife started a foundation that does peer-to-peer mentoring in high schools around the country. We touched the lives of about 200,000 kids a year, it's grown dramatically, put about $100 million into this project. It works, we have objective data. We need more of those kinds of experiments. At CMS, we're looking at models. CMS is Medicare, folks over 65. Medicaid, people who, as Hubert Humphrey has said, are at the dawn of their life, children, 53% of kids are on Medicaid. At the twilight of their life, older folks who don't have money, they go on Medicaid frequently, and then those living in the shadows. Those are the classic categories that are in Medicaid. And all great people take care of their most vulnerable. We're a great nation, we're going to do it as well. That's the ultimate safety net of the country.

(48:11)
We have those two big issues, but the way we innovate often is around these models that we create to get people to come play with us in our sandbox and come up with better concepts, and we have ones that are dedicated to mental health services. We, for example, go into institutions, to places where people are institutionalized, and provide them primary care services. We spend time trying to get folks who have dementia, for example, better tied into the system. We have all kinds of models we're working on, including a MAHA model that will allow multiple folks to be able to get access to support to just figure out what works and what doesn't work. Some of this is not medical, we shouldn't medicalize everything. The value of having some spiritual belief in your life probably is real and significant and hard to replace that. Loneliness is a massive problem.

(49:03)
The last surgeon general's report quantitated it as equivalent to smoking 15 cigarettes a day, which I think that's pretty accurate. The impact of substance use, which is often what you turn to if you can't get other connection in your life and is worsened dramatically by loneliness. If you count lost work days at elect, we're talking about $100 billion a day. Including incarceration, maybe $150 billion. Not a day, a year. These are major costs that we're absorbing, because they're not taking an emotional crisis on head first. And again, I point out the fact it's going to have to be multifaceted. You can't just throw money at these issues. Well, we see what's happening in California and Minnesota and other states when you just throw money at a problem. It's not that the problem's not there, is that throwing money at it allows it to be diluted in its impact, but also taken by people who do the wrong things with it.

Dr. John Sherin (49:56):

Yeah, no, I would agree. Obviously, waste, fraud, and abuse are big challenges, and so is the paying-for-service model where we check off a box, because it was process dealt and delivered in a compliant way, and that may or not impact the outcome of a human being. You brought up a couple of really important things. One of them is this idea of medicalizing our population, and much like diabetes type one and type two, there's a big fundamental difference in terms of the biology, and the type-two diabetes really requires a lot of lifestyle attention in particular, but we don't really think about that so much in the mental health and addictions arena.

(50:43)
And what I would say is, when you do that, when you're focusing on diagnosing someone and getting them a treatment plan and delivering clinical care, when there are other options, you're actually not just disserving them, because that can have its liabilities, but also, you're stealing the really critical clinical resources from the people that I've cared for my whole life in the VA, in the county, in the government systems who are the people who are revolving in and out of hospitals, on and off the streets, and in and out of the jails. I think, in alignment with your vision and the secretary's vision, figuring out ways to go after people suffering from the human condition with human condition solutions and not clinicalizing them are imperative.

Dr. Mehmet Oz (51:27):

Without question, and I also believe that we have created in our culture an expectation that they're, relatively speaking, quick fixes. They come in the form of small pills or injections. They do tend to be expensive and there's lots of marketing around these concepts, and I want to be respectful of the fact that there are incredible advances that have been made in our ability to treat cancers and autoimmune problems and mental health issues as well, but most of these mental health issues are not from a deficiency of some chemical. There's a broader... A problem that is existential for a lot of folks, and a holistic approach will work better. But falling asleep is hard to do, because you don't actually fall asleep, right? You glide into sleep with a ton of effort, and those of you... How many good sleepers are out there? Put your hands up.

(52:15)
There are a couple of there, right? My wife is a world-class sleeper. I just watched this. She'll take nine hours and awake rested and fresh, but that is... Our growth hormone is generated by our sleep, our ability to learn is improved dramatically. Kids who are under chronic stress, their amygdalas don't get the appropriate nourishment, so they don't learn well, which is why kids in these environments, again, we're in schools around the country, it's hard for them to learn, and for that reason, they get held back in other ways. I don't want to turn to medicine to provide all the solutions, but we can provide guide rails, and I do think there are places where we should give treatments that historically have been marginalized. I'll give you a good example. We have two large clinical trials now on dementia, showing that there's either... Well, let's just be conservative.

(53:07)
There's a slowing down or stopping of the symptoms of dementia. We have tests now that are available, like a test called PTAL-217, blood test, you could all get it, that will predict fairly accurately, we believe, that, within 10 years, you're going to have dementia. A lot of mental health conditions start because you stop having... Your complexity management starts falling away. That's probably a better way of thinking about it, I think. Complexity management is something we should enjoy and you have multifaceted, you got to get the kids to school, get folks at work set up. But when you stop being able to do that because you're having cognitive impairment or other issues are going on in your life, you start to get depressed and down, so it turns out that these clinical trials have resulted in fairly attractive findings. If you have lifestyle approaches that are effective enough that you might want to know if you're at risk, you'll take the test.

(53:56)
Otherwise, why would I give you the test to tell you that, in 10 years, you're really in trouble? Most people are not going to welcome that test, understandably. We need to allow some of these ideas that our mothers probably could have told us about to be part of the healthcare system and do it in a way that makes financial sense, because they're based on outcomes. You mentioned this earlier, so I like this. Most of the healthcare system is based on the number of widgets you build. How many procedures do you do? How many patients do you see? It's like a shoemaker. How many soles are you hammering into the bottom of the customer's shoes? Every shoe you hammer, you get paid more, so you want to do as many as you can. If the work's not so great, doesn't last that long, you still get paid, so there's a lot of incentives just to do more.

(54:39)
And what's not appreciated often is if folks who are not noble in their pursuit of the healing art of medicine are allowed to game that system, they make a ton of money, and what do they do with that money? They push the other people out of the business, so they begin to take over like pariahs, or piranas is a better example with goldfish, just eating all the good guys, pushing them out of the way and they take over the ecosystem. It is our job to support those efforts. When good people watch bad people get away with stuff, it's our fault. It's the fault of good people who didn't do much about that, and I've been forced already in my one-year tenure at CMS to take some pretty Draconian actions in areas where we probably could have been more surgical if we just intervened earlier.

(55:27)
But by the time I got here, it's so far gone that you have to burn the whole town down, because you don't know who's good anymore, and everyone's going to run away and, hopefully, the good people will come back and set up shops and rebuild the place, but you don't want to have to do that. We risk that mental healthcare systems if we're not able to appropriately adjudicate what works, support it, but base reimbursement on value. You get someone healthy again who's got a mental health condition, that's unbelievable value to the economy and to the ecosystem and to our morality, so we ought to do that.

Dr. John Sherin (55:57):

Yeah, amen to that, and I think you're right. Investing in the outcomes that we want and that we agree upon is the critical move, because we don't know what we're getting right now. And if we're just checking boxes around a compliant process, we're completely missing the ball, and I think the innovation at the ground level for the people who do the work, and I say this as someone that did street psychiatry in skid row, what we need for those people is not necessarily on the recipe from CMS. One of the things that we haven't had a chance to talk about, because we're running out of time, if you want to make a quick couple of statements, is rural health and the issue of mental health and addiction challenges in our rural system, which is... Well, in our rural communities, who are so hard to provide access.

Dr. Mehmet Oz (56:49):

60 million Americans live in rural parts of this country, we have a way of defining that that's pretty objective. Their life expectancy is about nine years shorter than those in more urban parts of the country. It's massively different, and mental healthcare issues drive a lot of that. We do not have enough practitioners for mental health support in these areas. The Rural Health Transformation Fund is a 50% increased investment over what we currently spend for Medicaid in these rural healthcare systems. It's the largest investment of its kind ever made. And in all the states, 50 states were given a chance to compete for this money, they all got some of it, and a large number of these applications included mental health support systems. But I'm telling you right now, there's no question about it, whether you want it or not, the best way to help some of these communities is going to be AI-based avatars.

(57:36)
Agentic AI, taking the ability to do the intake, just catch the patient, customize to what their needs are, understand what they're up to. Please, go play with these tools, they're unbelievable. They'll pick up subtle little nuances in how you're saying things, if you do it on purpose, it's actually cool to find out, that will alert the avatar, but more importantly, the doctor they're going to report to that there's something going on. When the clinician connects with you... And they will always be a doctor. 50% of our cortex is designed to read the face of the person in front of you. I can look at you and tell you're bored, happy, excited, running away, whatever's... But before you say a thing, and we are hardwired to read each other for that reason. We're social entities by definition, we got to where we are because we're social entities.

(58:20)
The key question is, how do we use AI thoughtfully in that setting? And if we do it right, we'll build a much more sustainable healthcare system around mental health issues. God bless you.

Dr. John Sherin (58:29):

Yeah. God bless you. Well, we're getting the red flash.

Dr. Mehmet Oz (58:31):

I see it. That's a break for commercial. That's what that means.

Dr. John Sherin (58:36):

Thank you. Thanks so much for your time. Thank you.

Tom Koutsoumpas (58:51):

Well, again, thank you all. Thank you, Dr. Oz, for being here with us and your commitment to mental health, behavioral health, and addiction. I also wanted to acknowledge Dr. Oz, as he was talking about fraud and abuse, recently visited a program of ours that we work with in Las Vegas to look and assess at the issues around fraud and abuse in hospice care, which is really distressing. And then went to California and did the same thing, so he's really on the move to address those issues, which we're very, very grateful. We're about to do some chair moving here, and then we're going to welcome our next panel and get out of your way there. Our next panel is named Patient Centric Behavioral Health: Integration, Prevention in Chronic Disease. And our moderator is Deborah Witchey, the CEO of the Association for Behavioral Health and Wellness.

(59:45)
And our panelists will be listed on the screen here, which they already are, with their titles and positions. As soon as the chairs are up here, come on up. It's a big panel. All right. Thank you, thank you. Good to see you, thank you. Hi, how are you? Thank you.

Debbie Witchey (01:00:25):

Well, hello, everyone. I'm going to go ahead and get started as everyone gets seated. I'm Debbie Witchey, as you heard, the president and CEO of the Association for Behavioral Health and Wellness, and we are going to dispense with any biography, so that we have maximum time to discuss our topic. Super excited about being asked to moderate this panel. This is really the heart and soul of what I'm interested in, which is integrating healthcare, so that we aren't talking about physical health and mental health, but we're just talking about a person's overall health and focusing on prevention and functionality and having a really great life. I'm going to sit down, but just wanted to say that this is such an important issue, because when you think about, say, cardiac care, a person who has depression and cardiac care is two to two and a half more times likely to die or end up with rehospitalization after the first year.

(01:01:33)
Think of someone with diabetes, they are more susceptible to having depression if they're also diagnosed with diabetes. A person with serious mental illness is three times more likely to develop obesity, so obviously, brain health and physical health go together, and that's what we really want to focus on. I'm going to kick off by starting with Dr. Bhatt. She's with the American College of Cardiology, so I have the really simple question, which I've given a little tidbit of, tease, but why do we want to integrate care and what happens if we don't?

Ami Bhatt (01:02:12):

Well, first of all, thank you for having me and thank you to the administration for this. I think, first of all, you just think about cardiovascular disease, number-one killer of Americans and absolutely preventable in the majority of cases. If we look at where we're going with the administration now, we have our good friends, Jacob Schiff and Will Gordon, doing access. We have Michelle Tarver at the FDA leading tempo and now, as of last week, we have Heather Warwick, leading advocate through ARPA-H. All of these programs are moving to set up a cardiometabolic infrastructure in the United States to be able to provide care for prevention in chronic disease. It would be silly of us to do that and not think about mental and behavioral health, because what we're doing is we're moving from the tertiary centers and this approach to the end of healthcare and cardiac care to really recognizing we want to move to where the patient is, and we used to call that "The last mile of healthcare."

(01:03:13)
We take care of you in the hospital, we send you home, that's the last mile. We need a reframing. That is the first mile of healthcare. It starts with the patient in their home, in their community, and we need them to engage, and you cannot engage when you are suffering from mental health disorders. To do chronic disease right, we have to say that mental health partners with the physical health to really make a difference, and I think that's why you see so many of us here today who may not do this every day for a living, but it's such a part of what we need to do moving forward.

Debbie Witchey (01:03:44):

Terrific. All right. Dr. Kamal is with the American Cancer Society, and I think, in many ways, cancer is figuring this out. When you think about the standard of care for many people with a cancer diagnosis, they have a team of providers, which may be surgeon, radiation oncologists, oncologists, but they also typically are also given access to a behavioral health provider, a nutritionist and others. What has cancer figured out that maybe the rest of us haven't?

Arif Kamal (01:04:18):

Yeah. Well, we figured some things out. We've got some room to grow for sure. In the US, every 15 seconds, someone is diagnosed with cancer, and importantly, on the other side of that, every day, about 1,000 Americans surpass the threshold of living with cancer for five years or longer. And while we'd like to think that they're all cured, and hopefully that will be the case at some point in time, many of those people will actually be living with cancer, and to the point of needing an interdisciplinary, multidisciplinary team, we've thought about it through the lens of biology, radiation oncology, surgery, medical oncology as well, but the concept of whole person cancer care is still evolving, because we have this wonderful ability now to think of 18 million plus survivors who are living with cancer or living after cancer, but for whom their entire life and trajectory has been completely changed because of the diagnosis they've gone through.

(01:05:11)
And what we find is that, for many people, as was talked about earlier, loneliness, social isolation, major depressive disorder, anxiety disorders and other things, substance abuse disorder as well, are becoming increasingly commonplace, because for some of these issues, they really are a function of time. And oftentimes what we find is that, for people with cancer, they may come out on the other end financially devastated, maybe alone. Many of their relationships may have gone away, so on the other side of that are significant challenges as well. Fundamentally, as we think about nutrition support, as you mentioned, we're still getting there, as it relates to behavioral support. We have to think about payment and access and workforce and really establishing that it is a standard of care no different than having a medical oncologist or other biology-based professionals in your corner as well.

Debbie Witchey (01:06:01):

All right. Next we have Dr. Nordberg with Reliant Medical Group. Reliant has put a big focus on integrating chronic care management and behavioral health. How have you done it and why have you done it?

Samuel Nordberg (01:06:14):

Thank you for the question and for the opportunity to be here. I have the great privilege to serve in a healthcare environment where the vast majority of our payments and our financial modeling is based on value-based care, with behavioral health carved into that value, which means critically that, when you're successful managing the behavioral health of somebody, you benefit both on the behavioral health side and on the medical side in terms of reducing the cost of care and improving the quality of that patient's life. And this is really important, because when we started from scratch, looking at how would we redesign, rebuild integration at scale, we really wanted to make a couple of key things possible, and I'm going to try to illustrate them in a patient story really quickly. A patient came into their PCP telling their PCP they thought they were going to quit their job. This is a patient with a 30-year career as a paramedic, is now a leader of paramedics, a trainer of paramedics, and had started having panic attacks. And the PCP tried to gauge whether they knew what to do, the right medications, and decided they were out of their league, so they went into the medical health record and they pushed a button that said, "I need behavioral health right now." And in less than three minutes, one of my people, an integrated clinician, was in the room with the patient and the PCP. They had a brief conversation, my person then pulled the patient into another room, gave them a tablet and said, "Would you please complete some questions for us? Because it's going to help us figure out how best to help you."

(01:07:51)
They then reviewed the results of that tablet together and they learned that what was really going on was that the patient had post-traumatic stress disorder, and that's what was driving the panic. And that integrated clinician knew immediately, from the 40-plus different treatment lanes and options that they had available to send this patient into, exactly where that patient needed to go. They came into our trauma team and they came to me, because ever since my own experiences with trauma on 9/11 and the World Trade Center, I have made that my central focus clinically, in terms of how to treat it, and he and I got to work. Because we got to it so early, because we got to it in advance of him leaving his job, in eight weeks, we were able to do the work necessary for him to make a couple of adjustments, both up here and at his workplace, so that he did not quit his job.

(01:08:43)
He found himself in a place where he was able to accept some of the things that had happened to him in the past and where he was able to feel afraid... Forgive me for a second because I'm pulling this out. He was able to feel afraid, but not let his fear stop him from doing things.

Samuel Nordberg (01:09:00):

... and as we ended, he gave me this challenge coin. If you're in some of the services, you'll know the challenge coin. This is one that says, "Fear is a reaction. Courage is a choice." This illustrates a couple of key things about integration. First and foremost, be shoulder to shoulder with primary care, but do not overburden them. You have to pull patients when they need to be pulled. It's the first critical piece. Second is timing. It has to be fast. You have to operate at the pace of primary care, and you have to operate at the pace that a patient needs when they've finally had the courage to come forward and tell somebody that they need help. They don't need help in four weeks or three months. They need help today. So that patient was scheduled to see me within 48 hours of voicing their need to their primary care.

(01:09:56)
Third key piece, data. Data and the collection of data must become a clinical skill. You must build it into your clinical model such that there is no distinction between data that we collect and the clinical work that we do. And when you do that, you will find that data collection becomes routine, and then you are able to actually do a lot of the research that we do and publish on things, because the data was already built in. It wasn't special. It wasn't an administrative task. And then the last piece is none of this would work... We wouldn't even gotten it off the ground in a fee-for-service environment. So that value-based payment, that longer-term payoff, and the medical behavioral payoff jointly contributing to contribute to that ROI, that's critical for integration to work.

Debbie Witchey (01:10:45):

Yeah. I often say if a person's having a heart attack, you don't make them wait to see a specialist, you get the cardiologist there right away. And behavioral health should be the same. So good point, and great story. All right. Dr. McGinn, CommonSpirit, integrated delivery network, 30 states, I believe, and growing probably.

Dr. McGinn (01:11:04):

Yes, yes.

Debbie Witchey (01:11:06):

Rural, urban community-

Dr. McGinn (01:11:07):

We'll say 24 for now, and not up to 30. Soon.

Debbie Witchey (01:11:11):

Okay. Well-

Dr. McGinn (01:11:12):

Urban.

Debbie Witchey (01:11:12):

... growing to 30. And rural, urban. So very complex to try to build an integrated delivery network with all of those in such a broad area, but also very different populations of people. So how did you do it, and why did you do it, and how is it going?

Dr. McGinn (01:11:30):

Yeah. Well, first of all, thanks for the opportunity. CommonSpirit is in 24 states. We're in 30 communities. We have everything from critical... We are the largest critical access provider in rural healthcare, and we're also the largest Medicaid provider in the United States. We have one of the largest value-based programs, with 2.5 million patients in our programs across the United States, and we're a faith-based organization. And we've come to this conclusion that integrated delivery care is the best thing for both the bottom line and for the care of our patients. And at some point, you just have to come to that realization that we want to be with the patient throughout their journey. And that journey, a small piece of the journey is in the hospital. Some of it's at home. Some of it's in their clinics and the primary care clinics throughout the whole journey.

(01:12:19)
That's key to our success, and behavioral health is front and center to that success. We have four tenets. One is you got to screen, and you got to screen early. Then you've got to enable access. Then you want to address the quality of the behavioral health, because there's a lot of healthcare out there. Behavioral health in particular is vulnerable to poor evidence-based care. Navigation is a key to our success in this space. Across all of our primary care clinics and all of our emergency rooms, we're screening for addiction, depression, and anxiety. We then have a group that we work with and we've partnered with where we've elevated the care in our primary care clinics. I am a general internist primary care provider. I've been caring for chronic illnesses my whole life, and behavioral health is the first thing I think about if I'm going to manage diabetes, hypertension, and heart failure.

(01:13:11)
So we have trained our primary care providers in partnership, and we do warm handoff to the community providers. So it's screening early, then it's access to treatment. It's also quality in the evidence. And we also have navigation programs. So if somebody's acutely ill in our clinic or in our ER, they get navigated right away, particularly to addiction issues. You need to address those quickly. These are automated programs. Some of these are done automatically. Some of these are phone calls at home, some follow-up issues, but you have to be able to look at all of these issues together. I have treated patients suffering from diabetes, hypertension, hypercholesterolemia, heart failure. If they're suffering from depression, none of those are going to get treated. None of them are going to get treated. Because if you don't address that underlying problem... CommonSpirit, it's about integrated delivery care across the continuum and weaving behavioral health into everything that we do, and it's mission central for us.

Debbie Witchey (01:14:14):

Terrific. All right. Tim, you are next, and Secretary Kennedy actually touched on the question I want to ask you, which is that we need to properly incentivize integrated care in order for it to work. And Sam also spoke about this. So how is that done? How do we measure, how do we successfully incentivize care delivery so that we are looking at success and outcomes and quality?

Tim (01:14:45):

Yeah. Well, first off, thank you for the opportunity to be here. And I got to say it's a little intimidating to follow four national clinical experts as a non-clinician, but mostly-

Dr. McGinn (01:14:53):

You'll do fine.

Tim (01:14:54):

Yeah, thanks. I appreciate the personal stories that you've shared, because it's so important as individual examples that are just so important not to lose as we think about the system. And for me, working at Optum, I have the opportunity to work across the system with many providers, many payers, and the good incentives really depends on good measurement. And the challenge that we have with mental health in the United States, while we have really strong evidence, and the evidence is very clear on what works, as you said, the evidence isn't always deployed consistently across care delivery. So we see a lot of variability, and that makes things incredibly challenging to measure.

(01:15:34)
Now, we are doing some incentives today. We generally tend to focus on simple process outcomes, simple to measure, not necessarily simple to deploy. So things like follow-up after hospitalization or access to care, medical adherence, these are all incredibly important, but we're really not to the point where, at scale, we're fully incentivizing the outcomes, so actually seeing improvement from an individual over time measured in a consistent way. So from where we sit, I think there's a couple of things that as an industry in partnership, collaborating, we really need to get after. One is ensuring that we have really strong standards that are deployed in a way across the system through clinical pathways that enable clinicians to make it easy for them to do the right thing. Delivering care is incredibly difficult. So how do we make it easy through clinical pathways? We're doing some really exciting work on that with a number of partners who are here today.

(01:16:32)
Second is making sure that we have data moving across the system so that we can see what works, what doesn't. That needs to be bidirectional, so not just to the managed care organizations, but to the providers as well, to the individuals who are actually delivering care in real time. The measurement, which not just at the beginning of care, but continuously, so that we can adjust and make sure that individuals are getting the right level of care as their needs change. And all that I think is what enables payment and different types of incentives. So bundles we've talked about, value-based care. All of this is really critical to ensure that we can tie the activity to real outcomes, and that's only going to happen if we work together. So excited to be here today and really continue to support that.

Debbie Witchey (01:17:18):

Thanks. All right. Now we have Dave Merritt with Blue Cross Blue Shield Association. Dave, you're probably going to build on what Tim just said, but my question is similar for you. We are seeing health plans focus more on looking at what are the outcomes in behavioral health, what does quality look like, how can we deliver the best care possible for patients, whereas the focus, as opposed to quality access, was just basic access a few years ago. So what is that change about, and what are plans doing to help drive that forward?

Tom Koutsoumpas (01:17:51):

Yeah, thanks for the good question. And thanks to Secretary Kennedy, Administrator Oz, and Action for Progress for leading on this issue. Blue Cross Blue Shield companies, we cover, serve, and support 120 million people across the country, so every state, every zip code, and mental health support is absolutely essential to the coverage that we provide. According to our claims data, one in five adults either have a diagnosis or have a condition that needs help. Half of all kids have symptoms of depression. When you think of social media and addiction and just getting through COVID... And politics alone is enough of a reason to drive you to seek care many days. But that's why we are expanding access and why we have a central role to play to expand access. Over the last five years, we've actually grown our behavioral health network by 55% across the country, where the Blues are now the largest behavioral health network in the country.

(01:18:54)
The reason why is because you do need to have that initial support wherever you enter the system. And it's really great to hear the coordination with primary care. Primary care actually deserves a huge shout-out. They have been, for all intents and purposes, the front line in the mental health crisis. According to our data... I want to make sure I get this right. According to our data, one in four mental health diagnoses comes from a primary care provider. So that's nurse practitioners, internal medicine, pediatricians. In fact, for kids, 41% of all diagnoses in our network come from primary care providers, and 38% of our members are treated solely by their primary care physician and primary care provider. So that initial access is absolutely essential, and we coordinate with and complement those efforts with over 250 individual programs addressing youth mental health across the country.

(01:19:51)
We have a huge $10 million partnership with the Boys & Girls Club of America on a youth mental health initiative. And the reason I say all that is because it has to be integrated, it has to be coordinated, and it has to be an all-of-the-above strategy to give access to the people who need it. And we, like Optum, are focusing on how that coordination integration is most effective, and looking at outcomes, looking at evidence-based therapies, making sure that the specialists and those primary care providers are coordinating. We have a Blue Distinction Center. It's a centers of excellence across a number of different specialties, but one of them is around substance use treatment and recovery. And because of that coordination and looking at quality outcomes, we've actually seen a 27% decrease in readmissions over 90 days through those programs. So really effective and highly efficient, with spending actually becoming lower. So we think it's all of the above, primary care and integration really essential to everything that we do.

Debbie Witchey (01:20:57):

Terrific. All right. We have time, I think, for one last question, so a little bit of a lightning round. Not too much, but we have eight minutes. So you can only pick one. Looking forward five to 10 years, what is the single most important component from your perspective that's needed to ensure successful integration of behavioral health and physical health? And we'll start at the other end this time. So Dave?

Tom Koutsoumpas (01:21:27):

It's a great question. Secretary Kennedy touched on it. I really think it is an all-of-the-above approach, whether it is nurse practitioners, primary care, using technology and AI, things like telehealth. We were very happy to see that the Congress is extending that flexibility. If there was one good thing from COVID, it was probably telehealth becoming routine. And so I think it really is an integration of the technology with the physical providers, and having that system of health to meet that patient wherever they are and wherever they enter the healthcare system. They have to be cared for very quickly and then passed along to others and coordinate that care.

Debbie Witchey (01:22:11):

Terrific. Tim.

Tim (01:22:13):

I agree with everything you said, and I think I would add the integration and the connectivity across the system. We've got to close the daylight between physical, mental, social, and the way we do that really is through data, through technology, but also alignment and collaboration across the system. And so it's incredibly important, and I think find a lot of value in starting that here.

Dr. McGinn (01:22:44):

So I'm going to give you multiple answers. Sorry, I'm going to cheat.

Debbie Witchey (01:22:47):

I knew someone would.

Dr. McGinn (01:22:48):

Yeah. I think that I agree with everything that was said. I think if we don't get the parity issue taken care of in terms of paying for this care... And there's a lot of unfunded elements of this care. There's navigation. There's the virtual components to it. There's care at home. There's a lot of things that we need to look at that we're not really reimbursing, but I do think fragmentation is the number one enemy that we have. Patients move from one thing to the next. And how do we have a fluid continuity? At CommonSpirit, we want to know we're with you the whole journey, and behavioral health is going to be with you at every piece of that journey. Whether you're in heart failure, getting hip replacement, getting cancer treatment, we're going to know from the minute you're in the hospital, outside the hospital, and behavioral health is going to be integrated into all that pieces.

(01:23:33)
So patients feel you're with them the whole way. Right now, it's like, oh, you have this ASC over here, or you go to this acute care center over here, or you go to this over here, and every time you go, you're telling your story again. They want to know that you know your whole story, including your behavioral health. Top of the list, behavioral health. Nothing else works if that's not working.

Debbie Witchey (01:23:56):

Terrific.

Samuel Nordberg (01:23:59):

[inaudible 01:23:58]. Agree, agree, agree, and-

Dr. McGinn (01:24:01):

If you start down there, you can agree with everybody and add on.

Samuel Nordberg (01:24:06):

And what I would say is integration is remarkably hard. Even when you create the incentives to do so, there are still massive change and implementation-related barriers, and what we need are more learning health systems like Reliant that can provide early indicators of what works and what doesn't. We need more published work on the real-world application of research and guesswork and seeing what sticks in the real world. To build those learning health systems, what we need is precise data. We need data and measurement that is as complex as our patients are. That means we need a revolution in how and what we measure in our patients. In order to do that, we also need a revolution in how clinicians perceive measurement.

(01:25:04)
Right now, most clinicians perceive measurement as an administrative burden imposed upon them. We need to flip that. Clinicians need to see the tremendous value that measurement can add to their clinical practice, making them in fact better clinicians. And there's a wealth of research on this that is poorly disseminated. So those are some of the key components if we're really truly going to execute on the remarkably complex logistics and change management of integration that have to happen.

Debbie Witchey (01:25:35):

Dr. Bhatt.

Arif Kamal (01:25:38):

I think when people think about cancer, it's tempting to describe it as an abnormality of biology, but the reality is in the last 30 years, mortality for cancer has gone down by 34%. And where we're left is the other things, the other B, the basics. The basics are relationships, their purpose, their nutrition, their feeling of connectedness. And when you look across the cancer continuum of why better things aren't happening, from prevention to early diagnosis, screening, survivorship, you will find a pull-through of behavioral health challenges that challenge people as they're trying to thrive from going from one stop to the next.

(01:26:13)
We know that fundamentally that we do team-based care in cancer pretty well, but these things around mental health support and so on have been seen as an add-on, an extra, a nice-to-have. And fundamentally, for us to continue to close that mortality gap from 34% to a number much higher than that, these have to go from nice-to-haves to have-to-haves. And fundamentally, at the end of the day, everyone with cancer, and their caregivers and the survivors and the people they love, should be able to count on equitable access to behavioral healthcare no matter where they are in this country or who their insurance provider is.

Debbie Witchey (01:26:47):

Now Dr. Bhatt.

Ami Bhatt (01:26:50):

Oh, gosh. We don't have enough clinicians, and we have more and more patients. And that's not going to change in the next five to 10 years. I wish it were. It's not going to. And so I'm going to say those words which are said in almost every panel nowadays. We need the digital health and we need the AI. We need it, because there's not enough of us, and there's too many people to be cared for. As we do that, I think there's three different ways to do it.

(01:27:22)
One is we think of ourselves as clinicians, doctors, nurses, but actually, if we just open the aperture and think of how many people consider themselves caregivers, if we include rural America and community health workers, and we could use AI, digital technologies to help upskill people to triage better, help catch that patient early on in their journey because we help them get the knowledge they need, not for exquisite care that takes the 35 years I trained for, but just, "Are you sick or not? Do you need attention now or not," we can use AI and digital technologies to really expand the number of caregivers we have.

(01:28:04)
Then I think the second part is if you actually look at providing care for people... And this is scary, but I'm going to say it. Think about the teenager who has anxiety and eating disorder. Think about the postpartum mom with depression who's at home in her bedroom, and then going to the baby's room. Think about the active businessman who thinks he has ADHD because everyone says so, but actually, it's anxiety and OCD, and the treatment for that is completely different. Or the elderly person, like my grandma, where we don't know is it depression or is it loneliness. All those people are seeking help on their own, because people are providing mental health chatbots. They're providing companions. And so the industry and the consumer industry is bringing these digital and AI technologies straight to our patients, and I think we have to take the responsibility, as people interested in building healthcare systems, as clinicians, to say we are going to help build a version of that system that empowers our patients.

(01:29:03)
And so it's scary, but it's even more scary if we don't go there. So I think we need digital health and AI to empower our patients and to empower all the people who call themselves caregivers. And if we do that, then I think in five to 10 years, we're going to see a model that works not only for mental health, but for everything else that we care for right now.

Debbie Witchey (01:29:22):

Terrific way to close. I think what we've heard today is that everyone is very aligned on what is needed and what we need to do. We are starting to see some progress, and the important piece moving forward is that we all are... need to work together, meaning all, to drive this forward. Because I think we all see the same vision that is this integrated care delivery system where we're not talking... Someone said to me earlier, "I'm going to be so happy for the day when we don't talk about brain health and physical health in separate boxes," and amen to that. So thanks so much for the time, and thanks so much to the terrific panel. Let's give them a round of applause. Thanks so much.

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