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COVID-19 is a one-in-a-generation type of event; the last time something like this happened was literally 100 years ago. And no matter how much we know it's a possibility, we can never truly be prepared for it. The effects will likely be long lasting, especially, and not just in terms of physical health, but our mental health as well.
On Wednesday, Vator, along with HP and UCSF Health Hub, held its second virtual salon of the year, centered around mental and behavioral health, in which representatives from different corners of the healthcare industry discussed some of the things they are doing to help prepare the mental health space for coming onslaught of people affected directly, or indirectly, by COVID-19.
The panel was moderated by Dr. Archana Dubey (Global Medical Director, HP Health Centers, HP), and Bambi Francisco Roizen (Founder and CEO, Vator), with speakers that included Dr. Clare Purvis (Director, Behavioral Science, Headspace), Billy Deicht (Investor, Oak HC/FT), Dr. Todd Czartoski (Chief Medical Technology Officer, Providence Telehealth) and Eva Borden (Managing Director, Behavioral and Medical Solutions, Cigna)
Francisco opened up the session by mentioning a recent article which talked about the potential for a "silent pandemic" of mental health problems that could sweep the country as a result of the virus.
"I think the authors were concerned that as we move out of this current normal into a new normal of uncertainty, there’s going to be a number of cases of stress and anxiety. I wonder if our mental health system is prepared for that," she said.
Borden spoke first, noting that the need for timely and easy access to behavioral and mental healthcare is not a problem that has just come up before of COVID-19
In fact, she said, Cigna had been doing its own studies on the effect of isolation before COVID even arrived on the scene. In one study, which was done in 2018 and then again in 2019, Cigna traced the percentage of people who declared that they felt lonely, which rose seven percentage points to 61 percent in 2019. And the effect was even worse among people who worked remotely.
"We had this situation happening before COVID-19, now imagine that we’ve isolated people, many are working from home, and now there’s added anxiety, stress, in a number of different areas," said Borden.
"How do I think this has practically changed my day job? I would say from a beneficial perspective, the demands of COVID-19 have largely accelerated Cigna’s strategy of getting our customers access to timely behavioral healthcare."
Borden identified three trends that have accelerated its behavioral health strategy, the first being that push for virtual behavioral care.
"It was something we already believed in, and now this simply accelerated the adoption, which has been great. Next is expanding adoption and coverage for getting that emotional counseling; I don’t need to wait for visits that are going to diagnose me with depression and anxiety but they are visits that are available just to help deal with emotional concerns that you have," she said.
Finally, the acceleration has come from an increase in the access and availability to digital tools.
"I may not be someone who wants to have, or can even right now, have a face-to-face conversation with someone, or I may not be ready to do that, but there are digital tools out there."
Deicht spoke next, giving the investor perspective, noting that, "In every way, all of our companies have felt the impact of this, obviously, as well as the people at my firm."
"We are seeing that many of our companies are providing healthcare solutions right on the front line of the COVID-19 crisis, and those could be primary care folks or folks delivering care at home or some of the behavioral health providers," he said.
While many of them have been focused on it defensively, meaning managing headcount and managing expenses and cash preservation, there’s also what he called, "an offensive focus on how they can be nimble and innovate on their product."
"I would say, overall, this crisis is a bit of a galvanizing moment for our management teams to persevere and prevail as a team, and I think we feel confident that they’ll emerge stronger from the crisis, but there’s a lot of adapting," said Deicht.
He also agreed with Borden's point about virtual healthcare being accelerated as a result of the COVID-19 crisis.
"There was all this talk about well, ‘We have to do this or we have to do that.’ and now it’s, ‘We have no choice, we have to launch the product,’ and they’re launching it and it’s working. It felt riskier. ‘Should we launch it? Should we invest behind virtual care?’ Now it’s, ‘We have no choice because it’s the only way we can see our patients.’ It’s forcing these companies to innovate, and it’s really paying off. It’s been interesting to see; there have certainly been hard choices that have had to be made, but I think there have been some silver linings for many of our companies."
Purvis also echoed something one of the points that Borden made.
"As a clinical psychologist, its long been known in our field that mental health and social isolation, these are long standing issues, these are not new problems," she said. "One thing to think about that’s happening is, given the significance of the global crisis that we’re going through, these chronic and acute stresses are activating some underlying vulnerability for a really large segment of the population, and it’s introducing new stress to all of us."
Many people have what Purvis described as "an underlying biological and/or psychological vulnerability" which can mean depression, anxiety and addition. They can be triggered by the person's environment, which activates that underlying risk.
"A common way of explaining this is that biology may load the gun but the environment pulls the trigger. So, when we think about this changing context that’s going on in all of our lives globally, the COVID-19 crisis has disrupted a lot of those healthy routines and social connections and it’s really a significant risk factor worldwide for mental health problems," she said, explaining that some of the consequences could "persist long after this pandemic has stabilized or passed."
Some what Headspace is doing to help people in the moment include making sure that more people have access to the platform by working closely with global NGOs, health systems, and government officials. It has also created a special, curated set of content that is freely available, called Weathering the Storm, which is meant to help people buffer stress response and alleviate stress.
When Czartoski answered, he started by talking about the uptick in virtual visits that Providence has seen since COVID began: in 2019, the company had 100,000 face-to-face virtual visits for the year, so about a little under 300 a day. By the third week in March of this year, it was seeing over 10,000 visits a day.
The company launched its virtual behavioral health product last years, after the company's own health plan came to it and said, "We don't feel like we’re doing a great job of caring for our own providers and caregivers, particularly when it comes to stress and burnout. You’ve done all this stuff in telehealth, can you build us a platform for behavioral health?"
It launched in June of last year and one thing that was surprising, Czartoski said, is that over 20 percent of the people using the service are physicians, a group who Czartoski says "are notoriously difficult to get to ask for help."
"Part of the trigger for this was we had some suicides; we had burnout scores of 50 to 60 percent, just like the rest of the country, and that seemed to be getting worse, not better," he said, noting that a big issue was how long it took to get an appointment before the program was implemented.
"On average, our response time was about eight days to when you could to someone. If you think about being in crisis, or having a really bad shift in the ICU or the ED, and the response is, ‘We’d love to talk to you, the first availability is eight days from now,’ you can imagine why our scores weren’t great and why we felt like we weren’t addressing the need, so we were able to reduce that down to zero days. By launching an on demand service that’s led by counselors, not psychiatrists, as the tip of the spear, we were able to see about 65 percent of patients same day or caregivers same day, and essentially 100 percent within 48 hours, based on their preference."
Referring back to the article she previously mentioned, Francisco said it sound like it "would be inaccurate based on the conversations here, where it sounds like everyone here has been pretty much prepared and the technologies you’ve have had in place, they’re just now being utilized more."
She then asked the panel to talk about some of the stressors that they are seeing in their respective spheres, including among physicians, as well as startup entrepreneurs.
Borden again spoke first, and talked about a partnership that Cigna has with Express, which allowed the company to look at how has its pharmacy utilization changed as a result of COVID-19.
"For the five years prior, from to 2015 through 2019, there was actually a decline in anti-anxiety medication, and anti-insomnia medication, of 12 and 11 percent respectively. Over a five year time period, we saw these drugs decrease; in one month, from mid-February to mid-March, we saw a 34 percent increase in anti-anxiety medication," she noted.
There are three groups that Cigna helps from a stakeholder perspective, Borden said, the first being its customers, who have problems that can include needing to get virtual applied behavioral analysis to treat their child's autism, to people who are in situations that involve domestic violence, to people who are simply worried about having enough food.
"A very common one that happened early on was AA and NA, making sure that there were virtual meetings. It's just the cultural pieces of those stressors. It wasn't, ‘I need therapy,’ it’s, ‘How can you help me, with all the things I was already accessing, how do you help me get into a virtual care setting?’ That was one of the early things we saw from customers," she said.
The second group are Cigna's clients and employers, who started out by making sure people are still covered by virtual care, and who are now asking how to help stressed out workers who have been laid off or furloughed. Finally, there are the healthcare providers themselves.
"We had one hospital that was on the front lines and called us and said, ‘We need your help now. Our physicians are showing signs of PTSD and we need help now.’ One of the most important things we can do is make sure they knew we have coverage, access to counselors 24/7 365; you do not need to wait, you can pick up the phone and get help right now," said Borden.
"When I think about the stressors, a lot of these things, like Claire was referring to, can show up in behavioral health needs, but we’re finding very base level needs that are showing up between our customers, clients and healthcare providers."
Czartoski added that Providence is also seeing a lot of PTSD in healthcare workers, and blamed it on the nature of the disease itself.
"Dying from acute respiratory distress, respiratory failure is not a pleasant thing, and for front line caregivers, nurses and physicians, seeing that multiple times a day, day in and day out, just takes a toll. Lack of PPE, stress around not having enough masks and protective equipment has been a big stressor," he said.
To help alleviate some of those concerns, Providence has been able to cut down on the use of PPE by 50 percent per hospitalized day, per patient simply by giving people iPads, which means having fewer people going into the room, including nurses, so they aren't using a new set of gloves, gown and mask every time they want to talk to a patient.
"We can connect better with patients by using a virtual visit from outside the room, when I’m not wearing a mask and I’m not wearing a gown, and I don’t look like an alien. If you’re sitting in a room by yourself, day in and day out for a week, 10 days straight, and the only thing you see if someone who’s in protective equipment head to toe, it’s a very isolating feeling. So, provisioning them with a tablet, and the ability to connect with family members and their nurse, who’s on the other side of the wall, but is not covered in protective equipment, can actually really help that sense of isolation for these patients."
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