Behavioral Health Hot Topics

Gerald (Jud) DeLoss, CEO, Illinois Association for Behavioral Health, Tania Archer, Counsel, Moore & Van Allen, Allison Petersen, General Counsel, INTEGRIS Health, and David Shillcutt, Partner, Epstein Becker & Green, discuss hot topics in behavioral health, including trends in managed care behavioral health, federal and state funding for behavioral health, and school-based crisis programs. Jud was Faculty Chair, and Tania, Allison, and David were members of the Faculty, of AHLA’s new course, Behavioral Health Law & Compliance 101. From AHLA’s Behavioral Health Practice Group.

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Transcript

SPEAKER_03: 0:00

Thank you.

SPEAKER_00: 0:27

Welcome to today's podcast, Behavioral Health Hot Topics. My name is Jud Delos. I am the CEO of the Illinois Association for Behavioral Health. I'm also on the AHLA Board of Directors. Previously with the Behavioral Health Task Force, I'd like to make a quick shout out to a great resource that AHLA has recently introduced, Behavioral Health Law and Compliance 101. It's an online course. It's designed for attorneys and other professionals that are new to behavioral health. There are 15 modules that you can review at your leisure, at your speed, and learn more about the behavioral health field and the requirements, regulations, nuances of behavioral health as it relates to the rest of the healthcare world. I'd like to turn it over now to Tanya to introduce herself.

SPEAKER_02: 1:20

Thanks, Judd. Appreciate that. I am Tanya Archer, counsel with Moore and Ben Allen in Charlotte, North Carolina. I'm on our litigation team, but previously served as a compliance director for a community health center. So my practice focuses on financial regulatory and healthcare compliance.

SPEAKER_04: 1:40

Everyone, my name is Allison Peterson. I'm general counsel for Integra's Health, which is a large charitable health care system located in Oklahoma.

SPEAKER_01: 1:50

And I'm David Shilcott. I'm a partner at Epson Becker Green. We're a national law firm that focuses on health care and labor and employment. I do a lot of work in behavioral health, managed care, and regulatory compliance, as well as being the vice chair of the behavioral health practice group for AHLA.

SPEAKER_00: 2:09

Very good. I think we'll kick off our first topic of conversation today, trends for managed care behavioral health. David, what trends are you seeing in how managed care companies are responding to behavioral health service demands and delivery changes?

SPEAKER_01: 2:29

Yeah, you know, one of the first questions or most common questions that I get these days is what the impact of the mental health parity law is both at the federal and state level. And while we see a wide variability among states in terms of how they are overseeing and enforcing mental health parity, I'm not seeing a lot of impact on patients at this time. I'm not seeing a lot of impact of parity enforcement per se. That said, there's a lot of parity adjacent laws, I would call them, that are driving more changes to coverage and service delivery. You know, one of the simplest types of laws that we're seeing increasing amount is just prohibitions on things like prior authorization for mental health and or substance use disorders. You know, one thing that I like about these kinds of laws is that everybody knows what they mean. And so the providers, the patients, the payers They're pretty clear about what's required, and payers tend to comply with them. They tend to increase utilization. In many cases, that is a good thing. I think not all utilization is equally good, but they are certainly improving access. One of the overlooked downsides, I would say, for providers is that it tends to shift payer behavior towards retrospective reviews, recoupments, fraud, waste, and abuse-type strategies, those can really put more risk on providers. And so, you know, you win some on the front end, you lose some on the back end. Behavioral health providers in particular tend to be smaller. They tend to struggle more with those types of interactions with payers. And so it's an unintended consequence, I would say, maybe not fully unintended, but it is a consequence to watch out for and that needs to be planned for in states that are passing those types of laws. A related requirement with regard to utilization management that I would also characterize as still sort of, I think we're still determining what the real impact is going to be, is the trend towards requiring gold carding for prior authorization and other forms of utilization management. So for providers that meet certain criteria, then you're not required to get the prior authorization or maybe even concurrent reviews for certain types of services. The impact of those laws on behavioral health, I think, has been muted in most cases because they tend to come with criteria like having an approval rate above a certain threshold, like you might have to have more than a 95% approval rate for your authorization requests. They also might have utilization volume minimums. And so you have to be seeing a certain number of the payer's patients in order to qualify. And again, because behavioral health providers are often smaller, as well as the sort of inherent subjectivity of a lot of the criteria for many behavioral health services means that denial rates are often a bit higher. It can be harder for behavioral health providers to meet those very high thresholds to qualify for gold carding programs.

SPEAKER_04: 5:53

Hey, David, I would just offer that even for behavioral health providers that aren't smaller, so like within my health system, behavioral health services are often isolated, unintentionally even, where our billing departments, our coding departments, the majority of their resources are focused on our larger service volumes. And so you have to have those subspecialists who can really seek out the opportunities where we can be getting a higher return on our billing or a higher return on our prior authorization practices. And oftentimes it takes work and focused attention on your behavioral health departmental leadership for them to even know who they raise the flag to or who they interact with when there is a problem like what you're describing in the rules changing with how you're interacting with payers. So I think it's a unique problem that can run the gamut on size even in a complex health system environment.

SPEAKER_01: 6:55

Yeah, that's a really great point. Another sort of gloss on that is that the gold carding requirements often apply at the practitioner level. And so, again, the volumes may not be adequate to meet the thresholds for gold carding. So interesting concept, but I think the impact for behavioral health has been muted. Another area that we're seeing a lot of interest in among states is these emerging requirements for the payers to use authorization criteria, medical necessity guidelines that align with or constitute generally accepted standards of care. It's a really interesting concept. I think this is, we first started seeing this at a national level with the WIT v. United decision where the plaintiffs alleged that United's coverage guidelines did not align with generally accepted standards of care. One of the biggest questions for me is still, what is a generally accepted standard of care? The WIT court articulated 12 or 13 principles But that decision is the only place that I've ever seen those principles collected as such. Many states are simplifying it by specifying specific guidelines for behavioral health, either explicitly saying something like the American Society of Addiction Medicines guidelines, the ASAM criteria. or the LOCUS or CALLOCUS for behavioral health, those types of guidelines. And in other cases, they're saying national nonprofit provider association guidelines. Some of them, I think, work pretty well, especially where we see a trend of some of the third party vendors of medical necessity utilization management platforms incorporate those guidelines. So like MCG and Interqual are now incorporating some of those guidelines into their platforms and where that's getting integrated. I think it works pretty smoothly. But in other cases, it's not clear what the generally accepted standard of care should be. And for the purpose, one of the concerns that I have, a point of ambiguity that I don't see anyone really resolving at present, is that the purpose of the provider association guidelines is generally oversimplifying somewhat to set a floor or threshold. You need to do at least this much. Your services need to be at least intensive enough to avoid malpractice because that's what this comes out of is malpractice. This concept of generally accepted standard of care. It's malpractice if you don't do at least this much, which is sort of the converse of what managed care is set up to do, which is to say, you know, Everybody could benefit from more services to some extent. How much is too much? And, you know, given limited resources. And so I don't think there's an easy fit when we talk about things like urine drug testing. You know, I don't know what the generally accepted standards of care is for a ceiling. I know what it is as a floor. And so, you know, how it's not clear. I don't think how states are interpreting that.

SPEAKER_00: 10:18

David. Here in Illinois, we've for several years, actually prior to the WIT decision even, utilized the ASAM criteria, but it was more focused on the patient placement criteria rather than the generally accepted standards of care that you mentioned. So I see... The kind of the tension between the two and your comment, I think, rings true about the fact that it does set a floor in terms of standard of care. I think there are opportunities for providers to meet those standards, obviously, to utilize the patient placement criteria so that the individual is placed in the correct residential outpatient detox setting, etc. I'm just wondering if that might also open up an opportunity, as you mentioned, there's a floor, there isn't a ceiling. Could that somehow tie into more of a value-based care reimbursement model? Utilize better outcomes, better quality care, etc.?

UNKNOWN: 0:00

?

SPEAKER_01: 11:22

Absolutely. I think everybody hates utilization management to some extent. And value-based payment methodologies are certainly one of the better, it's hard to call anything a best way out right now, but certainly one of the better ways to try to align incentives between payers and providers. We're definitely seeing a growth in interest there. There's still data issues in terms of just having enough information to design those value-based incentives appropriately. There's volume issues for behavioral health providers being able to take on sufficient financial risk for it to work appropriately. But where we can set those up, I definitely think that is one of the better outcomes. Level of care determinations are, I think, the area where this concept works the best. to the extent that you have a delivery system that has the appropriate levels of care. Another challenge there is just that intake interview is not always reimbursed appropriately or adequately. And to do the ASAM criteria appropriately, that is a really long, intensive interview. And I think that a lot of payment methodologies, especially in a fee-for-service type setting, are not adequately compensating providers to implement the criteria with fidelity. So that's another area where value-based can really help to improve implementation. Shifting finally to out of network utilization, this is another network adequacy and out of network utilization. This is another area I think that we see a lot of frustration from patients around the country. Probably everybody knows somebody that has had trouble getting an appointment for a behavioral health or addiction treatment service at some point. And then the question is, you know, what sorts of policy solutions should we be following to address this? Mental health parity has maybe promise that is yet to be delivered on, mostly because we still don't have really clear guidelines about what constitutes comparability for network access. You know, I really am hoping that academia and think tanks are going to help us think about better network adequacy standards that could be applied, not just to MAPIA, but also directly through state law. Time and distance standards are not really adequate. Provider to member ratios are really inadequate. They don't really get at the individual level that the types of information that we need to make sure that most members are getting access, appropriate access. One interesting approach that I'm seeing in some states is just a mandate to cover out-of-network services on an in-network basis if no in-network provider is available. That can be labor-intensive to implement, and a lot of, I think, is still to be determined about the extent to which providers and members are able to advocate for themselves effectively. effectively to avail themselves of those requirements. But I think it's an interesting approach that intuitively makes a lot of sense. somewhat more blunt force version that I saw in New Mexico is that there's a governor order to just require all out-of-network substance use disorder treatment services to be covered on an in-network basis. Predictably, that drove a pretty significant spike in out-of-network utilization. The question for me that I haven't seen fully untangled is how much of that is just shifting from in-network to out-of-network. I think a not in somewhat significant proportion of it is, and I don't know that that makes sense in the managed care delivery context that we have in our country today, but to the extent that it's allowing for out of network services where truly there was no in-network provider available, I think that is the issue that we're trying to address and may be effective.

SPEAKER_00: 15:36

Similarly, I'm seeing some activity in the private insurance world with respect to coverage for psychiatric or psychiatrists. The large number of psychiatrists that are out of network in private insurance panels, et cetera, and the inability for patients to get in. So many just go the route of paying out of pocket. I have seen more recent legislative attempts to tie reimbursement rates to Medicare or to other formulas to raise that reimbursement rate to, I guess, entice psychiatrists to participate in those insurance panels. I'm not sure. It's not the same process that you're talking about in terms of insuring in-network coverage for out-of-network providers, but it's kind of a a corollary to that, I think, providing a little bit of a push for the private insurers to raise reimbursement, to bring in more psychiatrists, sort of a carrot approach.

SPEAKER_01: 16:48

Yeah, I think that is really the biggest question that we face right now is how to get more of those psychiatrists in particular and other mental health providers to participate in insurance networks. you know there's a few surveys suggest that reimbursement rates are not one of the top, they are a reason, but not one of the top three or four reasons that providers cite for participating in insurance networks. Where I've looked at data on this, the comparability, if you're benchmarking to Medicare, comparability between behavioral health providers and med-surg providers actually does work out pretty well if you're looking, if you're controlling for health systems versus small providers, if you're controlling for the types of services that they're actually billing for. And so there's There's a lot of different ways to think about that, but I would say on the whole that small increases to reimbursement may not have a transformative impact. It's an interesting approach, but I think that most likely you're gonna need to think more broadly about ways that payers can mitigate some of the burdens of participating in network and beyond just reimbursement rates in order to really move the needle.

SPEAKER_04: 18:09

You mean in the paperwork, David?

SPEAKER_01: 18:12

Yeah. Yeah. Authorizations. Yeah. Like the the the investment in behavioral health and just like revenue cycle management and, you know, billing and coding and all that is so much lower compared to medical surgical specialties. I were seeing behavioral health catch up. Certainly, you know, in the past few years. But I would say, you know, if you think on like a 30 year scale, I'm still way behind just in terms of the in the arms race between between providers and payers, just not nearly as mature on the provider side in terms of that investment and for lots of reasons. But I think that's going to drive it more than anything.

SPEAKER_04: 18:57

The other aspect that I think is unique about behavioral health is that people are able to successfully run cash practices. So they are able to have a more niche-focused patient population and run a cash practice. I think this is kind of a trend that we're seeing in dermatology as well, that you get to go do the patient population that you enjoy serving and cut out as much of the administrative overhead that you don't want to deal with and that no one thinks is fun dealing with. And that's how you can keep your business a small business. Because you're right, to scale all that administrative overhead, it requires size and significance in order to support the technology and the man hours to actually make your way through the paperwork and the back and forth that all those relationships require.

SPEAKER_01: 19:49

Well, I could talk all day about this stuff, but I'm interested in hearing, Judd, I know you've been looking a lot at federal and state funding for behavioral health. Where are you seeing these trends?

SPEAKER_00: 20:03

Well, I think we're really in uncharted territory right now, David. I think with the administration at the federal level, with the changes that are coming down, sometimes without advance notice, are having some major impacts upon providers and others. For example, just this week, while we were preparing for this podcast, the federal government announced a clawback of about$11 billion in ARPA funding that had been designated for public health as well as behavioral health. So the announcement here in Illinois, for example, related to about$28 million in behavioral health funding that was dedicated towards our mobile crisis response teams, our first episode psychosis response and some recovery homes, SUD response. And so the question that I think is on everyone's mind is, if this happens, are states prepared to step in? And if not, what can be done to maintain at least a bare minimum level of funding for providers to ensure that services can continue? My thought on that is there's very little that states could do to fill that heavy void. One of the areas that might be possible is the opioid settlement funding. that had been reached by the state's attorney general that relates to the settlements with the opioid manufacturers, distributors, consultants, et cetera. That might be an opportunity or a way to fill the gap there. Currently, I think we're at about$50 billion overall in settlement proceeds that were part of the national settlement. A variety of states participated, and the vast majority of states did participate in that process. And I think most have set up what were intended to be, and I'm hopeful, particularly here in Illinois, that the process will be carried out in a way that was vastly different than the tobacco funding litigation. The settlement of that litigation was carried out where the funds sort of disappeared and there wasn't a lot of accountability, so to speak, with respect to how those funds tied back to the damages, the negative impact of tobacco. So I don't know if there are other ways or other concerns. Obviously, each day is a new day when it comes to the federal decision Alison, I know that there were some changes with SAMHSA recently announced as well.

SPEAKER_04: 23:03

Right. So what also occurred this week is that there was recognition that there's going to be some consolidation happening from agencies that previously have been recognized as distinct entities It appears that they're going to be consolidated into a new administration for healthy America. And so SAMHSA, the Substance Abuse Mental Health Services Association is going to be consolidated. And that's not a guarantee that there will be cuts to funding or cuts to even positions. No SAMHSA positions have officially been listed as in the news articles right now as those that are being cut, but I think it's to be expected that it's likely to occur. What's interesting in my realm, in the broader healthcare delivery realm is that Medicaid is the single largest payer of behavioral health services for adults in America. And Medicaid is also becoming more and more of a prominent payer for substance use disorder services as well. So with the cuts that Doge has said that it's going to implement in our federal government. Of course, there's been a lot of speculation for a long time about what that means for Medicaid and Medicare. There's been a lot of assurances that Medicaid won't be cut or that Medicare won't be touched, but it still seems really hard to believe that you can't touch those entities or those delivery mechanisms just given the sheer size and scale that they represent in our federal budget. So I think that's another area for us to just continually watch as to how do you cut Medicaid? How do you consolidate SAMHSA? And what are those impacts on delivering behavioral health and substance use disorder services in states, particularly with those who have federal matching programs? You know, I think that's something that Oklahoma especially is keeping an eye on of when those federal dollars go away. It's not as if Oklahoma has a designated rainy day fund ready to swoop in and say, okay, we've got the rest. We're fully expecting that we're going to be seeing a reduction in overall spend that we're going to have to accommodate. Do any of you have any other thoughts on how you know, the potential cuts. We don't know of any certain, but any potential cuts that could be coming our way that could be impacting the delivery of behavioral health

SPEAKER_02: 25:46

Yeah, Alison, I'll say I think I've shared your skepticism in watching the news, not just this week, but maybe even since the new administration came in, that there's all these assurances that there's going to be more efficiency but less spending, that programs will remain intact despite all of the restructuring. And so I think it is a little difficult to believe. I think a healthy amount of skepticism in this area is healthy to kind of repeat that. But, you know, speaking from, I guess, from my background with community health centers, they rely on federal grants and monies for a lot of their funding in order to provide medical care, dental care, behavioral health services, and substance use services, especially. And so I think they have very little wiggle room for revoking or rescinding funding or grant support and expecting for their programming to be able to survive. I think we saw there was actually a little bit of whiplash. There was some more kind of quick decision of funding. Don't know exactly what the outcome of that's going to be yet. But the programs are having to, I think, quickly figure out how to still provide services and provide for the need because the need doesn't go away just because the funding does. And so I think you and I at some point within this group have talked about how if you remove one set of resources, it means that there is weight on some other portion of the system. And so where is that support and service going to come from? Who's going to have to kind of thin out or spread their resources more thinly to figure out how to still provide and meet those needs.

SPEAKER_04: 27:34

Definitely. And, you know, as far as a health system like mine, what we're doing to prepare for potential cuts is really recognizing that we could have higher ER volumes of patients who are otherwise currently provided for the FQHCs or in community behavioral health centers and We're really being intentional about where we have investments in our community and where we have, let's say, free health fairs, recognizing that in the future, we're going to need to be intentional to find places where there are pullback or drawdowns of care, of that preventative care or of that early intervention care that right now is keeping people out of that crisis and emergency situation, necessitating them to visit our ERs. We don't have a shortage of volume in our ERs in Oklahoma. So this is not a situation where we're excited about having more patients coming to our ERs. We wanna be sure that the patients that are coming to our ERs are the ones that need to be there and that we are able to treat those lower acuity conditions or non-emergent conditions at the right level setting. And so really partnering with FQHD's Community Behavioral Health Centers and identifying where they are experiencing cuts or delineation and, sorry, where those community behavioral health centers may be experiencing reductions in their abilities to meet the community need. How's the health system like us able to step in and partner with them, perhaps formally or informally, or how are we able to infuse another element of preventative or non-emergent care alongside them? Ideas that we have that we're exploring is partnerships with behavioral health telehealth companies, is looking at how we are already able to access some of those services, but in our rural communities where they are not due to a lack of broadband. So we're really looking at how we're drawing attention to what that means for their ability to access care at home. different levels of our state government to ensure that they see those deserts and what that could mean in terms of if you've got an overrun ER with someone who didn't need to be there, had they had access to a different point of care, then when you are an emergency or your loved one is in an emergency, it could be that much harder to reach us. So really personalizing the impact that some of this could have in terms of escalating the need and creating emergencies, whereas today those emergencies are being avoided by preventable or community intervention. Tanya, you and I had also had some conversations about some school-based crisis programs that you have familiarity with. What are the benefits and challenges of those school-based crisis programs?

SPEAKER_02: 30:30

Yeah, so, I mean, obviously, I think school-based programming is crucial. The school has kind of presented a foundation to address things like anxiety, ADHD, ADD. We've seen, you know, over, unfortunately, over the last decade or so, increases in gun violence in our school systems. And that, I think, is directly related to behavioral health issues that haven't been addressed or maybe were not previously identified. So I think some of the benefits definitely include being able to address those things early on having some early intervention with students to prevent health problems from escalating having Reduction in barriers to mental health services will make it more accessible for those students, especially in underserved communities. And sometimes that includes those rural communities that you just mentioned where access may be difficult, transportation issues may exist. To the point about guns, gun violence in our schools, just hopefully reducing providing a safer school environment. If students have their needs met, if they're getting support for mental health issues or even for substance abuse issues, then hopefully we're seeing safer school environments and then reduced behavioral issues because they're being addressed at the school system. And we've said, you know, for years, the school is where a student spends most of their day. Most of their interactions are going to be in the school environment. So it just kind of provides an opportunity if they do need intervention, whether that's earlier or they've already had some intervention and they need some pickup of those services to have that at the school level. But as for challenges, I think we've already started talking about funding. Funding is always going to be, always has been, and always likely will be a hurdle. It impacts the ability to hire and retain qualified staff. I do know that it is more difficult to recruit and retain staff in those harder access areas or in rural areas, which are actually at higher risk or may have higher incidence of need for behavioral health services. So provider shortages, I think that happens across the behavioral health kind of realm, but specifically in the school system and in the school-based environment, that has a different impact. There's still a stigma, I think, about accessing behavioral health issues. And in the school system, you're in that kind of adolescent age where you're experiencing a bit of anxiety anyway, it might add some extra angst if you feel like you may be exposed or someone may see you accessing those services. And then I think kind of going back to recruitment issues, there may also be like training and capacity give good training to the staff so that they are equipped for the issues that are going to come up at a school level. I think adolescent behavioral health services are by definition going to be different and distinct than adult school, adult behavioral health services. So making sure that you've got staff that are adequately trained, not just present and not just willing to be there, but also able to actually give targeted and intentional behavioral health services to those students.

SPEAKER_04: 34:03

Yeah, Tanya, our interaction with schools has been along those lines of supporting community programs. I think it's rare that charitable health systems don't have some form of a community giving program and health insurers, you know, for-profit companies do this as well. Major companies in communities are always giving back to the community in a variety of ways. But I think healthcare facilities or healthcare systems specifically recognize the importance of investing in that early preventative interaction, particularly in adolescents. So Integris Health partners with a group called the Hope Squad. The Hope Squad is a school-based program that supports schools in identifying students to help raise the need, to recognize the need in their, I was about to say colleagues, but in their fellow students. So the Hope Squad is training students and administration to recognize crises building before it becomes to a crisis point. so that those students can get help before they're in an emergency situation. And that's such an obvious smart investment from a health system like Integris Health where you're just trying to identify where someone needs help before they're at that crisis point where they have to come to the ER and come to the most expensive cost setting. That's also something that you can see where managed care companies would be supportive of from an access point as well. So I think the school-based programs, there's a plethora of options and with the funding challenges that we discussed before that might be coming our way, that I think that's where you're going to see some smarter investments being shifted from those community giving programs, focusing on preventative care, access to care in order to fill the void that may be created with funding challenges. One other comment I just feel the need to make which is the cuts that could be coming from the federal level and then the state's inability to fill the match or to fill the void that could be created. Sometimes those are characterized as malicious or mal-intent. And I just wanna draw attention to oftentimes the legislators that are involved in those decisions are put in really difficult positions. And this isn't a situation in which anyone is wanting to hurt someone or wanting to cause harm. I think it's important to remember that these are big numbers And then a lot of big impacts can boil down to some small decisions that could just be, you know, a shift here that then has dominoes that cause, you know, that clinic that was in that one rural community to close. And that couldn't really be entirely foreseen by the decision that was made thousands of miles away. So, you know, I'm not trying to defend all of the changes that are happening, but just to acknowledge that at least as we're interacting with our state legislators and our federal delegation Our whole goal is ensuring that they just understand the importance of the funds or how the funds are used now and what possible impacts could be as they're wrestling with really tough decisions with some big goals. Those goals also have an objective to do good for America or to do good for the nation in ways that that are different than what our current funding or structure is set up for. So that's just something that I always try to step back and remind myself of whenever we're confronted with some of those big changes and unknowns that could be coming our way.

SPEAKER_02: 37:42

Yeah, I agree with that, Allison. I think, you know, as we move forward and, you know, we're kind of in this resource question mark area that it's going to be important to have. Number one, those partnerships that you talked about, like with your health system and the community health service. systems, but also to make sure that everyone realizes we're all kind of trying to figure it out as we go along. It's a bit of an unpredictable arena that we're in right now, and everyone's trying to make sure that they're not just being compliant, but that they're also servicing the needs. And so that does lend itself to kind of a difficult, challenging area where sometimes difficult and challenging decisions have to be made. So completely agree with that.

SPEAKER_01: 38:28

Yeah, if there's a call to action here, in my opinion, it's that where we have major budget cuts potentially and concurrent to major reorganization and staffing cuts, especially at the federal level, those regulators often create that sort of connective tissue between those very hard funding challenges that get made at the legislative level and the on the ground impact of the funding. And so, Alison, the types of community investments and support services that you talk about that we help to render care cost-effective, keeping people out of the ER, making sure that we're spending the money in the right place. So often those are, I think there's a risk of those, they're often funded through sort of supplemental ancillary types of programs, special authorities and Medicaid, things like that. Things that are going to be appear to be on the chopping block often and are going to be easy to get lost in the shuffle, especially where the regulators and policymakers that were responsible for creating them and understand their value and how they fit with the system may be getting reshuffled or getting no longer in their roles. And so I think there's a real need for providers and advocates to come together and understand that the policymakers that have traditionally been in that intermediary role may no longer be in place and that we need to be able to talk with funders about the need for these ED diversion, crisis stabilization programs, school-based service that are cost effective and are as well as being integral to quality outcomes.

SPEAKER_00: 40:36

This is a fascinating discussion and to piggyback on some of the comments made as well as add to some of the excellent thoughts. In addition, as David mentioned, I think there is a need for the mobile crisis, the community intervention programs that do divert folks in crisis from the ERs and the EDs, which are less effective in treating the situation. Those in mental health crisis also cause disruption within the emergency departments with respect to those needing more of a medical surgical intervention. And it's more cost effective to utilize a less intensive, more mental health-focused intervention. So the rollout of the 988 crisis line, the use of mobile crisis teams, the introduction of community-based living room programs and other crisis stabilization type facilities are less expensive if you're looking at it from a cost-effective standpoint, less intrusive or less invasive, less of a disruption for those that are in need of a physical medical type of intervention in an emergency department, et cetera. So all of that kind of comes together in addition to keeping in mind, I think all of us touched on this a little bit today, the idea that if we're not able to treat patients those with a behavioral health need or a crisis, then it's going to have to be addressed in some other way. And that might fall upon Allison's system in their emergency department. It might fall on a school-based crisis program that has to intervene in a more serious matter and working with the managed care organizations and how they seek to provide the best care and obviously manage costs. So I don't know if If any of you have any final thoughts for today to sum up, I sort of done so right now, and I'd like to turn it back over to each of you.

SPEAKER_04: 42:48

Hey, Jed, I would just comment that the Behavioral Health 101 program that you mentioned at the top of the hour covers a lot of those different intervention points and gives a definition of what they are and how they interact with the behavioral health care services continuum. And it's been great talking to you guys. I've loved learning from each of your perspectives. So thanks so much for having me.

SPEAKER_02: 43:13

Yeah, I think my final thought would just be that in addition to being compliant as we move forward, we'll, as usual, have to also be intentional and creative and, you know, create partnerships and find resources maybe to make sure that we're still servicing those behavioral health care needs.

SPEAKER_01: 43:32

Very well said. I really appreciate the discussion today and I

SPEAKER_03: 43:36

hope we can do it again soon.