Leadership Dialogue Series: Addressing the Behavioral Health Crisis with John Muir Health

00;00;00;28 - 00;00;39;05
Tom Haederle
Hospitals and health systems are playing an increasingly important role in providing behavioral health care, whether in their own facilities or by helping patients connect with community resources. It's a positive trend, but the need for behavioral health resources is great, and the gap between needs and resources remains wide. Welcome to Advancing Health, brought to you by the American Hospital Association.

00;00;39;15 - 00;01;09;14
Tom Haederle
I'm Tom Haederle with AHA Communications. In this leadership dialog series podcast, John Haupert, president and CEO of Atlanta-based Grady Health System and the 2023 chair of AHA’s board, is joined by Jesse Tamplen, vice president of Behavioral Health Services at John Muir Health. That's near San Francisco. Tamplen notes that in all of California, our most populous state, there are fewer than 100 acute psychiatric beds for children under the age of 12.

00;01;09;26 - 00;01;32;06
Tom Haederle
John Muir Health has 10% of those beds. It's a nationwide situation. The two leaders discuss how hospitals are working with local and state organizations to create new pathways to appropriate care and treatment, as well as preventive services. And they review the role of adequate reimbursement to cover the cost of behavioral health services. With that, let's join John and Jesse.

00;01;33;11 - 00;02;03;28
John Haupert
Good afternoon and thank you, everyone for joining me today for another leadership dialog session. I'm John Haupert, president and CEO of Grady Health System in Atlanta, Georgia, and also chair of the board of trustees of the American Hospital Association. I'm very much looking forward to our conversation today as we talk about the critical issue of behavioral health, an issue that has only worsened during the past few years since the pandemic, but has long been  stigmatized as well as underfunded.

00;02;04;28 - 00;02;32;21
John Haupert
With the mental health crisis in our country worsening, the hospital field is finding itself more active in developing an advocate for solutions to help patients and families, as well as also our own caregivers who have seen increased rates of anxiety and burnout. At Grady, like other organizations, we are working to build a stronger infrastructure to meet all behavioral health needs of those we serve.

00;02;33;06 - 00;02;54;15
John Haupert
And as a matter of fact, Grady Health System is the largest provider of mental health services in the state of Georgia outside of the prison system. I am very pleased to introduce my guest today, Jesse Tamplen, an expert in this area, who will offer his insights on some of the most pressing challenges currently facing our behavioral health system.

00;02;55;29 - 00;03;27;07
John Haupert
Jesse is the vice president of Behavioral Health Services at John Muir Health, a not for profit health system organization east of San Francisco. John Muir Health offers both inpatient and outpatient treatment programs across the entire spectrum of care for children, adolescents and adults who have psychiatric or behavioral problems. And Jesse also serves on AHA's Committee Behavioral Health. Welcome, Jesse.

00;03;27;07 - 00;03;30;03
John Haupert
It's an honor to have you join us today.

00;03;30;23 - 00;03;34;09
Jesse Tamplen
Good morning, John. It's a pleasure to be here and have this conversation with you.

00;03;34;27 - 00;04;03;12
John Haupert
So, Jesse, let's go ahead and dive into a few questions so that you can share your views on several different issues surrounding mental health, behavioral health, and how health systems are bridging the gap. We know that the pandemic only worsened the longstanding challenges our nation faces around access to adequate behavioral health services. What trends have you seen over the past few years, particularly in the period post-pandemic?

00;04;04;08 - 00;04;37;19
Jesse Tamplen
Thank you. As you mentioned, we know that there is a behavioral health challenge with people, children, adolescents and adults receiving care in the United States pre-pandemic. Post the pandemic, we've seen the incidence rates of self-harm, suicide, substance abuse, anxiety, depression, eating disorders increase dramatically. Where we're seeing that impact many times within the system the most is in our primary care settings. 

00;04;37;19 - 00;05;03;12
Jesse Tamplen
When it becomes very acute, it comes into our emergency rooms and then our med surge acute care hospitals. If a hospital emergency room is fortunate enough to be associated with an acute psychiatric hospital, they're able to get patients the care that they need. But many times that I think people have seen throughout the country that we have a lack of acute care, behavioral health beds in the United States.

00;05;03;20 - 00;05;30;28
Jesse Tamplen
And unfortunately, when people become acute, they often stay in our emergency rooms waiting to get care. We do everything we can to make sure that people can go back to either their primary care provider or find specialty mental health providers. But we know that we're in short supply within that workforce. So those have been some of the clinical challenges that have been impacting the the community and the patients that we serve.

00;05;31;22 - 00;05;47;00
John Haupert
I was really pleased to see that you all offer psychiatric behavioral health services to children and adolescents as well. What are your views on the availability of mental health services for children and adolescents?

00;05;47;19 - 00;06;21;14
Jesse Tamplen
There's opacity for children and adolescents. The Children's Hospital Association for America mentioned that we are just at a, you know, a crisis in youth mental health. In California, one of the largest states, there's less than 100 acute psychiatric beds for kids under 12 years old. John Muir Health has ten of those. So we represent 10% of all of the states, the ICU level of care for youth.
 
00;06;21;14 - 00;06;46;22
Jesse Tamplen
We have 24 adolescent beds and John Muir, 20 years ago made the commitment to youth and adolescent mental health to make sure that kids would not be sent out of their communities to receive treatment. So we're very fortunate in our local community that when kids need to access that critical lifesaving care, they can remain in their community. Across the country and through the state of California,

00;06;47;04 - 00;07;18;09
Jesse Tamplen
many times you don't have those services within your community or your health system. So those kids who need care, who need to be as part of their family are many times sent four or five hours away from home. John Muir is a local nonprofit where we serve our community. But when it comes to our acute psychiatric hospital, we are an anchor institution for all of Northern California and many times the state for our youth and adolescent specialized psychiatric inpatient treatment.

00;07;18;25 - 00;07;45;16
John Haupert
Wow. Know, that's a stunning number to hear that in a state the size of California, there's 100 beds available for those services. But at the same time, as you and I know, we shouldn't be stunned because nationwide, the amount of inpatient care available for pediatric and adolescent patients is woefully underfunded and available. So let's move on to another question.

00;07;45;27 - 00;08;09;20
John Haupert
Hospitals and health systems are playing an increasingly more important role in providing behavioral health care, whether in their own facilities or by helping patients connect with the resources available in their community. Can you share with us any short term collaborations you've seen that are successful in meeting the behavioral health needs of a community or even longer term solutions we should be talking about?

00;08;10;10 - 00;08;37;27
Jesse Tamplen
Yeah, this is an exciting area. After the pandemic, some of the stigma and discrimination of mental health decreased in talking about it and allowing people to really share their behavioral health. And I think and the pandemic really allowed more innovation to come forward where we've had some very exciting partnerships with our state in California and locally, our local health jurisdiction, is we've created...

00;08;38;10 - 00;09;01;27
Jesse Tamplen
it started off as a substance abuse, a navigator in our emergency room just supporting the opioid crisis. And then that really evolved into a behavioral health navigator. We know that there's not enough preventative services in the community. And so no matter where people are getting services, many times when they become acute, you hear everybody say, if you become acute, go to your local emergency room.

00;09;02;04 - 00;09;28;10
Jesse Tamplen
And our emergency rooms are already strapped with the care that they're providing and COVID 19. So we've created a behavioral health navigator that supports those patients, both substance abuse and psychiatry. Many times they're people with lived experience or they have professional education, working with the emergency room team, the family and the community to get the person that care that they need to be able to access care.

00;09;29;03 - 00;09;54;08
Jesse Tamplen
Not only do we keep them in the emergency room, but they're able to float up into our medical hospital. And many times, if they are following up with our own primary care, they will go support that individual into primary care. It's been incredible to have that that behavioral health navigator for our patients because we're meeting them anywhere they are in our health care system and helping them navigate the complexity of getting services.

00;09;54;22 - 00;10;26;24
Jesse Tamplen
One of the challenges in behavioral health, you may know the service that somebody needs, but they're are significant waitlists. It doesn't exist in your community. So you really need an expert navigator to support the patients. And so that's one area that we have been using are behavioral health navigators. And then we partner with our fire departments. Right now we're doing an innovative project with one of our local fire departments where they're looking to not have a police first response, but a fire response to behavioral health care.

00;10;26;24 - 00;10;35;06
Jesse Tamplen
So we're working with them to create a new clinical pathway. So those are two innovative programs that we're currently working on.

00;10;35;26 - 00;10;58;10
John Haupert
I thank you, Jessie, and I'm so pleased to hear you bring up the topic of navigators and behavioral health, particularly navigators that have a lived experience with behavioral health issues, have been there, done that. So not only are they navigating for the patient and getting the care that the patient needs, but they're also also serving as a peer support individual for that person.

00;10;58;10 - 00;11;13;22
John Haupert
And that's really great. So I know top of the list for many is better integrating and coordinating behavioral health services with physical health services. Any thoughts, advice or maybe wishes that you can share on this type of integration?

00;11;14;19 - 00;11;44;23
Jesse Tamplen
This is where I'm passionate about. I think for us to really move the needle on the health inequities in behavioral health, we need to treat physical medicine and psychiatric medicine the same. We need to treat it clinically, which many people want to do, but we also need to treat it economically. The reimbursement in those areas. One area that I would love to share with you is that in hospitals, John Muir has two acute care medical hospitals and one acute care psychiatric hospital.

00;11;44;23 - 00;12;10;14
Jesse Tamplen
And we have a transfer center. And as you know, the transfer centers, when you need a bed, when you need specialized care, referring provider calls up the transfer center to find the best care for them within the hospital. Over the last year and a half, we wanted to make sure that we integrated both physical and psychiatric medicine. So we integrated the transfer center with our acute care psychiatric hospital.

00;12;10;20 - 00;12;39;12
Jesse Tamplen
So now there's one number for anybody to call to get inpatient treatment. And not only does it create easier access and decreases the stigma and discrimination for people seeking care and providers seeking care, but it's an upstream area where we're working with our workforce also to say we're not treating physical medicine and psychiatric medicine different because we know that we don't have enough beds in California for psychiatric patients.

00;12;39;21 - 00;13;02;10
Jesse Tamplen
We are so we know they end up in our emergency rooms, which is not the best care or in our medical hospitals, which is not the best care, but we're still going to treat that. So if we start with a transfer center, develop those clinical pathways, it's part of the education model that we're increasing care clinical protocols no matter what setting you are within that, within the hospital needing care.

00;13;02;19 - 00;13;13;24
Jesse Tamplen
So that is an area that I'm very excited about and we've had unbelievable success over the last year with integrating our transfer centers, both physical and psychiatric.

00;13;14;11 - 00;13;39;13
John Haupert
Well, that that's a fantastic approach. And it's interesting in the evolution of health care in our country that we have separated those two mental and physical health aspects of an individual, when I always refer to it as whole person care. If I'm a primary care physician, I need to be able to evaluate not only the physical, but are there mental health issues at present as well.

00;13;39;13 - 00;14;11;21
John Haupert
And let's treat all of that together. And I so appreciate the work you're doing around that. There have been long been issues around inadequate reimbursement, as you just mentioned, for behavioral health services, as well as significant shortages of behavioral health workers. Those challenges have likely only worsened over the past few years. Can you explain for our audience how poor reimbursement drives shortages of behavioral health workers, and how does that have an impact on inequities within our health system?

00;14;12;10 - 00;14;36;02
Jesse Tamplen
Thank you. And when you get into behavioral health economics, it's almost like you have to have a Ph.D. in economics because it's not a simple: two plus two equals four. I wish it was. And so what we know is many times behavioral health is either capitated or their stringent authorizations, or in physical medicine, you can show up to any emergency room and be treated.

00;14;36;10 - 00;15;08;00
Jesse Tamplen
But many times, if you're on government insurance, especially at a local health jurisdiction, you have to go to your county of origin to receive care. So your zip code is determining your access and ability to receive care. We also know if your zip codes determining that it's increasing health inequities. And so one of the challenges that we have is the mental health reimbursement does not cover the cost of care, especially in a hospital system that wants to provide whole person care as you mentioned.

00;15;08;00 - 00;15;32;04
Jesse Tamplen
I'm a big proponent that to integrate physical and psychiatric medicine, you need to be part of a hospital system that runs emergency rooms, that runs surgery, that runs primary care, specialty cardiology, because that's where you're going to be taking care of the patients and you're going to have a system and a leadership group and clinicians who know how to take care of the whole person.

00;15;32;22 - 00;16;00;16
Jesse Tamplen
When you carve that out, then you start having standalone behavioral health programs, which there's nothing wrong with that. But when you look at the health inequities that you are talking about  - when you're diagnosed in the United States with serious mental illness, you're dying 25 years younger than the average population. And it's not due to your mental illness, it's due to preventable health conditions, obesity, diabetes, cardiovascular care.

00;16;00;27 - 00;16;24;04
Jesse Tamplen
How we carve out our reimbursement and we say we want to treat all person care. When you carve out that reimbursement and your providers and your workforce are just focusing solely on behavioral health, but then they're excluded from providing that primary care, that whole person care. Making sure you're managing somebody's diabetes or obesity or you're not part of a system that has that knowledge.

00;16;24;12 - 00;16;55;14
Jesse Tamplen
You see the impact of that stigma and discrimination. And it's one of the reasons why people are dying 25 years younger in the United States with a serious diagnosis. When we look at reimbursement behavioral health providers, you look at our BSN, our Bachelor of Science in nursing, large education, financial investment of time investment becoming a psychiatrist, significant financial time investment, becoming a social worker, a psychologist, a marriage, a family counselor.

00;16;55;22 - 00;17;17;01
Jesse Tamplen
So people want to follow their passion, provide whole person care. They've taken out the student loans. They made the time investment. And then when they're looking at where do they want to practice? They look at the level of reimbursement and they're like, I may not be able to pay off my student loans because of the reimbursement. So many of them will go into private practice.

00;17;17;10 - 00;17;39;19
Jesse Tamplen
So in behavioral health, you really see kind of a two tier system where you have private practice, where people are taking cash because they don't want to deal with the carve out reimbursement in private practice, which we want to support. But being part of a hospital, we're looking to recruit our professionals. Our professionals are on call 24 hours a day, seven days a week, providing critical care.

00;17;39;23 - 00;18;02;22
Jesse Tamplen
And the challenge of reimbursement puts a huge impact on our ability to recruit. We know recruiting for health care workers across the country is a challenge now. In behavioral health it's even more exacerbated not only because of the low reimbursement, but additionally, after the COVID 19 pandemic, there was a huge investment in digital health specifically and behavioral health.

00;18;03;01 - 00;18;35;00
Jesse Tamplen
Behavioral health, many times it's not a procedure medicine. It's cognitive medicine. Cognitive medicine goes nicely, virtually. So there's a huge drain on the behavioral health workforce. If you're a psychiatrist or if you're a nurse, if you're a counselor, to be able to provide online therapy counseling, which is incredible for a work life balance. But when you're providing ... when you're an anchor psychiatric institution, not only in your community, but across the state for children and adolescents, that exacerbates the workforce.

00;18;35;08 - 00;18;55;15
Jesse Tamplen
And a lot of that drop is driven by the reimbursement that we're getting for behavioral health, which is vastly underfunded. I think in March of last year, 2022, the General Accountability Office just highlighted how mental health reimbursement is underfunded in the United States.

00;18;56;17 - 00;19;39;27
John Haupert
Well, Jesse, thank you for that answer. You touched on so many important points. And I'll be honest, I had not heard before that significant lifespan difference for patients with chronic mental health conditions, that really is tragic. And it really points to the issue of having separated the two and underfunding mental health across the board. So one last question, Jesse, a challenge I'm hearing more and more about is the growing administrative burden, a huge piece of this, as in prior authorizations. Some state Medicaid programs are trying to reduce the burden behavioral health workforce teams face, and there's talk of other efforts.

00;19;40;13 - 00;19;50;14
John Haupert
But how are you managing that? Are there solutions you all have been able to work through with your state Medicaid program or commercial insurers to to reduce that burden?

00;19;51;15 - 00;20;36;29
Jesse Tamplen
That is a great question. And many times to patients, it is an offstage challenge that they don't know until they face it. Prior authorization for behavioral health is significantly overburdened. Then you are is significantly overburdened because of the carve out. And I'm going to highlight some of the challenges that people may not be aware of, and I'll tell you what we're working on with the American Hospital Association, California Hospitals Association with our local municipalities ... is one of the areas that I try to bring education to is when somebody comes to our emergency room, we know our emergency rooms, they're our to support the most vulnerable and their most critical time of need.

00;20;37;08 - 00;21;04;05
Jesse Tamplen
And when any other outpatient service can't take care of somebody, they send them to our emergency room to see that receive that care because we're there 24 hours a day, seven days a week to care for the members of our community. Well, if you have a cardiac condition and you go into the emergency room and it's a life threatening condition, regardless of your payor, socioeconomic status, race, ethnicity.

00;21;04;28 - 00;21;33;16
Jesse Tamplen
If you have urgent and emergent care, you get admitted into the psychiatric hospital and then you work on all of the authorizations. If they have insurance, not insurance afterwards. We have a federal law, Empala, that really supports that level of care and that level of access. The challenge with reauthorization and behavioral health is many times when it comes to Empala people don't feel that Empala oversees behavioral health.

00;21;34;09 - 00;22;02;27
Jesse Tamplen
We know that it does from the Centers for Medicaid and Medicare Services. But when an individual comes into an emergency room and they need care, many times it's requiring pre-authorization, but it's an emergency care. And that reauthorization could take five, six, eight, nine hours. And so people are talking about the lack of beds in the community for psychiatric beds, behavioral health, which is true.

00;22;03;07 - 00;22;29;21
Jesse Tamplen
But they also what what they're not talking about is the burdensome of pre-authorization where we're delaying care, because if it is a Medicaid program, a local health jurisdiction or a commercial insurance program, they're requiring authorization or they're going to deny that care. Many times we will the hospital or admit that person. But then on the back end, we get denials.

00;22;29;21 - 00;22;54;01
Jesse Tamplen
We have to fight with authorization because we said that's the right thing to do because we need to get the person to the specialized care that they need. And so for me, when I really look at what are things that we can do to really help provide whole person care, integrate physical and psychiatric medicine, many of it is following the guardrails that the regulations are already in there and making sure that they are enforced.

00;22;54;08 - 00;23;24;02
Jesse Tamplen
That's also what the General Accountability Office mentioned last March in their report is that there's regulations on the books. But when it comes to behavioral health, not everybody always follows those rules. So I've been working with the California Hospital Association, our local health jurisdiction and the state, to really make sure that we know that when somebody comes into our emergency room, we do not look at their financial status and we get them to the specialized care that they need in-patient.

00;23;24;15 - 00;23;50;18
Jesse Tamplen
And for people who are not familiar with this, they may say, wait a minute, this is what's always supposed to happen. But there's been a long precedent, a community standard where people require pre-authorization, which backs up our emergency room. But most importantly, it delays critical lifesaving treatment to people with acute psychiatric or addiction medicine challenges. And the worst situations of this is what is called the ping-pong effect.

00;23;51;00 - 00;24;09;26
Jesse Tamplen
I don't know if you've heard of the ping-pong effect before in behavioral health, but somebody comes into your emergency room. They're like, oh, we're not quite sure if this person needs inpatient treatment. Our attending ED physician says, yes, they do. Then somebody says, send them to our psychiatric emergency services. And so we're like, but we have an open bed available.

00;24;10;09 - 00;24;30;21
Jesse Tamplen
But they say, send them to ours. We send them to theirs. They're like, oh, we agree with you. And then they send them back to your acute psychiatric hospital. Not only is it a burden on that patient and delaying care, but you're using ambulances, you're using people's times. The cost is coming up. But because behavioral health is carved out, the costs are in different domains.

00;24;30;27 - 00;25;04;09
Jesse Tamplen
So people are not seeing that total cost or focusing on that total care. So I'm kind of a zealot when it comes to making sure that we have access in our emergency rooms to lifesaving care for acute psychiatric hospitals. And I've been in the field for over 25 years. I've made some progress, but it's still a fight. And I think right now, with behavioral health being in the spotlight after the COVID 19 pandemic, we can really start driving some of those quality measures which we have in the physical health side many times.

00;25;04;15 - 00;25;18;07
Jesse Tamplen
But I feel all parties are mainly government health insurance, are coming together to really drive for, you know, drive that forward. So I'm hopeful, but we're not quite there yet on the issue.

00;25;19;06 - 00;25;49;05
John Haupert
Well, Jessie, you really have done a fantastic job today in getting the points across that we need to be focused on. There's a very real reason that HHS has has targeted specific issues within society and health to assure funding for and behavioral health is one of those. I want to thank you for joining us today. I appreciate you sharing your insights on how we can best support behavioral health services and integrate treatment and the whole person care.

00;25;49;29 - 00;26;16;07
John Haupert
I know this is a topic that can benefit everyone listening, and I encourage anyone who may be struggling with feelings of anxiety or depression to please reach out to someone who can help. You can visit AHA.org and AHA's Physician Alliance website for additional resource is focused on stress coping and mental health for health care workers. Until next time.

00;26;16;07 - 00;26;23;09
John Haupert
Thank you, everyone, for joining us today. I hope you'll be back next month for our next leadership dialog. Thank you.