Chair File: Leadership Dialogue — Behavioral Health Solutions With Jeremy Musher, M.D., Chief Behavioral Medical Officer at Lifepoint Health

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Tom Haederle
Health care providers coast-to-coast have seen a significant rise in the past several years in the demand for behavioral health services. Broadly speaking, behavioral health encompasses those things that affect overall well-being, including mental health issues and substance use disorders. Many hospitals and health systems want to fully integrate behavioral health treatment as a core part of patient centered care.

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Tom Haederle
But there are barriers that often stand in the way and make it more difficult.

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Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this month's Leadership Dialogue Series podcast, Dr. Joanne Conroy, CEO and president of Dartmouth Health and 2024 Board Chair of the American Hospital Association, explores how hospitals and health systems can best meet the need for behavioral health services with Dr. Jeremy Musher, chief behavioral medical officer at Lifepoint Health in Brentwood, Tennessee. They discuss how to overcome some common obstacles to effective treatment, including access issues, reimbursement challenges, and the stigma of receiving treatment.

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Tom Haederle
And, they offer possible solutions. Let's join them.

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Joanne M. Conroy, M.D.
Thank you for joining us for another deep dive into a very important topic on the Leadership Dialog series. It's great to be with you. I'm Joanne Conroy, CEO and president of Dartmouth Health and the current chair of the American Hospital Association Board of Trustees. Today's discussion is critically important and it impacts all of us. It can be our own experience or the experience of a family member or a friend.

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Joanne M. Conroy, M.D.
And the issue is mental health. We know concerns around mental health have only worsened over the past few years. Those needing mental health services have long been stigmatized, and unfortunately, reimbursement for their care has been lagging for decades. Access to adequate mental health is perhaps the single most challenging obstacle that we all face as health care professionals at this moment in time. And finding these services is even more difficult in rural areas.

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Joanne M. Conroy, M.D.
With the mental health crisis worsening, hospitals and health systems are finding themselves more active in developing an advocating for solutions. At Dartmouth Health, like other organizations, we're working to build a stronger infrastructure to meet our patients behavioral health needs. Across the continuum of care. And we are super fortunate today to have our guest, Dr. Jeremy Musher, who's chief behavioral medical director at Lifepoint Health.

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Joanne M. Conroy, M.D.
Lifepoint Health is a health care delivery network with facilities in 31 states. The system includes 60 community hospitals, but also more than 60 behavioral health or rehab hospitals, along with hundreds of other sites of care that span the health care continuum. Jeremy, before we jump into our discussion, I know that the audience really likes to get to know our guests a bit.

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Joanne M. Conroy, M.D.
So I'm going to ask you to please share a little bit more about yourself and your journey into health care, specifically towards behavioral health. And I also wonder if our paths may have crossed the South Carolina when you were at the University of South Carolina, because I was in Charleston for a long time.

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Jeremy Musher, M.D.
I don't recall our paths crossing, but, we may have. I was there for a while. Actually, I started, doing my residency. I completed that in the Navy. So I was, Armed Forces scholarship student and, did my residency in the Navy and then was on active duty for a total of about six years. As you mentioned, I've worked in academia.

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Jeremy Musher, M.D.
I was, the residency training director or vice chair of the Department of psychiatry and associate dean for student affairs at the University of South Carolina. And in more recent years, I was the medical director for the psychiatric emergency services at Western Psychiatric at the University of Pittsburgh. I've also in the past been a psychiatric surveyor for CMS under the conditions of participation.

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Jeremy Musher, M.D.
And then for about 25 years had a private consulting company working with psychiatric hospitals and systems to ensure compliance with regulatory guidelines. I've also represented the American Psychiatric Association as the advisor to both the CBT panel and the RV Update Committee for about 15 years. About eight years ago, I joined the national psychiatric company Springstone as the chief medical officer and chief clinical officer.

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Jeremy Musher, M.D.
And then we were acquired, a year ago February, by Lifepoint Health. And now we are the Lifepoint Behavioral Health within Lifepoint.

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Joanne M. Conroy, M.D.
So behavioral health has become an incredibly important aspect of delivering care, not just at a facility level, but at a system level, which is probably behind the acquisition of Springstone by Lifepoint, really understanding that they had a gap in their services that they had to fill. But that gap has gotten wider during the pandemic and the economic challenges of the last few years.

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Joanne M. Conroy, M.D.
And I think people believe that, you know, access is still very, very difficult. What trends have you observed as you kind of look from a national level?

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Jeremy Musher, M.D.
According to the World Health Organization. in the first year of Covid, the global prevalence of anxiety and depression increased by about 25%. And in the United States, before the pandemic, about 8.5% of adults experienced elevated depressive symptoms. But in the early months of the pandemic in 2020, that number climbed to almost 28%. 2021 it was about a third of all U.S. adults, about 33%. Among young people aged 10 to 24

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Jeremy Musher, M.D.
suicide is the second leading cause of death in the US., with rates rising for decades. Between 2016 and 2022, children's hospitals saw 166% increase in ER visits for suicide attempts and self-injury among children 5 to 18. Youth suicide during Covid increased. The median monthly overdose deaths among persons age 10 to 19 increased over 100%, with 90% of those involving opioids, most of which were fentanyl.

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Joanne M. Conroy, M.D.
So you are looking at this from a national level, though, and I'm sure you say, why? As a group of leading health professionals, especially around pediatrics, those are scary statistics. As leaders, how do you devise a solution for that? Or how do you create a safety net for that? It seems an incredibly difficult problem to put your arm around.

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Jeremy Musher, M.D.
It is. And it really takes coordination and cooperation amongst, both the health care providers as well as the government. Right now and for some time, part of the difficulty in gaining access for patients has been because there aren't enough psychiatrists, there aren't enough behavioral health providers. Part of that is reimbursement issues...the barriers to access that CMS has, because of rules that haven't changed over many years, including Medicare, has a 190 day limit to lifetime mental health admissions.

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Jeremy Musher, M.D.
The institutions of mental disease, the IMD exclusion prohibits Medicaid from paying for psychiatric admissions and freestanding psychiatric hospitals for people aged 21 to 64. And something we struggle with all the time is the inpatient documentation and staffing requirements CMS has under the two special conditions of participation. All of these things, along with the payers and their authorization limits that psychiatry has that are different frequently than acute care, make it difficult to provide the services that so many people need.

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Joanne M. Conroy, M.D.
So let's talk a little bit about that pediatric population. We had a seminar for adolescent behavioral health a couple of years ago, I think. It was after the first wave of the pandemic when we thought it was safe, even though it really wasn't over. But we, you know all met in a ballroom, really kind of talking about the issues that adolescents and kids were facing.

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Joanne M. Conroy, M.D.
And what amazed me was the burden that we put on school nurses, and probably the lack of infrastructure to support them. Because they're kind of on the front line in the school systems, identifying some of these needs. It's a kind of a really robust kind of health system, or the alternative sites where you can actually identify these kids early and maybe get them help.

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Joanne M. Conroy, M.D.
Is that on the radar screen? It's almost like not just giving care within your facilities, but what are you doing in the community to really identify these kids early on?

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Jeremy Musher, M.D.
Well, we do work in some of our locations with local school systems, for instance Most of the work we do is, unfortunately, after they've been identified and come to the hospitals. But with the education that goes on, both we provide and many others provide in the communities, it is that identification comes earlier. We have in all of our freestanding psychiatric hospitals, an assessment area, sort of like, mini emergency room.

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Jeremy Musher, M.D.
And we see adolescents come all the time where we're able to give a screening and an evaluation and determine if their services are needed and if so, what level of care. So that helps get adolescents and sometimes younger kids into the system of care. We also work with primary care providers and pediatricians in terms of providing the kinds of backup and expertise that sometimes they need in order to treat more severely ill, kids.

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Joanne M. Conroy, M.D.
You know, we've invested heavily in telehealth, and we offer a lot of tele psychiatry, both to our emergency rooms, but even to our primary care clinics, if they have questions about resources or a diagnosis or a child where a telesite visit can actually help. How prevalent is that across the industry and is it something that we should invest more heavily in?

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Joanne M. Conroy, M.D.
Or if you had money to invest, where would you invest it to help kids in the best possible way?

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Jeremy Musher, M.D.
Definitely telehealth would the high on the list. We've been doing telehealth and psychiatry for years before the pandemic. But it really took off during the pandemic. And we've found that we can do groups, via Telehealth, as you said, we can consult with ERs. Even CMS has seen, there are so many advantages to the use of telehealth, predominantly from an access standpoint.

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Jeremy Musher, M.D.
They have lowered the barrier to access on telehealth and particularly for behavioral health, going forward. So the site of service won't matter anymore the way it used to. Telehealth makes a big difference. What we've found in our system is the patient satisfaction is, in most cases, equivalent to in-person visits.

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Jeremy Musher, M.D.
Plus, you don't have the difficulties of transportation. And so long as the insurers paid for it, that doesn't become a barrier. So, yes, telehealth, for sure would be one of the important areas to increase access going forward.

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Joanne M. Conroy, M.D.
Almost 80% of our behavioral health visits are virtual now, and the no-show rate is almost zero. And, you know, we don't always, think about the stigma that was associated with seeing a psychologist or a psychiatrist for not only a child, but even an adult. You all remember where you would enter one way and you'd exit another way.

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Joanne M. Conroy, M.D.
It was like reinforcing the stigma, although I totally understand why people did it, but it kind of validated that for everybody. There was a stigma to going to see a behavioral health expert. You know, we are doing some things up here at the college that are really interesting, where people can sense from how a adolescent actually interacts with their phone in terms of texting, identifying behavioral health issues early on.

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Joanne M. Conroy, M.D.
Have you heard of a lot of research in that realm, like how do we take a technology that we think causes isolation and try to use it to identify diagnoses before they actually manifest in different ways?

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Jeremy Musher, M.D.
Actually, there's been some, I think really interesting research going on. It's not out in the wild so much yet, but, there are apps, that they are working on, on iPhones and other phones, that use, for instance, the accelerometer in the phone to measure movement of the individual. And by using algorithms and AI you can use that information and other information - calls, texting, use of online access, etc. - to say, for instance, this individual has been reducing their movement over this period of time.

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Jeremy Musher, M.D.
Maybe they're depressed or other use of the phone to help identify. And then, the apps can proactively reach out to the individual and ask, are you feeling okay? Would you like to reach out to your therapist? Would you like to find a therapist? Those kinds of things. So yeah, we are seeing technology start to be used in ways that I think will make a huge difference.

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Jeremy Musher, M.D.
We're also seeing CBT - cognitive behavioral therapy is an evidence based form of therapy for anxiety and some forms of depression, etc.- and there are apps that you can use on your phone or online that help walk through some CBT treatment.

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Joanne M. Conroy, M.D.
Wow. And so with technology, although the cause of isolation may be some of the answer to isolation for many individuals in the future, Lifepoint acquired your organization for probably a specific purpose. What do they want to achieve at the Lifepoint health system level, and what would they like to achieve at the community level by adding you to their portfolio of health care services?

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Jeremy Musher, M.D.
Before we were acquired, Lifepoint Health had acquired Kindred Rehab about a year before us, and kindred had a couple of behavioral health hospitals. They had just started some interest in, behavioral health hospitals. But by acquiring Springstone, we brought to the table, 18 freestanding psychiatric hospitals, as well as about 35 outpatient clinics, across nine states.

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Jeremy Musher, M.D.
So it was a way for Lifepoint to essentially jump start their development of behavioral health resources. In addition, they already had, behavioral health units in many of their acute care hospitals. And so now across...we have about 2,500 inpatient psychiatric beds when you combine the behavioral health units in acute care hospitals with now 24 freestanding psychiatric hospitals across 31 states.

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Jeremy Musher, M.D.
So the idea in acquiring us was to get more involved in meeting needs in the communities of patients who needed behavioral health services and they weren't getting them. And part of the model going forward has been to develop joint ventures with predominantly med surge hospital systems who don't have enough behavioral health resources. And so by forming a joint venture with Lifepoint, we together can build a freestanding psychiatric hospital, for instance, or, work in the communities and bring those much needed behavioral health resources to the communities, particularly to more rural communities.

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Jeremy Musher, M.D.
The mission for Lifepoint is making communities healthier. And that's what we're moving to do as quickly as we can.

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Joanne M. Conroy, M.D.
Well thank you. You know, this topic is one that I think everybody will benefit listening to. And I want to encourage anyone who is struggling with feelings of anxiety or depression to please reach out to someone who can help. You can also visit the AHA.org or AHA's Physicians Alliance website for additional resources that are focused on stress, coping and mental health for health care workers.

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Joanne M. Conroy, M.D.
Thank you again, Jeremy. And until next time, thank you everyone for joining us today. I hope you'll be back for next month's Leadership Dialog.

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Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.