By KIM BELLARD

These are not happy times in America.

Now, I’m not thinking about the increasing cultural wars, the endless political bickering, the troubles in the Med-East or Ukraine, the looming threat of climate crisis, or the omnipresent campaigning for the November 2024 elections, although all those play a part. I’m talking about quantifiable data, from the latest World Happiness Report. It found that America has slipped out of the top 20 countries for the first time, falling to 23^rd – behind countries like Slovenia and the U.A.E. and barely ahead of Mexico or Uruguay.

Even worse, the fall in U.S. scores is primarily due to those under 30. They ranked 62^nd, versus Americans over 60, who ranked 10^th. A decade ago those were reversed. Americans aged 30-44 were ranked 42nd for their age group globally, while Americans between the ages 45-59 ranked 17^th.

It’s not solely a U.S. phenomenon. Overall, young people are now the least happy, and the report comments: “This is a big change from 2006-10, when the young were happier than those in the midlife groups, and about as happy as those aged 60 and over. For the young, the happiness drop was about three-quarters of a point, and greater for females than males.”

“I have never seen such an extreme change,” John Helliwell, an economist and a co-author of the report, told The New York Times, referring to the drop in happiness among younger people. “This has all happened in the last 10 years, and it’s mainly in the English-language countries. There isn’t this drop in the world as a whole.”

Jan-Emmanuel De Neve, director of the University of Oxford’s Wellbeing Research Center and an editor of the report, said in an interview with The Washington Post that the findings are concerning “because youth well-being and mental health is highly predictive of a whole host of subjective and objective indicators of quality of life as people age and go through the course of life.”

As a result, he emphasized: “in North America, and the U.S. in particular, youth now start lower than the adults in terms of well-being. And that’s very disconcerting, because essentially it means that they’re at the level of their midlife crisis today and obviously begs the question of what’s next for them?”

Gen Z is having a mid-life crisis.

The researchers speculate that social media, political polarization, and economic inequality between generations contribute to the low scores for younger Americans. Jon Clifton, CEO of Gallup, believes: “Young people have more social interactions, but feel more lonely,” and that they aren’t as connected to their job, churches, or other institutions.

“One factor, which we’re all thinking about, is social media,” Dr. Robert Waldinger, the director of the Harvard Study of Adult Development, said in a NYT interview,. “Because there’s been some research that shows that depending on how we use social media, it lowers well-being, it increases rates of depression and anxiety, particularly among young girls and women, teenage girls.”

Others note the impact of the pandemic. Professor De Neve said: “general negative trend for youth well-being in the United States [was] exacerbated during covid, and youth in the U.S. have not recovered from the drop.” Similarly, Lorenzo Norris, an associate professor of psychiatry at George Washington University, who was not part of the World Happiness study, told NYT:

The literature is clear in practice — the effect that this had on socialization, pro-social behavior, if you will, and the ability for people to feel connected and have a community. Many of the things that would have normally taken place for people, particularly high school young adults, did not take place. And that is still occurring.

“It’s a very complex time for youth, with lots of pressures and a lot of demands for their attention,” Professor De Neve diplomatically observed.  It was not true in all countries that younger people were the unhappiest, and Professor De Neve suggests: “I think we can try and dig into why the U.S. is coming down in terms of wellbeing and mental health, but we should also try and learn from what, say, Lithuania is doing well.”

Did you ever expect Lithuania might be a role model for our young people?

Professor Helliwell told CNN that young people are reflecting what is going on around them: “Almost whatever institution you’re in, people in North America seem to be fighting over rights, responsibilities and who should be doing what to improve things and who is to blame for things not going well in the past.”

Amidst all the gloomy findings, the report did say: “The COVID crisis led to a worldwide increase in the proportion of people who have helped others in need. This increase in benevolence has been large for all generations, but especially so for those born since 1980, who are even more likely than earlier generations to help others in need.” They may be less happy, but Gen Z and millennials aren’t less charitable.

So there’s that.

Honestly, if young people aren’t depressed, they’re not paying attention. Social media is dominating their lives, whether Instagram is making them feel depressed or TikTok is driving them to harmful mental health content. They can see the impacts of climate change but not any sign that their elders plan to do anything about it. Their jobs are neither satisfying nor economically viable enough to allow them to build wealth, especially when suffering from crushing student loans. They don’t expect Social Security to help with their retirement, whenever that may be and whatever that might look like. They have no reason to think that the largely geriatric politicians understand them or their needs.

And when it comes to health care, they can see the attacks on women’s health, the inadequate support for mental health, and the gap in technology versus in the rest of their lives.

They have every reason not to be happy. 

The thing about mid-life crises is that they’re supposed to happen, you know, mid-life. Youth is supposed to be a time of optimism and exploration, of wanting to change the world. If current youth is already unhappy, we can’t assume they will grow happier, like those of us over 60 seem to have. This is the America we’re bequeathing them; the question is, are we OK with that?

Maybe a trip to Lithuania isn’t a bad idea after all.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

By JON KOLE

Nearly 66 million Americans are currently enrolled in Medicare, a number that will likely swell towards 80 million Americans within the next seven years. These are our mothers, fathers, aunts, uncles, grandparents and friends – and, maybe, you. 

A significant portion of these millions of people need mental health services – and, yet, many face long wait times or aren’t able to find a therapist at all. On average, Americans have a waiting period of 48 days before receiving mental health care. At present, two notable provider groups – Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs), which summed to approximately 415,000 in 2021 – have not been eligible to provide psychotherapy for people with Medicare.

Currently, Medicare only approves psychologists and masters-level Licensed Clinical Social Workers (LCSWs) to provide therapy to Medicare recipients. In July, CMS proposed policies that would significantly increase access to mental health services by adding MFTs and MHCs into the ranks of Medicare-eligible providers.  At a time where access to mental health services is acutely limited, it is startling that such a large pool of providers with advanced specialized degrees are not allowed to provide care.

There are many similarities between LCSWs and MFT/MHC training. In addition to an undergraduate degree, LCSWs, MFTs and MHCs have completed a two-year Master’s program, which is then followed by two years of supervised clinical practice prior to taking a licensure exam in their relevant discipline. Once they pass that test, they are able to practice independently in a wide range of settings.

Adding these trained professionals to the roster of available providers is a meaningful step to improve access to mental health services for Medicare members.

Improving access is not just about getting to a provider, though, t’s also about getting connected to one that a patient can feel safe with, connected to, and build a strong working rapport with. According to AAMFT, the satisfaction rate among patients engaged in care with a MFT is exceptionally high, with nearly 90% reporting an improvement in their emotional health after receiving treatment.

One key element in patient-provider connection is allowing options for demographic matching. Studies have shown that when patients from ethnic/racial minority backgrounds are able to connect with providers who share similar demographics, they report better health outcomes and increased satisfaction with the care provided. In one analysis, data gathered from Black caregivers showed 83 percent felt that having a mental health provider of the same race and ethnicity was important, citing themes like relatability, diversity in cultural experiences and the overall patient experience.Adding MFTs and MHCs has the potential to improve demographic matching, given that these are more diverse groups than PhDs or LCSWs.

Given the overall supply-demand imbalance, which is only predicted to get worse, the time is now to ensure that the entire qualified mental health labor force is able to work with Medicare recipients. The CMS proposal would do that. 

It is often said in health care economics that there is an “iron triangle” of quality, access, and cost. When trying to improve any of these domains, you always risk worsening one of the other two. With MFTs/MHCs typically collecting lower salary averages than LCSW and PhDs, this addition will likely generate cost savings for Medicare, leaving a question of quality. Will a Medicare member get the same quality of care with a MFT or MHC that I would get with an MSW or PhD?

The reality is for many conditions, including some of the most common depressive and anxiety disorders, we know confidently there are a variety of therapeutic approaches that are effective. In fact, there is strong evidence that quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures. This means for many of the most common conditions affecting Medicare recipients, the most important aspect of their therapy is not the letters listed after their provider’s name, but instead their provider’s ability to make them feel seen, validated, and encouraged to share and engage with the treatment recommendations made.

Finally, and most importantly, schools educating therapy trainees of all types historically have not emphasized the most evidence-based treatments. First published in Myrna Weissmans’ “National Survey of Psychotherapy Training” and outlined in Dr. Thomas Insel’s book Healing, “over 60 percent of professional schools of psychology and master’s of social work did not include any supervised training for any scientifically based therapy.” These numbers are only slightly better than those in MFT/MHC schooling. This is not a concern to be taken lightly. For conditions like post traumatic stress disorder, obsessive compulsive disorder, and eating disorders, offering evidence-based therapies can be the difference between meaningful recovery and persistent struggling. Ensuring patients are getting high quality evidence therapy is an issue not limited to MFT/MHCs and will require commitment across professional schools.

Fortunately, for all mental health providers, education does not conclude with their professional schooling. MFTs and MHCs, like social workers and psychologists, are required to complete yearly continuing education to maintain their licensure. There is great research interest in disseminating evidence-based training to therapists of all backgrounds as this is a demonstrated need across licensure. With greater focus from insurers, employers and clinical leaders on measurement-based care and evidence-based practices, MFTs and MHCs are increasingly required to document and demonstrate the evidence-based elements of their therapy work. 

As our population ages and our mental health utilization reaches all time highs, opening the door by adding over 400,000 additional therapists to support Americans depending on Medicare is a reason to rejoice. We have a real potential to reduce costs and improve access to mental health services to this population. And as to questions of ensuring high quality, all of us in mental health care, regardless of the letters after our name, have to own this challenge with commitment to continued education in service of those we treat.

Dr. Jon Kole is Medical Director and Senior Director of Psychiatry at Headspace

Flawed Accounting for the US Health Spending Problem

By Jeff Goldsmith

Source: OECD, Our World in Data

Late last year, I saw this chart which made my heart sink. It compared US life expectancy to its health spending since 1970 vs. other countries. As you can see,  the US began peeling off from the rest of the civilized world in the mid-1980’s. Then US life expectancy began falling around 2015, even as health spending continued to rise. We lost two more full years of life expectancy to COVID. By  the end of 2022, the US had given up 26 years-worth of progress in life expectancy gains. Adding four more years to the chart below will make us look even worse.  

Of course, this chart had a political/policy agenda: look what a terrible social investment US health spending has been! Look how much more we are spending than other countries vs. how long we live and you can almost taste the ashes of diminishing returns. This chart posits a model where you input health spending into the large black box that is the US economy and you get health out the other side. 

The problem is that is not how things work. Consider another possible interpretation of this chart:  look how much it costs to clean up the wreckage from a society that is killing off its citizens earlier and more aggressively than any other developed society. It is true that we lead the world in health spending.  However, we also lead the world in a lot of other things health-related.

Exceptional Levels of Gun Violence

Americans are ten times more likely than citizens of most other comparable countries to die of gun violence. This is hardly surprising, since the US has the highest rate of gun ownership per capita in the world, far exceeding the ownership rates in failed states such as Yemen, Iraq and Afghanistan. The US has over 400 million guns in circulation, including 20 million military style semi-automatic weapons. Firearms are the leading cause of deaths of American young people under the age of 24. According to the Economist, in 2021, 38,307 Americans aged between 15 and 24 died vs. just 2185 in Britain and Wales. Of course, lots of young lives lost tilt societal life expectancies sharply downward.

A Worsening Mental Health Crisis

Of the 48 thousand deaths from firearms every year in the US, over 60% are suicides (overwhelmingly by handguns), a second area of dubious US leadership. The US has the highest suicide rate among major western nations. There is no question that the easy access to handguns has facilitated this high suicide rate.

About a quarter of US citizens self-report signs of mental distress, a rate second only to Sweden. We shut down most of our public mental hospitals a generation ago in a spasm of “de-institutionalization” driven by the arrival of new psychoactive drugs which have grossly disappointed patients and their families. As a result,  the US  has defaulted to its prison system and its acute care hospitals as “treatment sites”; costs to US society of managing mental health problems are, not surprisingly, much higher than other countries. Mental health status dramatically worsened during the COVID pandemic and has only partially recovered. 

Drug Overdoses: The Parallel Pandemic

On top of these problems, the US has also experienced an explosive increase in drug overdoses, 110 thousand dead in 2022, attributable to a flood of deadly synthetic opiates like fentanyl. This casualty count is double that of the next highest group of countries, the Nordic countries, and is again the highest among the wealthy nations. If you add the number of suicides, drug overdoses and homicides together, we lost 178 thousand fellow Americans in 2021, in addition to the 500 thousand person COVID death toll. The hospital emergency department is the departure portal for most of these deaths. 

Maternal Mortality Risks

The US also has the highest maternal mortality rate of any comparable nation, almost 33 maternal deaths per hundred thousand live births in 2021. This death rate is more than triple that of Britain, eight times that of Germany and almost ten times that of Japan. Black American women have a maternal mortality rate almost triple that of white American women, and 15X the rate of German women. Sketchy health insurance coverage certainly plays a role here, as does inconsistent prenatal care, systemic racial inequities, and a baseline level of poor health for many soon-to-be moms.     

Obesity Accelerates

Then you have the obesity epidemic. Obesity rates began rising in the US in the late 1980’s right around when the US peeled away from the rest of the countries on the chart above. Some 42% of US adults are obese, a number that seemed to be levelling off in the late 2010’s, but then took another upward lurch in the past couple of years. Only the Pacific Island nations have higher obesity rates than the US does. And with obesity, conditions like diabetes flourish. Nearly 11% of US citizens suffer from diabetes, a sizable fraction of whom are undiagnosed (and therefore untreated). US diabetes prevalence is nearly double that of France, with its famously rich diets. 

Causes of obesity include: poverty and racial inequity, poor diet, lack of physical activity, prepared foods laden with processed sugar and salt, food desserts, etc. There has been an eerie correlation between the decline in adult smoking and  the rise in obesity; one lethal anxiety reducer replacing another beginning  in the late 1980’s, right around the time our health costs peeled away from the rest of the world vs. life expectancy. Our high rate of obesity undoubtedly contributed to the US  death toll from COVID. More than 70% of COVID casualties among the US population were obese or overweight. Obesity rendered the infected vulnerable to breathing and circulatory problems aggravated by COVID.

Our Appalling COVID Performance

And of course, per capita deaths from COVID in the US, though not the highest in the world, significantly exceeded the death tolls in most wealthy nations. According to the Economist, we lost  between 1.3 and 1.4 million people to COVID., the third most “excess deaths” of any country (after India and Russia).* Our peer group in the rate of excess deaths per thousand during the pandemic included:  Kazakhstan, Greece, Brazil and Estonia.  

Countries that excelled in combatting this pandemic, which had death rates less than one-fifth of ours- New Zealand, Taiwan, Japan, South Korea- seem to share two traits in common: competent governments capable of acting quickly and decisively to manage public health risks and populations that respected both scientific authority and public health mandates. In the US, we lacked both of these things.

* Excess deaths- deviation above the normal predicted level of deaths in a year- may be a better measure of the pandemic’s effects than “official” COVID deaths, due to complexities in attribution of deaths to specific causes and political interference by government

Toxic Libertarianism

During the pandemic, an ethos of F#@ck You Libertarianism took firm hold in much of the US: “My right to go bowling is more important than your right to be disease free! You are NOT the boss of me!” A gross imbalance between individual rights and responsibilities to the society manifest itself in resistance to masking, social distancing and vaccination. The same objections “libertarians” had to COVID precautions apply equally to traffic signals or drunk driving restrictions, which are also abridgements of individual rights in service of a common good. Basic and sensible public health measures became politicized in a tidal wave of social media-fired nonsense; any doofus with an Internet connection became his or her own epidemiologist or virologist. Public health is now, to many Americans, an elitist conspiracy to deprive them of their freedom. 

And the resistance was well armed.  A not-so-well-regulated militia of local citizens armed with semi-automatic weapons and walkie-talkies turned up to reopen the Crash and Burn Tattoo Parlor in Shepherd, Texas in April, 2020. Radical libertarian militiamen were convicted of a plot to kidnap and murder the Governor of Michigan based on her enforcement of pandemic closures! 

Not a Failed Economy but a Struggling Society

The US has certainly not failed as an economy. A recent Economist analysis show us pulling away from our European peers in wealth generation. It had a similar record in productivity growth. So it isn’t a resource shortage that is holding us back. The US is also  not a failed  state; it fought off a coup attempt after the 2020 federal election, and successfully defended the integrity of its election system in the 2022 mid -terms. 

But US society’s performance has been truly cringe-worthy. Start with a base layer of income inequality and the resultant unresolved racial and social class antagonisms, stir in pervasive obesity, widespread depression,  anxiety, and a high ambient level of anger, add over 400 million lethal weapons, flood with fentanyl and then a lethal virus and you are left with the chart which we began this essay. In the inimitable words of  Walt Kelly’s Pogo: “We have met the enemy and he is us”.

Health System Not Blameless

We cannot and should not absolve our health care system of blame; it is 17.3% of our economy. Our pharmaceutical industry, including wholesalers and retailers, lit the match that exploded into the epidemic of opioid addiction and deaths. But other corporate interests have contributed materially to the broader decline in Americans’ health. Our food industry -fast and otherwise-bears a lot of responsibility for the flood of cheap calories and oversalted prepared foods. Gun manufacturers and Second Amendment absolutists have facilitated not only the explosion of gun ownership, but the inability sensibly to restrict their use.   

And we can thank two generations of distracted state and national political leadership of both parties, and an ethos of “don’t worry, the market will fix it”, for abandoning our inner cities and much of rural America  notably the Deep South and “greater Appalachia”. This malign neglect created economic conditions that narrowed life choices, and a marked disparity in life expectancy depending on where you live (see map below). It also helped foster a deep and festering resentment among those who were left behind which found its expression in the election of Donald Trump and in the rioting that followed the George Floyd murder.   

What Isn’t Going to Matter Much

Is our health system too costly both to individuals and to US society? Absolutely. But the forces that push up the demand for care and generate those health costs are deeply imbedded in a poorly functioning society. The current roster of health policy nostrums favored by academia, the policy commentariat and the consulting community – “price transparency”, further shifting of health costs onto strained household budgets, converting Medicare to a voucher program instead of a “service benefit,” state administered hospital price controls and yet another wave of futile technocratic payment system tinkering for hospital and physician care such as that launched by ObamaCare – do not even graze the underlying problem.

What Might Actually Help

There are things we can do that might make a difference. We can create a safe “third place” besides prison and the acute care hospital for schizophrenics and others of danger to themselves or others (and dramatically reduce incarceration rates while at it). We can do a much better job of keeping the mentally disturbed away from firearms. We can break the cycle of revenge-driven shootings by intervening sensibly at the neighborhood level. We can also do a much better job of managing addiction in a humane and thoughtful fashion, by dramatically expanding both the quality and availability of addiction treatment.   

We can raise taxes on salt and processed sugar added to food, and use the money to fund research into food addiction. We can also reduce taxes on fresh fruit and vegetables to make them more affordable to the poor and near poor.

Most importantly, we can dramatically improve our system of social care, particularly support for family care-giving, as Elizabeth Bradley and Lauren Taylor suggested in their outstanding The American Healthcare Paradox. Anything we can do to strengthen American families’ ability to remain together will make a material difference in Americans’ health and reduce pressure on health spending. And even with all the pandemic related extensions of health coverage, 28.5 million Americans still lacked health coverage in 2022, whose costs of care were shifted onto the rest of us.

Fixing Broken Regional Economies

But none of this will matter much unless we can reverse the outflow of public and investor capital from the abandoned localities in our country, both urban and rural, and create dignified and lasting employment for those that live there. Life expectancy differences closely mirror the health of local economies. If the hospital is the largest employer in many of these communities, as it is, that is not an economically sustainable state of affairs. 

It is not random that the lowest life expectancies in the US (fifteen years or twenty years lower than the national averages in some counties) can be founded in regions of the US such as Appalachia and the Deep South that have struggled economically for more than fifty years. Buz Cooper convincingly argued in his brilliant Poverty and the Myths of Health Reform, that poverty and all its sickness-inducing correlates is the most important driving force in the variation in health spending, not flawed payment schemes or oversupply of care system resources.  

Source: US Census Bureau

The country is so big, both in geography and population, that it is difficult to understand or appreciate how things are for others that are geographically remote from us. But travel writer Paul Theroux, in his Deep South, said he found poverty in the American South that was worse than what he has seen in rural Africa.  There are significant health (and political) consequences for this poverty.  

Given the fragmentation, how we can get Americans to actually focus on helping each other may be the most difficult problem of all. It is galling to see totalitarian societies like China use our current troubles to justify stripping their own citizens of their freedom and dignity and abusing their human rights in the name of “social order”.

By the time those who have been damaged by neglect reach the Emergency Department, it is too late to help most of them.  Our present flawed social accounting system blames the health care system for the cost of patching up the damage from all the problems enumerated above. . You do not need a doctorate in sociology to realize that the problems that generate all those health costs lie much deeper. They are soluble problems.  We must use our wealth, ingenuity and boundless American energy to foster a sense of mutual responsibility that transcends racial, ethnic and social class boundaries to fix these problems.   

An excellent NPR report in March, 2023 entitled “Live Free and Die” explored these issues, as did a similarly excellent April, 2023 piece in the Economist. 

Jeff Goldsmith is the President of Health Futures Inc. This first appeared on his substack

Next is Julia Kastner, CPO & Chris Molaro, CEO, Neuroflow, and it includes a great brief product demo from Julia

Telehealth addiction treatment clinic Boulder Care just closed a $36 million Series B. I’ve got Founder & CEO Stephanie Strong here to talk about the virtual care company’s medication-assisted approach to opioid and alcohol use disorder treatment, and its growing-bigger-by-the-day presence in the Medicaid market.

In fact, more than 95% of Boulder Care’s revenue comes in from Managed Medicaid plans, and this focus on making medications like Suboxone accessible to traditionally marginalized patients is not only better for patients (drugs like these can cut all-cause mortality rate by half or more) but also compelling for payers. Stephanie says patients suffering from opioid addiction who go untreated are 550% more expensive to the plan than those who are not, and these types of medications facilitate recovery by making it bearable, blocking withdrawal symptoms.

We get into the details behind Boulder Care’s approach, which includes a number of wrap-around support services, including those provided by the startup’s care delivery team that is set to grow as a result of this Series B funding. And speaking of scaling… Does Stephanie have any concerns about challenges that Boulder Care might face prescribing-and-managing controlled substances as a result of the scrutiny created by Cerebral’s bad behavior? Any additional concerns about changes to the clinic’s telehealth practices when the Covid19 public health emergency comes to an end? And…what about competition in this space?? Particularly as similar-looking Bicycle Health announced its $50 million Series B just days earlier? A great inside look at how virtual care is changing the specialized mental health care space.

Otsuka Pharmaceuticals is expanding its mental health formulary – looking beyond traditional medications to psychedelics, and to the “intersection of technology and psychiatry” with digital therapeutics currently in clinical trials for Major Depressive Disorder. Kabir Nath, Senior Managing Director of Otsuka’s Global Pharmaceutical Business, lets us in on the thinking behind these bold moves, why the pharma co is even innovating to expand the spectrum of treatments available for mental illness in the first place, and how soon these new therapies will reach patients.

“Follow the science” is a key undercurrent of this conversation, particularly as we talk through Otsuka’s investments in psychedelic medicine start-ups Compass Pathways and, more recently, Mindset. Kabir says the body of clinical evidence for these therapies is building and we get his prediction on when they might become more mainstream and readily available.

We also get his take on digital therapeutics (DTx) and the work Otsuka is doing with Click Therapeutics in Major Depressive Disorder. Their clinical trial, done in partnership with Verily, is the first-ever fully remote clinical trial conducted in this space, and the hope is that it not only generates evidence to support the emerging DTx category, but that it also sets a precedent for a new, tech-enabled way to run clinical trials.

This is just the beginning. There’s lots more on the innovations changing pharma and the future of mental health care in this one. Watch now!

Big news coming out of Vida Health today as the chronic condition care startup announces that it will now be able to prescribe meds, med devices, lab tests, and more to its members. This puts Vida Health among the first of the digital health chronic care companies to evolve its offerings beyond apps-and-coaching, leading on this trend to take digital health chronic care into a more full expression of virtual care.

Vida Health’s Chief Medical Officer, Dr. Patrick Carroll, introduces us to the new offering which he tipped us off about when we met him a few months ago, new to his role at Vida and coming in hot from Hims & Hers where he built similar services as he took that company public as CMO.

The new prescribing services will cover both sides of Vida Health’s integrated model: mental health and cardiometabolic health, but in different ways. On the mental health side, Pat says members will be able to receive prescription meds for anxiety and depression ONLY at this time; on the cardiometabolic side, members working with Vida Health will NOT be able to get prescription drugs to help with diabetes or heart health, but would instead be able to get continuous glucose monitors (CGMs) prescribed, specialized diets, and labs, like A1C testing, that require a script.

Do these prescribing services begin to turn Vida Health into a primary care provider? If not, how do these new prescribing and medication management roles integrate with whatever other primary care offering is in place through a member’s plan or employer without adding cost or confusion to the patient experience? We talk through the evolution of both care model and business model as Vida Health adds another layer to its full-stack chronic condition management platform.

BY BEN WHEATLEY

A woman was walking in the crosswalk of a busy intersection as the rain started to come down. She looked cold, but more than that, she looked off. She had no shoes on her feet and her countenance was in disarray. It seemed to me that she was in the midst of a mental health crisis. 

The woman approached where I was standing and I suggested that she go into the Starbucks on the corner to look for her shoes. At least in there, it would be warm. She didn’t go inside, but instead went to the entrance and sat down on the ground. 

Someone must have called 911 because a policeman and an ambulance with an emergency medical technician showed up. The EMT brought a stretcher down from the ambulance as the policeman watched over the situation. The woman got on the stretcher and the EMT placed a blanket over her. As this played out, the policeman stood in the background, allowing the EMT to take primary responsibility for the interaction. Since the woman seemed to pose little risk to herself or others, the response seemed to be the appropriate one. 

In recent months, mental health advocacy groups and others have sought to limit the role of police in mental health crises. They note that “Mental illness is a health condition, not a crime, and health practitioners should respond to crisis calls, not law enforcement.” This is especially important because interactions between the police and the mentally ill have at times proven deadly. According to the National Sheriff’s Association, “The increasing number of confrontations between law enforcement officers and persons with serious mental illness [have led] to some unfortunate outcomes. Among the most tragic are officer-related shootings of the mentally ill individuals, many of which are fatal.”

The New 911 for Mental Health Crises

Beginning in July 2022, a new 3-digit telephone number (988) will be implemented to address mental health crises, cases involving substance use disorder (SUD), and individuals in emotional and/or suicidal distress. Many believe that 988 can serve as the basis for a reimagined crisis response system. 

988 originated as part of an effort to combat rising suicide rates. Calls placed to 988 will be routed to local call centers of the National Suicide Prevention Lifeline (NSPL). The 3-digit number is designed to make it easier for those in distress to reach help when they need it most, rather than having to remember the current 10-digit number.

For those in suicidal distress, just having someone to talk to is often enough to address the crisis. According to the Suicide Prevention Lifeline, “Numerous studies have shown that callers feel less suicidal, less depressed, less overwhelmed and more hopeful after speaking with a Lifeline counselor.” 

However, there are some cases that are more serious in nature and call takers may assess the person as being at “imminent risk” of suicide. In those cases, calls may be transferred to 911 and police may be dispatched to the caller’s location. The Lifeline seeks to utilize involuntary methods of suicide prevention only as a last resort. 

According to the Lifeline, “Some crisis center staff members report reluctance to call 911 for fear [that] local law enforcement officials [will] resort to inappropriate force, arrest, or other…undesirable outcomes for the caller in need of care.” However, critics of the NSPL allege that crisis center staff may “call the police pretty quickly…[because they get] really panicked [and feel] like it would be their fault if the person killed themselves.” This tension illustrates the potential push and pull that may come to exist between 911 and 988—including the appropriate role of police. 

Police Involvement in Mental Health Crises

Though it makes sense to say that mental health conditions should be treated as matters of health care, not criminal justice, the assertion becomes more difficult when tested against specific cases. For example, I am familiar with one case from twenty years ago involving a man who was experiencing psychotic delusions. He believed that the gym in his apartment building was an imaginary “Holodeck.” Wikipedia describes a Holodeck as “a fictional device from…Star Trek which uses ‘holograms’ to create a realistic 3D simulation…in which participants can freely interact with the environment as well as objects and characters [in] a predefined narrative.” He believed that the Holodeck was set up to show him “how to meet women in bars.” 

When he visited the gym in his psychotic state, there were two women working out, one on a treadmill, the other on the weights. He leaned against the wall behind the woman on the treadmill—already acting strangely. He wasn’t fully convinced that he was actually in a Holodeck, so he tested reality by using his index finger to poke the woman on her shoulder. In doing so, he committed assault. The cops came and took him to the police station in handcuffs. At one point while there, he said something or did something—or didn’t do something—that caused the cops to forcibly take him to the ground, face down, with the knees of several officers on his back and legs. He didn’t resist. However, later he went on a loud and lengthy rant. In one memorable line, he yelled: “Noah’s Ark is going over Niagara Falls, are you in or are you out?” He spent a month in an inpatient psychiatric facility. Subsequent to that, he received a year of probation for the misdemeanor assault. 

Though we can talk about a paradigm shift that recognizes mental health conditions as matters of health care, rather than criminal justice, this case shows how difficult it can be to extricate one from the other. In this case, there was a direct link between the delusional thought and the criminal action. In claiming that law enforcement should take a secondary role in mental health crises, we are saying that legitimate criminal complaints such as this one will not be charged or adjudicated. That seems unlikely. When we come to a specific, real-life example of mental health crisis, the notion of secondary police involvement seems much more difficult to achieve. 

This example demonstrates how the behavior of the mentally ill can push the limits of our empathy and understanding. Nevertheless, to address the mental health challenge that we face, more understanding is required. To quote Alisa Roth from The Atlantic, “In order to truly fix our broken approach to mental illness, there needs to be a change in attitude: one that goes from seeing people as inherently dangerous to treating them as human beings in need of help.” This change can move us toward decriminalization. 

Ben Wheatley has 25 years of experience working in health policy with organizations including AcademyHealth, the Institute of Medicine, and Kaiser Permanente.