The Covid-19 pandemic has exacerbated an already severe behavioral health crisis in the United States, which has led the health care industry to invest heavily in virtual telehealth—an investment that could do a lot a good, but isn't without its risks. 

Radio Advisory's Rachel Woods sits down with Advisory Board's Nick Cericola and Clare Wirth to talk about the potential consequences that could come with the health industry's recent investment in virtual behavioral health.

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Read a lightly edited excerpt from the interview below and download the episode for the full conversation.

Rachel Woods: The conversation that we're having right now is so important because it's a reminder that even in a moment where there's a lot of positive momentum, we have to be thinking about risks, whether that's the downstream equity impact of an initiative or any of the other kind of unintended consequences that even the best intentioned efforts can have. Nick, what do we risk as we go down this path of heavy focus on non-traditional entrants, heavy focus on digital behavioral health?

For example, providers who have moved into a self-pay practice have done so because that's where the most financial upside currently exists in behavioral health. Well, if they see more of their patients migrate towards digital health vendors because they're more accessible and more affordable, those traditional providers may see further challenges in maintaining their practices and meeting the needs of the patients who do continue to rely upon in-person consultations and expertise.

Woods: You're also talking about a marketplace that just gets a lot more complicated, right? And maybe I'll even use the word fragmented if there are a lot more options for me to choose for care.

On the one hand, that is a good thing, right? We said that it improves access, but does it ultimately mean that the behavioral health space becomes more fragmented than it has been in the past?

Cericola: So that was going to be my second thing, Rae. We already are seeing fragmentation on a couple of levels from the standpoint of consumers and employers who are charged with picking digital health vendors in the behavioral health space and elsewhere, they're confronted with a sea of options, right? Some of which have published data on outcomes, some of which are really relying on well-funded marketing campaigns to attract attention and users.

Woods: Not to mention the fact that some vendors kind of mimic traditional behavioral health and some are kind of text-based, right? Chat bot-based, right? How do you pick between all of the options and figure out what's the best thing for you?

Cericola: Exactly. There are a lot of asynchronous and app-based tools, some of which promise to do pretty incredible things, some of which have been able to share data, and others that haven't on whether or not those things have actually borne out.

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But I also think fragmentation exists for people who are in that ecosystem, as far as the inability for them to navigate across the continuum of care, right? Through a series of design choices, some of them intentional, some of them not, digital behavioral health companies have made it somewhat difficult for patients to escalate their needs in-person behavioral health care, to be referred to other specialists even to primary care, if that's where their need is.

And that is a problem that we're going to continue to see as long as we are in a marketplace that favors new entrants and before some force consolidates that space for the benefit of a more integrated delivery system.

Clare Wirth: And what do we think about the traditional care team where the primary care provider (PCP) has a patient who is getting care from this digital behavioral health, too? There's no feedback loop happening for that PCP to better manage that patient's chronic conditions.

And I'm putting my population health manager hat on here and thinking about the implications of if we're going to improve patient outcomes then we need these things to be better integrated. And that's just not going to be possible if this marketplace continues to become so fragmented.

Woods: I am a little bit struck by the fact that we started off this conversation on a very positive note and talking about barriers that have come down, such as access, stigma, costs. But I think what you're telling me is that if we're not careful, a lot of the barriers that we've been talking about historically might actually get worse and not better, at least for a portion of the population.

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Cericola: I think they could get worse, but I don't think that's a foregone conclusion either. I want to make sure that we're not suggesting that this is an inevitability. I just think it's going to take active measures on the part of traditional providers, payers, employers, and disruptors to make sure that the risks that we're describing are not perpetuated and not worse.

And in fact, I think we still could see a world in which those things are significantly mitigated based on the amount of financing that's being put into behavioral health space right now.

Woods: So let's talk about how to address some of these barriers. And I want to start off by talking about a barrier that we haven't actually talked about a bunch on this episode, at least. Clare, I know you and I talked about this ad nauseum in the last episode, which is just the fact that there is a massive mismatch between supply and demand, and the size of the workforce isn't necessarily getting any bigger.

Is there anything that we can do, and I mean saying we not meaning just the traditional health care space, but all of the new players who are looking to behavioral health, are there things that we can do to shore up more behavioral health supply?

Cericola: On one hand I think traditional providers in the behavioral space that specialists and PCPs need to adapt, right? Disruption is coming their way, whether they like it or not. So this is a time to think about improving throughput, creating new access by embracing digital modalities, right?

If you want to maintain your practice and continue to make yourself available as a provider in your marketplace, then it's time to embrace some of the characteristics of some of these new entrants.

But I also want to make sure that we cast that spotlight back on the new entrants themselves, who I think have a responsibility to build and sustain the behavioral health profession that it's not totally clear to me that they're embracing just yet.

Wirth: And Nick, what I think you're hitting on is that behavioral health management is care management. And that's something that traditional players, PCPs, etc., have to get their minds around for behavioral health.

And that digital disruptors and companies are doing a really effective job of, is pairing these one-on-one visits, patient engagement types of efforts with asynchronous, ongoing support to help manage their condition.