Unseen Opportunities in Mental Health, ft. Dr. Martin Hickey, New Mexico State Senator

Martin (00:00):
In my experience I always, being a physician, you want to go get through the symptoms and get down to the cause of the disease. And in the treatments you want to do the same as well. And here’s the take home point. There’s one word that is central to substance use therapy, mental health, and what have you. And that word is connection, connection, human connection.
 
Chris (00:33):
Hello Healthcare. Today I’m joined with Dr. Martin Hickey, who is state Senator of New Mexico district 20 and has served in a variety of leadership roles, chief executive officer roles in health plans and health systems in New Mexico, including the Loveless Health System, True Health New Mexico, and many more roles. But today what we’re going to be discussing, what we’re going to be digging in deeper is a sector of healthcare that is often ignored, which is mental health. We know that mental health resources across the country are lacking. And the system that, if we consider any kind of social safety net, it’s a very much a net where many people fall through with tragic consequences.
 
This is going to touch into subjects around substance abuse and mental health. A lot of things that have been stigmatized over the past that are now receiving a lot of new attention and destigmatization as a result of a lot of the things that we’ve been going through over the past few years with the pandemic, making these issues, bringing these issues to light, and honestly bringing us to more truth about how we’re impacted and how we suffer.
 
So Dr. Martin’s going to be discussing, kind of from a health executive perspective, not only like the issue and size and breadth and scope of the problem, but where healthcare executives can intervene and ultimately where there is financial opportunity there. We were discussing a little bit earlier that it is kind of said that it takes a discussion on financial opportunity to address these challenges. But the system that we live in now is presenting opportunities to address these.
 
So the exciting thing about working in healthcare, working with healthcare leaders is that we know that all the services that we offer have margins associated with them, but now we can focus on, hey, there’s a purpose to the margin that we’re seeking. If there’s, if this is the way that we have to solve the problem within the confines of the system, let’s explore that and let’s understand how we can do the best for our patients and be present for them from a mental health perspective. With that intro, Dr. Martin, I just wanted to give the opportunity to just give some of your background and let them know who you are better than I can.
 
Martin (03:08):
Sure. Thank you, Chris. I think you summarized the area very well. I’m a physician and I started my career not too far from here in Salt Lake in the Indian health service on the Navajo reservation for seven years, progressed through a number of different organizations. Ran the faculty practice at the University of New Mexico, became CEO of Loveless Health Systems back in the nineties, where we really pioneered disease management at the time. And also, I know now had a phenomenal mental health, behavioral health component to our highly integrated system and large medical group. And from there on to other roles in Blue Cross, what have you. And then I came home to New Mexico and started a co-op under the ACA under Obamacare. And that co-op was a health insurance company that was governed by its members. And in that experience, we decided that behavior health just wasn’t getting the attention that it should get. Substance use in New Mexico is just through the roof. Poverty in New Mexico, half the state is on Medicaid and no other state comes close to that.
 
And so poverty just exacerbates mental health, substance use issues. And we realized we really needed to address that issue in this co-op. And so we did away with all co-pays, co-insurance, cost sharing so that people would not be inhibited to seeking and getting care because they had out-of-pocket expenses. And those definitely turned out to be a barrier. We learned a lot from that. And then when I retired from that, after eight years, I looked at the legislature in New Mexico and saw that there was no one with a healthcare background there.
 
And crazy me decided to run. Sometimes have a little bit of buyers or remorse on that. But on the other hand, I did take that concept and put it into law in New Mexico. So your inpatient outpatient medications. Absolutely no out-of-pocket cost. And now I’m working on some other things we can go into that later, but so those experiences, and of course, rare, rare, rare is the family that isn’t touched by substance use. It’s just, it’s more prevalent than any of us want to admit, but the stigma I think is starting to go away and because of the huge need, that’s where the opportunity comes for health systems to get involved in mental health and substance use treatments and therapy.
 
Chris (06:18):
And I’ve been personally impacted by friends that have had substance abuse disorders. And I mean, I’m sure that there’s a powerful calling that you might have too. And I, before we jumped into the opportunity and the executive focus, I was curious if there’s a personal reason or it basically just curious about the inspiration for your calling to address behavioral health issues.
 
Martin (06:49):
Well, one, as I said in New Mexico, it’s a, can’t have a pandemic within a state… And the need is just huge. And I’ve seen it throughout my career as I that part in New Mexico, but yes, I have children. I’m the son of an alcoholic. And when it becomes more personal, you begin to pay attention. Now I will have to say that the experience in the family, sober, it’s working well, but it was a long road and it’s a hard road and it creates a lot of personal empathy, but here’s the other key piece as I present in Senate committees or do hearings and so forth, I always bring up that phrase rare as the family. And it’s amazing the number of people, either in the audience or fellow legislators that come up to me afterwards and say, “Hey, I’ve got a problem with my kid. Do you know where I can turn?”
 
People don’t know where to go. And it’s really unfortunate. And yet having seen my own personal experience in the family with children, the ability to get to sobriety and to a productive life, it is definitely there, but it takes a lot of effort and it takes a lot of interpersonal connection. I mean, that’s, in medical surgical, if you’re in a health system, we do things and we get paid for it. This takes just human connection all the way along the line, particularly in substance use, a year of sobriety at least. It means there’s got to be constant contact. Has got to be said. That’s huge opportunity for health systems to get involved. A lot of states address this through Medicaid and yes, particularly in New Mexico, it’s a huge population, but the prevalence of substance use is almost as much in families, middle class, well to do, as it is in those who have socioeconomic deprivations.
 
And so, again, I think that with the stigma starting to go away. With the federal government realizing they’re putting huge amounts money into this, that there will be opportunity for health systems who have the capital to make the investments to pay for the salaries of the professionals and their multiple levels of professionals to become involved and certainly be able to do it. I mean, they’ve got to make a margin. You can’t do anything in healthcare without a margin to invest in the future. So I’m hoping that people who are listening to this think, hey, where can I go? What can I do to get involved and provide this service to the community the same way we in healthcare have provided it for medical surgical illnesses for decades and decades.
 
Chris (10:08):
That’s exactly what we want to delve into. I think that there’s an opportunity to listen to these conversations, being aware of opportunities that we people may previously have been unaware of, allows people to then shape their strategy and incorporate these things into the overall plan for the year, three to five years, et cetera. So I’m eager to hear about, it was impressive to hear about how it’s being destigmatized, how people are willing to have the same kind of conversations with you that they might not have been willing to have 10, 20 years ago. So with those tides coming into place, could you talk a little bit about what some of these opportunities are and how these things are starting to take shape. And again, I know we’re focused on New Mexico right now, but I’m really interested in how healthcare leaders, the folks listening to this, can then start thinking about, well, what is this going to look like? Where in my region or my state?
 
Martin (11:12):
New Mexico is not unique. This is very generalizable throughout the country. There’s no question about that. I want to kind of, in my experience, I always being a physician, you want to go get through the symptoms and get down to the cause of the disease. And in the treatments you want to do the same as well. And if there’s one word, I used to teach at the University of New Mexico and at the end of a lecture seminar, I’d say, “Okay, there’s one take home point here. And here’s the take home point. There’s one word that is central to substance use therapy, mental health, and what have you. And that word is connection, connection, human connection.” And think about it just in terms of what you’ve watched on TV or friends or what have you know, people have up and downs who have issues with either adapting to new environments and adapting to COVID.
 
And I think COVID has taught us a lot that isolation and loneliness really exacerbate any underlying stresses. And, and that can lead to depression, to anxiety. We’re seeing a lot more bipolar diagnoses these days. I’m not sure if we’re more aware of it or something else is going on. And then of course, substance use, I mean, the opioid epidemic is just devastated and now with fentanyl and so on and so forth. And if you look back in therapies for alcoholism, which we’ve been doing with AA since the thirties. AA is all about a connection. You have a sponsor, you have other people, you always have other folks you can call. It’s connection, connection, connection. But let’s turn this into how do you actually build some sort of therapeutic process, whether it be capital investment in infrastructure, or really it’s people bringing people on board. Let’s use substance use. Whatever the substance is. And when an individual gets to whatever the bottom is, and again, usually encouraged by friends, they go into residential treatment. That’s a physical building. That’s a 24 hour, at least 30 days really should be 120.
 
You have to take the individual out of their old environment or their environment that stressed them out so much that they are using substances to deal with their stresses. Self-medicating. Whatever the substance is. After that is where another huge opportunity is. And it’s developing in the country. And that’s in what we call sober housing and where individuals graduate, so to speak, from residential treatment into a place where they’re living with four or five others. Again, that connection, that peer input is huge. And then after sober housing into AA. That’s why AA works is because people keep at it and stay with it, or other organizations that people can be involved with. But again, putting the sponsorship of all this together and the infrastructure in the housing is a critical part of it.
 
I know in New Mexico, the state is not going to go out and buy houses and communities, but systems can. And you can begin to find the individuals. Of course, we have to train a lot of people up because there is a huge shortage of mental health substance use professionals in the country. It doesn’t pay very well. We’ve got to address that issue. People say this is going to be expensive, but here’s the rub. If we don’t treat, if we don’t diagnose, treat, and support these individuals, they will come back in society, either through crime; therefore entering the justice system, or all of us eventually get chronic diseases. And those chronic diseases are three to four more times costly in individuals with an underlying behavioral condition. And so if we treat those underlying conditions, we will save so much money on the chronic side of care.
 
And that is critical. And in the health plan that we started in New Mexico, we did this. Our emergency room visits when we got rid of all the cost sharing dropped by 30% and were lower than our competitors on an apples to apples basis. Our admissions to hospitals were down by 25% compared to others. And so actually it became a business, essentially. It was our business model in the True Health New Mexico to do this. That’s how we made our money. So again, I think for society, there are definitely savings. And if we don’t, there’s going to be a lot more costs. And the worst thing of all is so many devastated lives, not just of the individual, but of the family and all those who are close to him or her.
 
Chris (17:10):
So I’d like to dig a little bit deeper into the impact, well, the nature of the treatments and the type of impacts of it that have occurred. You’ve given some overall, just some overall outlines, but I’d really like to just hear a little bit more about like the types of treatments that are being encouraged, the types of treatments that people can start looking to as effective means, especially if they hadn’t previously considered them.
 
Martin (17:36):
So let’s start with residential treatment centers. That’s basically a hotel in so many words where an individual is in group settings day in and day out, very structured program. Again, that’s a physical structure. It’s not a mental health hospital per se. It’s a residential, as it says, residential treatment center. And it’s for, it should be up to about 120 days. So then you have to bring in the staff and you have to have a psychologist or you have to have a psychiatrist. Very often there is an acute component when people are going through potentially withdrawal. And that’s usually a three to four day, and that’s in an acute care hospital, but then movement to the residential treatment center. There are some levels of freedom of being able to leave that center over that 120 day period, but you don’t have to have all psychiatrists and psychologists. Many masters trained individual.
 
And then what we call peer professionals, which are people who have gone through this. May in fact, be somewhere later in their first year of treatment and sobriety who then come in and become counselors. And we’re finding that these peer professionals have the, again, because they have huge empathy that people who are particularly in substance use, they can relate to them and they cost so much less on a day in day out basis. And it’s also helpful to them. And so you there, again, number of people touch connection all the way through. Then there are people who run sober housing and intensive outpatient IOP programs. A lot of folks turn to that first. It’s probably better after they’ve had residential treatment. Because as I said, you’ve got to get people out of the old environment that stressed them out so much so they self-medicated with the substance.
 
So then these programs, again, they’re individuals, they’re working with folks, but again, the person who is suffering the substance abuse has the connection with other people. And we haven’t talked about the pathophysiology of addiction. There are, as the AMA says, it is a disease. It is probably something in the neurologic pathways. Why do some people who drink don’t have a problem with it, can do moderation? Others get cravings? I mean, it’s just, and it’s the cravings that are really difficult to deal with. And that’s where other people that’s by going to other people say, no, hey, don’t do it. Let’s talk, let’s talk it down. And I mean, it’s almost like suicide prevention. We’re seeing a lot of that suicide lines. Talk, talk, talk, talk, talk. So that’s going to be an investment in terms of people.
 
There’s no question about it, but we’ve got to encourage people to go into the field. So we’ve got to pay much better than what we’ve done. And so that’s where a system, but then the systems can build the health plans. Now the health plans are going to go, well, wait a minute. I’m going to drive up my premium. But the health plans are going to see such a significant drop in chronic disease. It will more than pay for itself. As I said, it became our business model. It really works. And so the investment, I mean what we’re spending so much money on chronic disease and people with behavioral situations, if we took that money and invested it in people to reduce the number of people who are in crisis, we will overall society likely save money in healthcare. And so the economics turn out, but again, it’s shifting the focus of health systems from acute med surge over to the mind.
 
The other thing that’s really important here to get across to folks is that we think of health as the body. The body is run by the mind and we’ve just basically not paid any attention to it. I mean, there’s James, Freud, and I mean, there’s more going on today. And the neurochemical research going on in mental health substance use is phenomenal and we’re going to learn a lot more. And yes, there are some medications that definitely help both with mental health, antidepressants, bipolar, psychotic medications, maybe someday there’ll be electronic stimulation. That’s Elon Musk’s next foray is into neural transplants of some sort. There may be some procedure around, but right now it’s all about people and connection. But again, the investment in that pays for itself back to society by the reduction of chronic disease and the savings that are obtained there.
 
Chris (23:04):
So you’ve outlined a really deep future in terms of how like the future of how we’ll be addressing these things. But even in terms of the now it sounds like there, there are many examples, True Health included that address some of these issues on, oh, my cost is going to go up in this way. But it’s showing an overall savings based on one point that I love that you brought up was like, hey, we talk about the symptoms, but let’s get all the way down to the cause. So are there any show notes, are there any papers or things that you’d point people to to read about those impacts?
 
Martin (23:48):
Yes, actually Johns Hopkins and the PEW Foundation is formally studying the law that we put into effect last year. That is as of January 1 in 22. No commercial health plan exchanges can charge a copay co-insurance deductible. And they’re looking at the impact. There are tons of papers and I’ll get a copy of some to you so that the audience can look at them that demonstrate absolutely unequivocally, they’ve been done in academics and by Milliman, the actuary research organization, that if a individual or a group of individuals with just chronic disease with a commensurate group of similar chronic diseases and a behavioral situation, that former group is three to four times less expensive. So behavioral health issues do definitely drive up cost in chronic disease. And again, I will get you the references that you can share with the audience. My apologies.
 
Chris (25:06):
No, it’s all good.
 
Martin (25:06):
Memory off the top of my head. Other places for people to look. So, okay, interesting. Where else can I go? The Kennedy Forum, Patrick Kennedy, not Robert. The current Robert that is who’s the anti-vaxer, no Patrick who his father Teddy Kennedy. They both worked on legislation to improve access to mental health, but the Kennedy Forum is a place to look. The national organization. I just became familiar with them SAMHSA within the government, CMS and the department of labor is now drafting rules about equity and access to treatment for mental health, as well as med surgical for all health plans. This is called mental health parity. It was started by my old Senator, Pete Domenici, and Paul Wellstone out of Minnesota in 2008. And it’s grown through the ACA and a number of other pieces of legislation.
 
Well, right now, a health plan. And unfortunately it’s not being enforced nationally, but every department of insurance has the authority through this national bill. Every state department of insurance has the authority to enforce this. And a health plan must demonstrate how they are creating access to mental health services as well as they do to any other service. Or in other words, are they putting any barriers? Prior authorization? They can’t do anything more strict than what they do with medical surgical. And this is going to revolutionize health plans. They’re fighting it. United fought it desperately. California passed a bill, senate bill 855, if you’re looking, 2021. This year, my endeavor in the legislature will be to pass a New Mexico specific bill that’s got more teeth in it than even the federal bill. And here’s the other piece. The federal bill requires health plans to have geo-access to mental health services.
 
Well, if we don’t have a whole lot of behavioral professionals, then the departments of insurance and federally, the health plans have to go out and pay more money to attract them. And so we will begin to see people paid in behavioral health, mental health, substance use services at the Medicare plus percentage, a hundred plus 30% as we do in medical surgical. So that’s the other big revolution that’s coming into health plans and that’s the opportunity for health systems. You can charge a hundred, 130, 140% psychiatrists, 150. They’re very rare. It’s just like any other rare professional. So there’s a huge, huge opportunity to build these systems, bring in the professionals, train them up, and charge back against the health plan. And it will be supported by both federal legislation that’s already there, it’s just not being enforced, and states as we begin to pick it up and enforce it ourselves.
 
Chris (28:36):
So given that there’s this change in payment structure and funding that can help support these efforts, which should drive down costs in a number of different areas anyway, what’s your advice to the executives and the teams there that are looking to start to address this? Is it kind of wait and see on the legislation funding changes or where should people be starting and directing their focus right now?
 
Martin (29:06):
Well, they, as providers, if they get denied, they have all the legal means at their disposal through federal regulation, including self insurance. The department of labor has incredible work done establishing these guidelines. And again, I’ll provide the reference to you so people can go and look at it and begin to see that in fact, that if a health plan does not pay for chronic or long-term treatment, which is what they usually do, they say, “Oh yeah, will we’ll pay for a few days and then we’re out of here.” No. And as that happens more often and the court cases come in, and the right now CMS and the department of labor are both enforcing it. But again, they don’t have a whole lot of personnel on a national level. Right now if a provider isn’t getting paid, they can go to the department of labor or CMS and they are by law, have to investigate and bring the health plan into compliance. Here’s the other biggie, why this is really big business. Medicaid managed care, because it’s through a managed care mechanism, also has to comply.
 
And you’re talking about 130% payment for Medicaid treatment. Whoa. Yeah, that’s big. That’s very big. So again, huge financial opportunities. And I would look probably closest at California systems. I’m in the process of doing that this year and to begin to get more concrete examples of what the opportunities are. And I am encouraging systems in my state to, and I’ll sit down with them. I’ve done this in healthcare. What’s the return on investment to actually begin to build these systems, the residential treatment centers. It’s pretty simple math, ROI. And then the next step is to the sober living. And again, the attachment all the way through until the person is probably a year out. I mean, a year’s worth of treatment in therapy? And the demand for it? Is gigantic.
 
Chris (31:36):
So yeah, the one thing I really appreciate is that you point, a question I was going to have is on the data side, we often look like when we’re concerned about what issues going to impact privacy or what regulations might come out, we’ll look at the EU and see what they’re doing to get a perspective on what might be happening soon here. And then your example for that is looking at what California’s doing for a glimpse on what that might look like.
 
Martin (32:04):
Oregon is also another state that’s moving in the forefront. New York and Rhode Island are also looking at parity laws as well.
 
Chris (32:12):
So one thing that I like to emphasize a lot, like the people who’ve watched this and are gaining your perspectives. They might want to reach out, might have questions, be it on social media or whatever your preferred way of contact is. What’s the best way for people to reach out to you?
 
Martin (32:30):
The best way for people to reach out to me is at my email, martin@senatormartinhickey.com.
 
Chris (32:40):
Well, hey, I appreciate you being transparent. I appreciate you sharing personal perspectives that have shaped the type of legislation and leadership that you’re seeking and enacting today. So big, thanks for coming on and spending a little bit of time with us.
 
Martin (32:57):
Well, thank you for the opportunity and for those of you out there, please do not hesitate to get in contact with me. I’ll get you in contact with other people as well. And just think about your own family. That’s all you really have to think about. Is your own family and the pain you’re going through and the pain the individual in the family is going through. And there is relief. There is relief. There isn’t always a cure, but there is relief. And it’s about connection. It’s about professional connection. And those of you who are in decision making capabilities and systems start looking into it and build the capabilities for it. I mean, it’s almost like when we got anesthesia, what that did for surgery. When we got antibiotics, what that did for infections. The same opportunity is there for mental health and substance use. So thank you, Chris.
 
Chris (33:55):
Thank you, Martin. And for those who are interested in communicating about this within your organizations, again, read our show notes. Martin has shared a tremendous amount of information on the impacts and coming legislation. So we have all those details in our show notes below. If you’re interested in exploring more on the intersection of policy and strategy in healthcare, where policy is going to be guiding healthcare executive and leadership strategy. Today, we did an excellent video with Dr. Paul Keckley, who was a chief facilitator of the Affordable Care Act. between industry and the white house. So feel free to check out that interview and conversation, and until we see you next time, hello.
 
Speaker 3 (34:45):
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