Unraveling the Impact of Behavioral Health on Patient-Centric Care

Behavioral health is pivotal for overall patient well-being, yet healthcare providers are just beginning to recognize the significance of lifestyle factors and social determinants in delivering this sort of whole-person patient-centric care. In this episode of Value-Based Care Insights, host Dan Marino sits down with Dr. Matthew Burg, a clinical health psychologist at Yale, to explore how social determinants and behavioral medicine are addressing the clinical needs of patients. Gain insights into the challenges and opportunities involved in integrating behavioral health into patient care, in prioritizing quality outcomes over services, and in recognizing the importance of preventative measures to establish a more comprehensive patient-centric care delivery system.  

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Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I am your host, Daniel Marino. As many of us have known, working through a lot of aspects of not just value-based care, but working with primary care and just overall the care delivery that that occurs with patients behavioral health, behavioral medicine, understanding some of the lifestyle issues, some of the social, determinant factors. It is such a critical part of the overall care or the overall health to our patients. And the big challenge that we have here is that the physical medicine that's being delivered by our physicians really are responding to a lot of the clinical needs, the care needs of patients. And we're only starting to take into consideration the behavioral health components. And you, you can tell through some of the research and through a lot of the discussions, especially since the pandemic has occurred. Lifestyle issues, social, determinant factors, health equity issues are becoming just such a critical part of the care that we're delivering, not to mention the patient outcomes that we want to achieve and improving the health of our patients and our communities. 

Well, I'm really excited today to kind of dive into this topic a little bit further, and I'm extremely excited to have a wonderful guest. I'd like to introduce Dr. Matthew Berg. Dr. Berg is a clinical health psychologist within the Yale School of Medicine section of cardiovascular medicine. His he spent quite a bit of time in within his practice within his research, looking at some of the concerns and the contributions of stress emotional factors to instance of cardiovascular to disease, and so forth. Dr. Berg. Welcome to the program. 

Matthew Burg:

Thank you. Very happy to be here. 

Daniel J. Marino:

So, Dr. Burg, this is, you know again, I think a topic that is becoming even more top of mind. Many, many physicians, many provider organizations, are incorporating behavioral medicine into the care that they're, You know, that they want to provide to patients. But it's been a real challenge. From your perspective,  why has this been such a challenge of integrating behavioral medicine more in with physical medicine?

Matthew Burg:

Yeah. So I think there, there are several issues, I think, that even pivoting from fee for service to value based care is a challenge in itself. Just in the way a healthcare system is set up to deliver care that they're paid for. And so value based care is about outcomes. It's not about delivering so many services. It's about the outcomes that those services produce. And so that's a challenge and to make that shift, while at the same time recognizing the contribution of lifestyle and other behavioral factors into the how those factors contribute to patient outcomes. Sort of not only do these healthcare systems have to change their model, but now they have to incorporate something that they never had to before, to that, that to create the, you know, produce the outcomes that that pairs are increasingly interested in. 

So I think that that's a part of it. I think another part of it is that because that requires the integration of you know, people like myself, you know, clinical health psychologists and other Behavioral health providers, who have not been part of the model before. It's like, Well, where do we find these people? How do we connect with these people?  

Daniel J. Marino:

How do you even connect with the data? Right? And a lot of times what I've spoke to primary care physicians, they're only starting to ask the questions. For instance, around lifestyle, around health equity. And one, you know, was interesting. Some time back I was talking to a primary care physician, about this, and one of the challenges that he said to me is, Look, you know, I really care about their lifestyle. But when I ask the question, and they tell me their response, and what their challenges are, this particular physician said, I find it really difficult to respond to it right? I don't know how to fix the problem. Do you feel like maybe, that that it it's sort of like, you know, you have to be careful. What you ask for type of a situation is, that's what's that? What's maybe held physicians back?

Matthew Burg:

Well, I think I think that's a part of it. But I think, you know, a physician is trained to do medicine. You know, a psychologist is trained to do psychology. And what we're talking about here, you know, is engaging the patient in a problem, solving effort. Well, that's what a clinical psychologist that's part of their training. That's not part of a physician's training. And so, you know, I think, that the extent to which this emerging model is still physician centric is going to bring with it challenges that will be difficult to overcome. I mean, even where you know positions or consensus statements coming out about the care of cardiac patients and saying that lifestyle should be a focus, and who they task, who these white papers test to, to do that work as a physician, and I think that the physician is not prepared to do that. And that's appropriate. 

Everybody brings an expertise, and that's why, you know, an integrated care model is going to be better for delivering those outcomes that value based care because you you have them. A team delivering the care where each member of the team brings an expertise. And then the patient is being seen as a whole  person, not just a biological entity. They're they have biology, they have psychology. They have the social context in which they live, which bring social determinants of health for good or bad in in terms of their health outcomes and their ability to engage in the kinds of things that will promote their health. And so you really do need a team approach.  

Daniel J. Marino:

You know, that team based model, I think, is gonna be key. And we've we've talked about a lot of the aspects of a team based on, particularly when it comes to primary care, right? Because, you know, one of the things that we've discussed is if you're truly, going to you know, work through access and meet the needs of the patient. We should really be thinking about bringing in social workers, bringing in obviously apps, bringing in dietary and some of the other areas. But W, really what I'm hearing you say, and you bring up a great point. 

It's it's really an expanded focus beyond that right? It's really bringing in behavioral activation into the delivery of care to the patient. Right? It's really that expanded view through the team based model 

Matthew Burg:

absolutely. I mean, there are many patients where all it will take is the physician to say, look, I'm your physician, and what I'm what you need to do for your health is, get some physical activity or this or that, and that will be sufficient for to mobilize the patient. But there are a lot of patients where those kinds of you know just gentle reminders, or the, you know physicians sort of saying, that is not enough, that that somebody needs to be able to work with the patient. That will take some time, you know, in terms of how to mobilize, how to motivate a patient, to engage in the kinds of health practices that contribute to their Well being, I mean, it could be even something as simple as you know, Medication, adherence. You know, there are so many aspects where it's incumbent upon the patient to participate in their own care, and it's and that takes somebody with expertise in working with patients to engage them in doing that. And for many patients. It's sufficient for the position to say, Here, do this, but for others. It's more complicated than that, and it often does involve the conditions under which the patient lives. And so you need these additional experts as part of the team.

Daniel J. Marino:

You bring up a really good point. So you know, the focus typically is on the patient right meeting the treating their illness, meeting the individual care needs of the patient. But there's a lot of discussion around there that we should be thinking about this more on a macro level, right? Focusing on keeping the populations healthy and what do we need to focus on where we could respond to maybe some of the lifestyle challenges of the population or even social. Some of the you know the demographic challenges, if you will, of the population. But in my mind that's a real culture shift. Right? So how do we incorporate that that macro view of the community around managing the population and taking that down to the patient, giving the tools to the physicians and to incorporating behavioral medicine to drive that change?

Matthew Burg:

Yeah, yeah, you know. So I think again, it sort of brings us back to where we started in terms of the challenges that healthcare systems are facing and value-based care is inherently about prevention. It's about preventing the high cost, you know, downwind problems that people can have. Heart disease, you know, metabolic disease, you know, Major, major organ system diseases. And if we can prevent those, then then we're we'll save money, and the patient will be better off and have more quality of life. Years. You know it's been known now for several years, who report, along with others, that more than 50% of chronic disease burden is attributable to lifestyle and the conditions under which people live. But that's not what our healthcare system focuses on. And so we need to pivot. If we're really going to impact chronic disease burden, bring that down and bring down the costs that come with it. As you say, we're going to need to pivot to more of a preventive focus. It's going to have to be earlier on. And it's going to. It's going to require the incorporation of experts in those arenas that we now know drive that chronic disease burden. People who are experts at working with patients around their lifestyle. Around the stress of the conditions under which they live, about how to mobilize communities around those conditions to the extent possible. You know. How do? How do you find safe places to engage in physical activity? That's a question that for some the folks is more of a challenge. But engaging with the community, then be, is a way to begin to problem. Solve with them to address some of these these factors.  

And you know, we, we talk about social determinants of health always in this negative kind of way. But there are resilient communities. There are a lot of aspects, of of those social determinants that are positive. And again, it's about mobilizing these communities and working with them. And that is not necessarily the role of the physician alone. The physician has their role, and so do the other members of a healthcare team.  

Daniel J. Marino:

If you're just tuning in. I'm Daniel Moreno, and you're listening to value-based care insights. I'm here today with Dr. Matthew Berg, clinical health psychologist, with Yale School of Medicine and section cardiovascular medicine having a great conversation around the integration of behavioral medicine as a driver of patient outcomes. So Dr. Burg, I wanna, I wanna build on that a little bit. You mentioned early on, and I agree with you. The economics are really important to drive the paradigm chain paradigm shift right, you know I I've thought time and time again form follows function. If you don't have the right incentives, it's hard to make that change. But integrating behavioral medicine and the outcomes around that has been has been a little bit of a challenge. I think it's been tough to kind of see what some of those outcomes are. In, in your opinion, and then some of your research that you've done. How have you started to kind of bridge that gap around what those right level of outcomes are, as we think about driving the change?

Matthew Burg:

Yeah. Well, so you know, I think in terms of the experience I've had. Probably the most impactful was when I was working more in a clinical capacity and within a VA medical center. And I was there as the Chief of the Health Psychology Section at the time when first primary care was established as a model of delivering care. So, moving away from all specialty care focused elements, specialty care still there. But the primary care provider was now driving the overall care of the patient, and once that was present. They started. You know, these test programs. The VA started these test programs of integrated primary care. The team based care that I've been talking about, and the research that's come out since then. And the VA You know, as often as the case is a pioneer in testing out new models of care that are more cost effective. 

But you know, as this then became, you know, expanded. you know, or at least be, you know, began expanding nationwide, and people started doing research to look at the outcomes associated with this. I mean, what they find is that integrated primary care is less costly care, with better outcomes, better health outcomes and higher patient satisfaction. And so you know, you look at those things and you say, Well, okay, this seems like a winner. But how to create?

Daniel J. Marino:

To create economic model around that right to support it. Intuitively, I agree with you. It is the right thing to do and makes sense.

Matthew Burg:

Daniel J. Marino:

Just building on that, I am excited about some of these new innovation programs or these models that are starting to be released. You, you mentioned Arpa, H. And but you know, there's the heroes program, and we talked, you know, a month or so back in New York, the 1115 waiver that was out there. And how they're addressing health equity. All trying to integrate with CMS and incorporate into some level of value based performance. I'm really encouraged by that. And I think, as we start to look at these different programs. I can't help but think that at some point we're gonna start to refine what those outcomes tracking and the financial incentives around that. What it will look like.

Matthew Burg:

Yeah, you know, I agree. You know, it's not like, Oh, here it is, and we can just pull it off the shelf and make this this shift. I mean, this is this is a very large change. This is right, really steering the air aircraft carrier and we, you know, and we don't know how to do it and how to do it is not going to be a one. Size fits all and so we need. We need these test programs. To sort of figure the way through, figure out what works and what works, for whom? And healthcare systems need to be incentivized to engage in those tests.

Daniel J. Marino:

I agree with you. I think the healthcare systems do have to start thinking about this as an investment into not only their patients in their communities, but in also investment into their physicians and into their into their pro providers. You know, in in, in working with a number of the physicians around the country, and even hearing you talk about this. I often wonder how well trained the physicians are to incorporate behavioral medicine into the into the way that they practice. I mean, I would think, intuitively like you said it's the right thing to do. But practically is it being done? And I don't know. Do physicians have that right? I don't want to say skill, because it's not necessarily the skill, but maybe it's just the learnings in the approach.

Matthew Burg:

Well, well, you know I would. I would argue that maybe it is a skill set. You know much in the same way that physicians have over the years learn to work with physician extenders. How do you know PAs NPs physicians, you know, started in in larger healthcare systems. Physicians started to learn how to incorporate. A pharmacist when the patient had more complex. When the patient has more complex you know, medication regimens. Yes, they have to learn how to do it. And you know when I was talking earlier about the program at the VA Hospitals. I mean the program was about training. It was about training in integrated primary care. And that's how they set it up and started testing this model of care delivery by setting it up as a training program. And so you had medical residents. You had nurse advanced practice. Nurse trainees. You had pharmacy trainees. You had a dietitian trainees, you have clinical health psychology trainees. Who each of whom were each of whom were being managed by their attending. Right. And so the attendings were learning how to work together. While the these trainees were learning a team based model of care. And so, you know, the VA is arguably the largest training institution in the country. At least in the healthcare arena. And so you know, one can. One can imagine that a lot of physicians now are being trained in that way where we're not seeing it is in specialty care. So the notion of integrated cardiovascular care, for example, it's like you know, cardiology trainees there, cardiology, fellows and advanced fellows. It's all about technique. I'm learning how to do this intervention. I'm learning how to do these tests. I'm learning how to, you know. Manage a patient in a 15 min, visit. So so there, there's going to be learning that's going to be required as part of this effort to test out new models of care.  

Daniel J. Marino:

Well, as you said. I think I agree with you as you're as you're putting it forth. I think the skill level has to be expanded. I think the care model. How we're delivering care certainly has to evolve where we're taking that into consideration and not thinking about it. Maybe so episodic, if you will, and thinking about it, maybe a little bit more comprehensive, or certainly more holistic, as we're thinking about really that 360 view of what the patient needs are. 

Matthew Burg:

yeah. And you know, and I'm encouraged by these models that are emerging and these funding that are emerging and as a clinical health psychologist. You know, what I see is partly my role is to continue to encourage my colleagues to get involved and be involved and reach out with, you know if they're independent, practitioners find group practices to engage with, if they're part of a healthcare system, encourage leadership to look at these models and to participate in these models. 

Daniel J. Marino:

Matthew Burg:

Yes, when new, you know, ideas emerge, takes time for them to gain traction, I think. And I think that's what we're seeing. We're seeing this increasing traction. II believe that as these this new delivery model and this new way of contextualizing service and pay for you know how services, how healthcare is paid for. I think that will increasingly gain traction, because the outcomes are going to be better, and I think that the as that happens, there will be more and more opportunity.v

Daniel J. Marino:

I think the financial incentives will definitely drive the change. Well, Dr. Burg, I really appreciate your time. This is, you know, again, a great discuss discussion you brought up some interesting and certainly thought provoking points. If any of our listeners today. I think, are really thinking about how to incorporate more behavioral medicine into their care models, Any pieces of advice you might want to share, or some thoughts you might have on where they can start, or how do they move it forward?

Matthew Burg:

Yeah, you know, I think it's a great question. And I think, for you know, for clinical health psychologists. As I was saying, I think it's about reaching out. Finding opportunities to engage with medical colleagues. To, you know, even do presentations to get on the schedule for doing. You know the standard presentations that are part of what you know, how, how we all practice and learn, you know whether it doesn't have to be something as big as a medical grand rounds at a major healthcare institution. Group practices do have those times where they get together, and they're some in service that's done. 

 So I would encourage the people in my direct community to be actively engaged, to reach out to leadership of different, of their, the institutions around them, to leadership of their professional organizations as well. For my medical colleagues it's the same thing. It's about looking for opportunities to engage to reach out, maybe through professional communities as a starting point in terms of you know, how do you identify people who psychologists? You know, and their allied healthcare providers who are engaged in that behavioral medicine work. How do you identify these people. and it's like reaching out to the local professional organizations as well.  

Daniel J. Marino:

Well, II agree with you, I think you know, inserting both the clinical medicine in with the behavioral medicine and creating that alignment, probably through conversations. Education, training, I think, is really is really key. 

Well, Doctor Berg, again, I wanna thank you. Great discussion, certainly an area that is of utmost importance to how we're managing the care with our patients. Really appreciate your time. Thank you. 

Kevin Zhao:

Your welcome it has been my pleasure. 

Daniel J. Marino:

And I wanna thank all of our listeners for tuning in today until our next insight. I am Daniel Moreno, bringing me 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners