The Behavioral Health Two Step

Behavioral health has always been something of a pariah in America. If you have cancer, you can expect sympathy. If you are depressed, you’re more likely to be told to snap out of it. In part I believe this has to do with our culture. Americans practice a form of heroic medicine, placing a high value on curative surgeries and miraculous drugs. Unfortunately, patients with behavioral illness are often recalcitrant to both. Treatment is often hard fought, leaving many people and their families to struggle for decades, often in isolation. In some sense this is a national tragedy, especially given that by some estimates 1 in 5 Americans struggle with some form of mental illness.

In America, where healthcare can sometimes be defined as “compassionate capitalism,” the business model rules. We get what we pay for. And behavioral health services simply don’t pay. As a “pariah,” behavioral health has been underfunded and under appreciated for decades. Unlike the profitable specialty services (orthopedics, neurosurgery, cardiac and cancer care), you rarely see hospital or clinic billboards advertising mental health services. Truth be told, for many hospital administrators, mental illness is something their system is ill equipped to handle, an unwanted problem, clogging emergency rooms and taking up bed space. Perhaps, rather than making a largely emotional argument (more funding for behavioral health because it’s the right thing to do), we need to take a new tack positioning treatment within the accepted context of medicine today.

2a stepBehavioral Health Innovation Based on Acceptable Business Models

Certain diseases get the lion’s share of attention at today’s hospitals, at a time when going “at risk” means the healthcare system must look for ways to reduce re-admissions. Congestive Heart Failure (CHF), lung diseases like asthma, and diabetes are all carefully monitored for treatment effectiveness and patient readmission. But something’s missing in this approach. Although medications can help with many of these conditions, data indicates most of these maladies are adversely affected by co-existing depression and other behavioral health issues. That’s where the sidestepping comes in. While directly treating behavioral health may attract only limited interest, any good or service improving the outcome of CHF could win support. That is, by sidestepping depression and putting it in the context of a CHF “modifier,” a relevant business case could be constructed. Rather than build a new business for treating depression, build one for improving the efficacy of a CHF program by addressing the need to address co-existing mental health issues. The value of this business, like every other opportunity in the new framework, would be judged against healthcare outcomes.

It is regrettable that behavioral health issues must be reframed this way, but in some sense we are all being held hostage by the archaic and maligned billing incentives. Grants are one way of doing the right thing without a business model. But these efforts seldom reach a sustainable impact because they can’t depend on long-term support. And while I recognize that this type of solution will not meet the needs of the severely mentally ill, my hope is that as the value of behavioral health services is more widely recognized, there will be opportunities to improve the health of those patients where behavioral health is the primary problem and not strictly a comorbidity. Establishing opportunities for transformation within the existing framework may offer one viable solution as we all try to solve perplexing healthcare issues.

Reader Interactions


  1. Great thoughts. Agree that we need to put more emphasis on taking care of behavioral health. It affects a broad section of the country at some point in time.

  2. Alan, great comments here in your article, I agree. The example of a CHF modifier is a good idea. Many heart related issues and their associated meds have well known side effects related to depression in particular. We are not always treating the “whole person”…aka…mind, body, spirit.

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