In California, nearly two out of three adults with a mental illness do not receive mental health services, and only 1 out of 10 adults with a substance use disorder receives any kind of treatment. These gaps in care have drawn the attention not only of policymakers, but also health technology investors and entrepreneurs. Last year, health tech start-ups, including Quartet Health, Lyra Health, and Pear Therapeutics, raised nearly $400 million in funding for technology investments related to behavioral health. Investors have included leading venture firms like Venrock and Greylock Partners, as well as national private payers such as Centene and Anthem.

Although research supports the efficacy of some smartphone technology–enabled behavioral health interventions in controlled settings, widespread adoption has been slow, particularly among providers and payers in the safety net. As Thomas Insel — California governor Gavin Newsom’s designated state “mental health czar” — recently said, “As much as one might hope there’d be an app for that — it’s really complicated.” Insel has dedicated a significant portion of his career to technology-driven behavioral health projects, including a stint at Google life sciences subsidiary Verily, and as cofounder of the start-up Mindstrong, with which he is still involved. Recent pilots have demonstrated evidence of a variety of significant barriers, with neither entrepreneurs nor participating providers and patients seeing much meaningful improvement in access or quality.

The CHCF Innovation Fund is optimistic about technology’s potential to improve behavioral health care coordination and integration.

Last year, when mental health providers in Los Angeles County tested a smartphone app to help patients manage emotional distress, they encountered major setbacks, such as concerns about low patient engagement and compliance with patient privacy regulations. In 2015, low participation levels were reported in similar pilots testing computerized cognitive behavioral therapy in California’s safety net. Other behavioral health start-ups have been stymied in California by a complex behavioral health care system with fragmented funding streams and a daunting array of stakeholders that includes counties, Medi-Cal managed care plans, and public hospitals.

Despite these challenges, the CHCF Innovation Fund is optimistic about technology’s potential to improve behavioral health care coordination and integration that goes further than self-help apps. The fund recently conducted a landscape analysis of companies new to behavioral health tech. The analysis focused on technology-enabled services rather than applications and on those with some traction in the safety net. We identified three main areas where innovators are making meaningful progress:

• Collaborative care
• Telehealth medication-assisted treatment for substance use disorder
• Resource and service referrals

Time will tell whether companies find sustainable revenue sources for these promising services, effectively engage their users, and navigate California’s complex regulatory and reimbursement realities. Still, it’s worth paying close attention to these developments.

Collaborative Care

At least one in five primary care visits involves a mental health issue, but coordination between primary care providers and behavioral health specialists is rare. For patients who require care from a psychiatric specialist, less than 3% of psychiatrists and psychiatric nurse practitioners actively develop shared care plans in collaboration with their patients’ primary care providers.

The collaborative care model, which was developed at the University of Washington, pairs trained primary care providers with an embedded behavioral health care manager and psychiatrist to deliver evidence-based medication or treatments. When the primary care physician and behavioral health manager, using validated assessment tools, see that a patient is not improving, a consultant psychiatrist makes recommendations to the primary care provider to adjust the care plan. This model has been around for more than three decades and has been assessed in more than 80 randomized controlled trials. Although it is one of the most road-tested and trusted models for integrating mental and clinical health care, its adoption has been held back partly by providers who cannot afford the additional behavioral health positions or who lack the support to integrate new roles into existing workflows.

Those barriers are falling as technology-enabled platforms and tools like telehealth make care newly accessible and scalable — especially in the resource-constrained safety net. Companies like Concert Health and Mindoula are helping medical practices embrace the collaborative care model by providing remote care management and psychiatric services. A key question that remains is how California will reimburse collaborative care in Medicaid. New York State offers one example (PDF) of a possible path forward.

Medication-Assisted Treatment via Telehealth

Medication-assisted treatment (MAT) is the gold standard for treating substance use disorder, but there are significant shortages of authorized MAT prescribers in many parts of California and the US. Telehealth could save lives by making MAT more available in places facing prescriber shortages.

Early entrants into this field are using a range of approaches, which are outlined in CHCF’s recent brief Innovation Landscape Series: Telehealth MAT. Some approaches aim to expand the capacity of existing in-person prescribers of MAT by offering the virtual support of a remote psychiatrist. Others, like Groups, which has received a program-related investment from CHCF, offer in-person support programs and use telehealth to help with prescribing. There also are some academic medical centers piloting telehealth MAT initiatives.

All of the companies entering this arena face complex and rapidly evolving reimbursement and regulatory challenges. A recent paper, Opportunities and Challenges to Utilizing Telehealth Technologies in the Provision of Medication-Assisted Therapies in the Medi-Cal Program (PDF), analyzes the roadblocks facing telehealth MAT providers in Medi-Cal and provides recommendations for removing them.

Resource and Service Referrals

Providers who care for patients with mental illness and substance use disorders have to navigate major challenges in making referrals. In some cases, referrals involve specialty facilities and providers. Others involve community-based organizations providing social services, like housing. All are important to a patient’s stability and well-being. Yet the referral process is often hobbled by out-of-date information that can leave providers frustrated and patients without needed support. Even when a referral is made successfully through the conventional approach, there is inconsistent follow-up to let providers know whether the patient used the referred service.

Several start-ups aim to streamline this referral process. OpenBeds enables emergency department providers to see the real-time availability of inpatient and outpatient psychiatric services within a given geographic area. Currently used in seven states, providers can send a digital referral through OpenBeds and find an available inpatient bed in less than one-third the time it takes to refer via phone and fax. A CHCF publication, Catalyzing Coordination: Technology’s Role in California’s Whole Person Care Pilots details how other companies are partnering with counties to centralize and digitize local efforts to coordinate social services for patients with complex needs. Companies like Act.MD offer providers a central, searchable way to find needed services for their patients. They also enable providers to communicate directly with organizations in the network and track outcomes of the referrals they make. Similarly, Quartet’s referral management platform is bridging the gap between primary care physicians and behavioral health specialists to ensure that patients receive the care they need and that primary care providers are kept informed of their patients’ progress. Quartet also has received a program-related investment from CHCF.

Services like these are only as useful as the information they provide, and to maintain accurate, comprehensive networks, they need buy-in from a broad spectrum of partners, often including health plans, community-based organizations, and health systems.

Keys to Success

Technology alone cannot cure the complex structural problems that plague our behavioral health care systems. However, it does have an important role to play in expanding access and integration, especially on the provider side of the equation. If behavioral health entrepreneurs are going to succeed, they need to be honest about particular challenges to the field and be prepared to address them. And they will need cooperation — both from policymakers who have the power to remove regulatory and reimbursement barriers, and from providers willing to try new ways of solving old problems.

Rachel Lee

Rachel Lee was an Innovation Fellow with CHCF’s Innovation Fund, where she developed strategy on the foundation’s investments in behavioral health technology companies. Read More

Jessica Brandi Lifland

Jessica Brandi Lifland is a freelance photographer, instructor of journalism at City College of San Francisco, and mother. Her work with publications and nonprofits such as Operation Smile, Tostan, and the California Health Care Foundation has taken her all over the world, including West Africa, the Middle East, Kosovo, Burma, Haiti, and South America. Read More