Universal Health Services Inc. has picked Mark Friedlander, MD, MBA, to lead the sprawling health system's behavioral health services.
Behavioral health is a challenging field in medicine, but it is moving in the right direction, a new behavioral health leader at Universal Health Services Inc. says.
Based in King of Prussia, Pennsylvania, UHS operates about 400 acute care hospitals, behavioral health facilities, and ambulatory clinics in the United States and the United Kingdom. Mark Friedlander, MD, MBA, was recently named as the chief medical officer of UHS' Behavioral Health Division.
Friedlander is a practicing psychiatrist. Prior to joining UHS, he was CMO for a decade at Aetna's behavioral health unit, where his responsibilities included utilization management, quality, and clinical compliance. Before working at Aetna, he was corporate medical director for Penn-Friends Behavioral Health Systems in Plymouth Meeting, Pennsylvania, where he developed enterprise behavioral health strategies and implemented an emergency assessment capability to triage and manage high-risk patients.
Friedlander recently spoke with HealthLeaders on a range of behavioral health issues, including leadership, promoting evidence-based care, and achieving parity between health plan coverage of behavioral health conditions versus coverage of medical-surgical care. The following is a lightly edited transcript of that conversation.
HealthLeaders: What do you think will be the key to success in your new leadership role at UHS?
Mark Friedlander: I want to have a clear vision so that the people who work at the UHS Behavioral Health Division understand what we are dealing with. They need to understand that our commitment to patients is not just for someone who came into a hospital, got fixed up, and went about their way. For behavioral health patients, hospitalization is just one step in a journey.
The vision needs to recognize that behavioral health patients have a chronic condition that is going to keep coming back. These conditions not only affect individuals but also their families, their friends, and their jobs. These conditions do not occur in isolation. They are impacted by social determinants of health, health literacy, and access to care—those factors are aspects of the mission that UHS has for behavioral health.
When it comes to figuring out how to become a successful leader of a health system's behavioral health division, the important thing is having a clear strategic vision of where the organization is heading. At UHS, we are building a system for tomorrow that includes more than just hospitals. It includes peer counseling, it includes health coaches, and it includes secure transitions from one setting to the next one.
HL: Give examples of the biggest challenges of providing behavioral healthcare.
Friedlander: Even before the coronavirus pandemic, there was very high demand for behavioral health services, with limited resources. Stigma remains an issue. The delivery system is very fragmented, so navigation of the fragmented and confusing system of care remains a huge challenge for individuals.
Behavioral health is not like orthopedics; where if you break an arm and get an x-ray, everybody can see it is a broken arm. In behavioral health, the diagnoses are more subjective and somewhat expandable—there are blurred boundaries between what is normal behavior and what is abnormal.
HL: Standardization and evidence-based care are buzz words in medicine. How can behavioral health providers get away from subjectivity in the diagnosis and treatment of patients?
Friedlander: It is going to be an ongoing process, and there is no silver bullet. Subjectivity is present in many of the other medical specialties. There was a recent study in the Journal of the American Medical Association on the interpretations of electrocardiograms, which are used to detect heart arrhythmias and heart abnormalities. Depending on the level of training, the concordance of physicians on electrocardiograms can vary widely.
Our aspiration for standardization in behavioral healthcare does not need to be perfect. There does not need to be perfect adherence to a protocol or perfect agreement on a diagnosis, but the aspiration needs to be that standardization is the direction in which we are heading.
We know certain treatments work, and certain treatments have little evidence to support them. At UHS, we are emphasizing interventions that work. So, the quest for standardization and evidence-based care in behavioral health is a journey. It is not going to happen in one step. But psychiatry as a field has advanced tremendously. There are still some grey areas, but what works and what does not work is increasingly clear.
As I think about what UHS can accomplish, we are moving in the right direction. We are moving toward evidence-based practice. I would argue that in most of our facilities most of the time, the care that is provided is evidence-based.
HL: It has been more than a decade since the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. Is there still work to be done to achieve parity between health plan coverage of mental health care versus medical-surgical care?
Friedlander: The report card has mixed grades.
In terms of the spirit of the law rather than the letter of the law, we have a long way to go. We still see a system of care where behavioral health is in its own silo, and medical-surgical care is in its own silo.
There was a very good study released earlier this year by Milliman about the presence of a behavioral health condition driving medical costs. When we look at the overall spend of medical-surgical care versus behavioral healthcare, mental healthcare accounts for about 4% of the spend but it drives about 44% of the total cost of care. So, parity still has a long way to go.
Health plans still look at behavioral health separately from medical-surgical care. What we need to achieve real parity is to integrate behavioral healthcare into medical-surgical care. Behavioral health is undervalued. The coverage from health plans needs to manage behavioral health in terms of the total cost of care, not just the cost of behavioral healthcare.
If you look at the letter of the law, health plans can say that they are managing behavioral health benefits in a manner that is not more restrictive than medical-surgical benefits. That is probably true, but that represents the letter of the law rather than the spirit of the law.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The key to success in behavioral health leadership is to articulate a clear strategic vision, new behavioral health CMO Mark Friedlander says.
While subjectivity in diagnoses has been notable in behavioral health, the field has made significant progress in adopting standardization and evidence-based care, Friedlander says.
The biggest challenges in behavioral health include high demand for services despite limited resources, stigma, and a fragmented care delivery system, he says.