Latest / Becker’s Payer Issues Podcast / Jeremy Wigginton on Expanding Behavioral Health Access

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Jeremy Wigginton on Expanding Behavioral Health Access · Becker’s Payer Issues Podcast

• 0:01
  - The payer provider relationship has never been simple,
• 0:04
  - but what's happening now is something different.
• 0:07
  - Value based models are maturing unevenly,
• 0:10
  - prior authorization
• 0:11
  - reform is reshaping workflows on both sides, and
• 0:14
  - affordability pressure is intensifying.
• 0:17
  - The organizations that figure out how to collaborate
• 0:19
  - genuinely, not just contractually,
• 0:21
  - are the ones that will set the terms
• 0:23
  - for what comes next.
• 0:24
  - Becker's fifth annual fall payer issues round table
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  - brings together more than 500 executive level attendees
• 0:30
  - and 70 plus speakers for two days of
• 0:32
  - focused senior level conversation
• 0:35
  - on benefit design, network strategy, transparency,
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  - and the financial and regulatory dynamics that are
• 0:41
  - redefining how care gets paid for. Join us
• 0:44
  - November second and third at the Swiss Hotel
• 0:46
  - Chicago.
• 0:47
  - For the agenda and event details, visit beckerspayer.com
• 0:51
  - and click on the events tab in the
• 0:52
  - upper right.
• 0:54
  - Hi, everyone. This is Elizabeth Cassello with the
• 0:57
  - Becker's Payer Issues podcast.
• 0:59
  - I'm thrilled today to be joined by doctor
• 1:01
  - Jeremy Wigginton,
• 1:02
  - chief medical officer at Capital Blue Cross. Doctor
• 1:05
  - Wigginton, thank you so much for chatting with
• 1:07
  - us today.
• 1:08
  - Thank you. I'm really excited to have this
• 1:10
  - conversation, so thanks.
• 1:12
  - Of course. So can you give us a
• 1:13
  - little bit of background on your career in
• 1:15
  - health care and your current role?
• 1:17
  - Absolutely.
• 1:19
  - I was trained in the,
• 1:20
  - Southern Part of The United States in, in
• 1:23
  - medicine and received my board certification in family
• 1:26
  - medicine. I spent a number of years
• 1:28
  - in outpatient,
• 1:30
  - family medicine, pretty traditional family medicine for,
• 1:33
  - several years in combination with academics,
• 1:36
  - and some managed care when I was working
• 1:38
  - in the
• 1:39
  - health care
• 1:40
  - industry early in my career.
• 1:43
  - Around 2015,
• 1:45
  - I transitioned to managed care full time within
• 1:47
  - the Blue Cross system, and I have been
• 1:49
  - in Blue Cross,
• 1:50
  - in a varied number of roles since that
• 1:52
  - time,
• 1:53
  - dedicated full time to managed care. Currently, my
• 1:56
  - role is, as chief medical officer with Capital
• 1:58
  - Blue Cross out of Central Pennsylvania, out of
• 2:01
  - the Harrisburg,
• 2:02
  - Pennsylvania region.
• 2:03
  - And my role really encompasses all of our
• 2:05
  - clinical strategies across the enterprise
• 2:08
  - and coordinating those strategies with, our client needs,
• 2:11
  - our population needs,
• 2:13
  - as well as things like compliance and,
• 2:16
  - and making ensure we are committed to improving
• 2:19
  - the health and lives of those that we
• 2:20
  - serve and also the communities in which they
• 2:22
  - live. So,
• 2:23
  - quite a quite a task, but, I think
• 2:26
  - we have seen some good results in some
• 2:28
  - of the, efforts we've undertaken,
• 2:30
  - which I think we'll talk about today.
• 2:33
  - Yeah. So I know today we're gonna specifically
• 2:35
  - chat about some data that Capital Blue Cross
• 2:37
  - just released on behavioral health care and employer
• 2:40
  - costs. So can you give me a high
• 2:42
  - level overview
• 2:43
  - of that and some important data points for
• 2:45
  - people in this space to keep in mind?
• 2:48
  - Sure. Well, high level is that we we've
• 2:50
  - really been able to prove that earlier access
• 2:53
  - to behavioral health care
• 2:55
  - really helps to reduce the need for crisis
• 2:57
  - level care.
• 2:59
  - Capital saw our behavioral health related emergency department
• 3:02
  - visits decline
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  - just at nine percent in 2025
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  - compared
• 3:07
  - with the prior,
• 3:09
  - two year period from 2022 to 2024.
• 3:12
  - That was primarily because we insourced our behavioral
• 3:16
  - health capabilities
• 3:17
  - in 2025. We built an entire
• 3:20
  - in house model with expertise, with,
• 3:23
  - psychiatry,
• 3:25
  - with autism,
• 3:26
  - resources to support those types of, complex requests,
• 3:30
  - as well as integrated care management and other
• 3:32
  - clinical support resources,
• 3:34
  - within population health.
• 3:36
  - At that same time,
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  - we also underwent a significant expansion of our
• 3:40
  - behavioral health network by almost 40%, and that
• 3:44
  - includes a combination of both brick and mortar
• 3:47
  - providers as well as some virtual access,
• 3:50
  - professionals, not just physicians, but also,
• 3:53
  - those, support professionals as well.
• 3:55
  - The larger takeaway
• 3:57
  - really from that effort was that access, navigation,
• 4:00
  - and clinical support work,
• 4:02
  - they really need to fit together, and they
• 4:03
  - need to work together. And that a larger
• 4:06
  - network matters
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  - and certainly provides more access, but members also
• 4:10
  - really need clear ways
• 4:12
  - to find care and support them in connecting
• 4:15
  - to those care resources,
• 4:17
  - and the appropriate levels in care. So we
• 4:19
  - were able to create quite a comprehensive
• 4:22
  - in source behavioral health model,
• 4:24
  - coupled with some expanded network options
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  - and then supplemented that with some more robust
• 4:30
  - integrated behavioral health navigation
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  - to really realize some of these, additional,
• 4:35
  - success metrics.
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  - So how did you go about that network
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  - expansion,
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  - and how did you find good fits for
• 4:43
  - your network?
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  - Considering how a handful of behavioral health care
• 4:46
  - providers may not have historically accepted insurance, what
• 4:49
  - were those conversations like?
• 4:52
  - Well, we did some good old boots on
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  - the ground outreach. We looked for utilization
• 4:56
  - patterns in which we were seeing utilization of
• 4:59
  - both out of network, out of area,
• 5:01
  - behavioral health professionals,
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  - and we picked up the phone. We gave
• 5:05
  - them a call. We,
• 5:06
  - communicated with them, asked them
• 5:09
  - generally about their interest to join the behavioral
• 5:11
  - health network and, really, what were the barriers
• 5:13
  - to previously joining,
• 5:15
  - within the local network,
• 5:16
  - within the blue system. We got some varied
• 5:19
  - responses. Some were that, they wanted to have
• 5:21
  - conversations about reimbursement strategies,
• 5:24
  - and reimbursement models.
• 5:26
  - Some were that, they just needed more information
• 5:28
  - around how the partnership might work and really
• 5:30
  - just sort of the the nuts and bolts
• 5:32
  - of being a participating provider.
• 5:34
  - And just through that direct outreach, we were
• 5:37
  - pretty successful in being able to bring some
• 5:39
  - of those additional providers within our network, those
• 5:42
  - health care professionals,
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  - by looking at those utilization patterns, by looking
• 5:46
  - at geographic spread, and doing that sort of
• 5:49
  - targeted
• 5:50
  - outreach.
• 5:52
  - So the other thing that we did was
• 5:54
  - we really look for best in class,
• 5:56
  - high quality virtual,
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  - options,
• 5:59
  - both in terms of what other payers are
• 6:03
  - have done over the past several years and
• 6:05
  - adding to their own networks.
• 6:06
  - But we also listen to the market. We
• 6:08
  - listen to what our members were asking for.
• 6:10
  - We also listen to what our ASO,
• 6:12
  - our self funded clients were asking for in
• 6:14
  - the national space and in the local space.
• 6:17
  - So I would say a lot of listening
• 6:20
  - and,
• 6:21
  - conversation
• 6:22
  - to make sure we're making the right choices,
• 6:24
  - and I do believe we were pretty successful
• 6:26
  - with that.
• 6:27
  - So I know in the publication that y'all
• 6:30
  - had, Capital said it increased reimbursement rates, streamlined
• 6:34
  - credentialing,
• 6:35
  - and lowered administrative burden for smaller practices. So
• 6:38
  - how easy were each of those things to
• 6:40
  - do, and how feasible do you think those
• 6:41
  - things are for other insurers who might be
• 6:43
  - considering growing their networks in the behavioral health
• 6:46
  - care space?
• 6:47
  - Sure. Well, I'd say, first, it does require
• 6:49
  - conversation. You really have to assess the current
• 6:52
  - landscape.
• 6:53
  - Again, through those conversations we're having directly with
• 6:55
  - health care professionals,
• 6:57
  - we're able to pinpoint some of those administrative
• 6:59
  - burden,
• 7:00
  - pain points, whether it was with the prior
• 7:02
  - auth process,
• 7:03
  - was it with, with data exchange,
• 7:06
  - or was it directly with the reimbursement
• 7:08
  - rates that we were offering for specific services
• 7:11
  - or specific codes of the way our fee
• 7:13
  - schedule was set up? So
• 7:14
  - I would say while we were able to
• 7:16
  - build a model of approach that could certainly
• 7:20
  - be scaled to other payers,
• 7:22
  - every plan, every payer in every region is
• 7:25
  - somewhat different. It really depends on your capabilities,
• 7:27
  - what your current fee schedule,
• 7:29
  - looks like, what your reimbursement rates are, and
• 7:32
  - really having those conversations. So, again, through those
• 7:35
  - conversations, we're able to to identify
• 7:37
  - areas where we could,
• 7:40
  - increase some of our reimbursement rates,
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  - but also that we saw value when we
• 7:44
  - saw need to increase those rates so that,
• 7:46
  - members could get access to those specific services.
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  - So I would say, certainly,
• 7:51
  - there's some lessons to be learned that could
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  - be scalable,
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  - around,
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  - the approach,
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  - But I would say the details behind it,
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  - do get a little bit difficult to scale
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  - just because there's, such differences within market and
• 8:03
  - plan.
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  - But, I think it is certainly doable.
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  - And you mentioned the in house model as
• 8:09
  - well. So I'm wondering how did you balance
• 8:11
  - the in house model on who you were
• 8:12
  - recruiting there,
• 8:14
  - versus, like, when you were looking externally
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  - for expanding your network? Could you talk about
• 8:19
  - your priorities with that?
• 8:21
  - Well, our priorities really were to create a
• 8:23
  - partnership,
• 8:24
  - and dialogue, especially within our local network.
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  - As I mentioned, we brought in house
• 8:31
  - several,
• 8:32
  - different areas of clinical expertise.
• 8:34
  - We also integrated our behavioral health care management
• 8:37
  - staff.
• 8:38
  - Part of our expansion was also the addition
• 8:40
  - of those those, virtual,
• 8:42
  - access solutions. We have a partnership with American
• 8:45
  - Well,
• 8:46
  - which powers our Capital Blue Cross virtual
• 8:49
  - care platform.
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  - They also offer behavioral health resources, both,
• 8:54
  - physician resources, but also,
• 8:56
  - counseling and some other support resources.
• 8:59
  - So really, again, starting with a dialogue to
• 9:01
  - say, hey. Here's what our resources are. Let's
• 9:04
  - talk about what your resources are. How can
• 9:06
  - we work together? What happens when you get
• 9:08
  - a complex member that's a capital member? How
• 9:11
  - can we work together to get them access
• 9:12
  - or to get them supported?
• 9:14
  - You're welcome to reach out to us. We
• 9:16
  - may reach out to you. So it's really
• 9:18
  - creating that bidirectional
• 9:19
  - dialogue,
• 9:20
  - that open line of communication and trust within
• 9:23
  - those expanded providers and our and our already
• 9:25
  - existing provider network.
• 9:27
  - I think we and with,
• 9:29
  - also not just with the expanded
• 9:31
  - solutions, we also,
• 9:33
  - reached out to our existing partners in behavioral
• 9:35
  - health, some of those larger health systems
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  - in addition to some of those solo practices,
• 9:40
  - and asked them, how do we work closer
• 9:43
  - together now that we have this in source
• 9:45
  - model? So particularly
• 9:46
  - with those,
• 9:47
  - more complex, more challenging members, so those frequent
• 9:50
  - flyers to the emergency room or those members
• 9:53
  - or patients that may be frequently readmitted,
• 9:56
  - and how can we
• 9:58
  - work together to get them access, whether that
• 10:00
  - be brick and mortar, virtual, depending on resource
• 10:03
  - needs.
• 10:04
  - We also talked a lot about social determinants
• 10:06
  - of health. Some of these practices were located
• 10:09
  - more in the rural areas. And so what
• 10:11
  - additional resources may Capital provide
• 10:14
  - or offer,
• 10:15
  - to help them break down some of their
• 10:17
  - own barriers to accessing care if their members
• 10:20
  - were, having difficulty with transportation
• 10:24
  - or communication.
• 10:26
  - Really, what were those things and and how
• 10:28
  - can we support? So I would say much
• 10:30
  - like how we approach other things, it's it's
• 10:31
  - really we look to increase our partnership as
• 10:34
  - much as possible.
• 10:35
  - And I'm also just curious what the response
• 10:38
  - has been from employers and what your conversations
• 10:40
  - look like there when it comes to investments
• 10:42
  - in behavioral health.
• 10:44
  - Well, we're certainly continuing to see a steady
• 10:47
  - rise in utilization rates of behavioral health services
• 10:50
  - really across the board,
• 10:52
  - both in pharmaceutical expenditures for for behavioral health,
• 10:56
  - but also in inpatient and outpatient care. We
• 10:59
  - had also, for several years, seen,
• 11:02
  - increasing rates of ED utilization,
• 11:04
  - for
• 11:06
  - behavioral health. And so
• 11:08
  - we were seeing that, and our ASO customers,
• 11:10
  - our employer clients, were also seeing those same
• 11:12
  - trends and really wanting to know what more
• 11:15
  - they could do, what more we could do
• 11:16
  - to help to support members and their employees
• 11:20
  - in getting better access to care,
• 11:22
  - and managing some of those complex needs. Because
• 11:24
  - we know that,
• 11:26
  - unmanaged behavioral health not only leads to increased,
• 11:30
  - health care expenditures cost wise, it also contributes
• 11:33
  - significantly to absenteeism,
• 11:36
  - within those employee workforces.
• 11:38
  - And so they were very eager to participate
• 11:40
  - with us. They were very pleased to hear
• 11:42
  - that we were expanding,
• 11:44
  - meaningful access to behavioral health resources that could
• 11:47
  - help to,
• 11:48
  - manage some of those trends and get those
• 11:50
  - members the care that they needed.
• 11:52
  - We because we did see that significant decrease
• 11:55
  - in ED utilization,
• 11:56
  - certainly, we know that much of that ED
• 11:59
  - utilization on the behavioral health side was certainly
• 12:01
  - care that could have been provided at alternative
• 12:04
  - levels of care.
• 12:05
  - They certainly are are, more manageable out of
• 12:08
  - pocket cost for the member and the employee,
• 12:11
  - but also, for those ASO customers, they they
• 12:14
  - do see those,
• 12:16
  - increased costs for ED care, which could be
• 12:18
  - managed at a lower side of care. So
• 12:20
  - certainly,
• 12:21
  - a very positive response from employers
• 12:23
  - in what we were doing to help manage,
• 12:26
  - the whole person care,
• 12:28
  - behind their employee health,
• 12:31
  - as particularly as it pertains to some of
• 12:33
  - these utilization patterns.
• 12:35
  - When you're looking at utilization patterns more broadly,
• 12:38
  - are there other areas beyond behavioral health you're
• 12:40
  - thinking about now or where maybe you could
• 12:43
  - deploy
• 12:43
  - a similar model like the in house, resource
• 12:46
  - building as well as the external building up
• 12:49
  - the network?
• 12:50
  - Mhmm.
• 12:51
  - There's always opportunity to evaluate those, and they
• 12:54
  - do tend to change a bit. But I
• 12:56
  - would say
• 12:57
  - it's that specialty space. Sometimes we think of,
• 13:00
  - of behavioral health. Yes. It's integrated.
• 13:02
  - It should be part of our whole person,
• 13:05
  - model when we're outreaching to members, really asking
• 13:08
  - about their whole person health, health, not only,
• 13:09
  - you know, if they have chronic disease, how's
• 13:11
  - your blood pressure doing? How's your diabetes?
• 13:13
  - Do you understand your care plan from your
• 13:15
  - recent discharge? But also integrating,
• 13:17
  - behavioral health questioning and dialogue as well to
• 13:20
  - see how we can best support that. So
• 13:22
  - I would say it it is integrated, but
• 13:25
  - we do need to look at behavioral health
• 13:26
  - as a as a type of specialty because
• 13:28
  - it is somewhat unique.
• 13:30
  - We do need unique clinical expertise. So, similarly,
• 13:34
  - looking at some of those more complex,
• 13:37
  - specialty services,
• 13:39
  - that we support,
• 13:40
  - members within the network and nationally.
• 13:43
  - I'll use an example around,
• 13:45
  - autoimmune disease, kind of a broad category of
• 13:48
  - diseases,
• 13:49
  - but we know those members are on long
• 13:51
  - term therapies.
• 13:52
  - We know there's many autoimmune diseases. There isn't
• 13:55
  - a a cure all.
• 13:57
  - And so very similar behavioral health, it comes
• 13:59
  - up it comes down to, are you adequately
• 14:02
  - managing it? Are you managing the complications?
• 14:05
  - Are you managing your comorbid conditions?
• 14:07
  - And is your whole person health being supported?
• 14:10
  - I think of some of those other specialty
• 14:12
  - conditions like the immuno immunological
• 14:14
  - space,
• 14:15
  - and autoimmune disease space,
• 14:17
  - being very similar. These are these are long
• 14:19
  - term management conditions that can be quite a
• 14:21
  - burden
• 14:22
  - on members to manage,
• 14:24
  - alone.
• 14:25
  - So, certainly, as much of those types of,
• 14:27
  - areas we could
• 14:29
  - evaluate to either expand network, look for additional
• 14:32
  - solutions.
• 14:33
  - I also think about GI care. That's been
• 14:35
  - an that's been another
• 14:36
  - common area to look at as well as
• 14:39
  - perimenopausal
• 14:40
  - care.
• 14:40
  - Perimenopausal
• 14:42
  - care also requires quite
• 14:44
  - a commitment of, specific specialty resources, understanding
• 14:49
  - of what women's needs are around perimenopausal care.
• 14:51
  - There's also behavioral health component,
• 14:54
  - to perimenopausal,
• 14:55
  - care. And so that those are all spaces
• 14:58
  - at which we're looking to say, how can
• 15:00
  - we expand our network? Are they the right
• 15:02
  - expansion choices? And then how do we work
• 15:04
  - with our care managers, our navigators,
• 15:07
  - to outreach the right members to connect them
• 15:10
  - to the most appropriate resources?
• 15:12
  - And so far, building upon this model of
• 15:14
  - behavioral health, I think we're gonna see some
• 15:16
  - some success in those areas as well.
• 15:20
  - Do you have any other advice for industry
• 15:22
  - leaders as we wrap up?
• 15:24
  - I would say it really is about
• 15:27
  - conversation
• 15:28
  - and listening to the your current
• 15:32
  - health care network around what the challenges are.
• 15:36
  - We also need to be listening directly to
• 15:38
  - our clients, including employers,
• 15:40
  - and then our members. So member surveys are
• 15:42
  - very important, what we're seeing in terms of
• 15:44
  - member feedback,
• 15:46
  - what members are calling into for customer service,
• 15:49
  - or when we're doing outreach and identifying barriers.
• 15:52
  - I think we really have to listen to
• 15:54
  - the customer
• 15:56
  - to really understand what we can do to
• 15:58
  - help improve,
• 15:59
  - some of these areas of need.
• 16:02
  - So I always first seek to understand. I
• 16:04
  - don't try to seek to solve until I
• 16:06
  - fully understand. So I would say that will
• 16:09
  - continue to be a very successful,
• 16:11
  - strategy.
• 16:12
  - Well, doctor Wigginton, thank you so much for
• 16:14
  - taking the time to join us today. Absolutely.
• 16:16
  - It was a pleasure. It's great having you.
• 16:19
  - And to our listeners, if you'd like to
• 16:21
  - hear more podcasts from Becker's Healthcare, you can
• 16:23
  - visit beckershospitalreview.com.
• 16:25
  - Thank you.