Q&A: DBHDS Chief Clinical Officer Alexis Aplasca, MD on moving towards value-based models of care in Virginia
Alexis Aplasca, MD is the chief clinical officer at the Department of Behavioral Health & Developmental Services (DBHDS). For the past several years, DBHDS has worked to close the gap between behavioral health services covered by public providers—such as Medicaid and Virginia’s 40 community service boards—and commercial providers.
In this Q&A, Aplasca discusses the integration of evidence-based treatment, state legislation she hopes to see next session and what behavioral health will look like post-pandemic.
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Nicole Pasia: Behavioral health services in Virginia are covered by public providers, such as Medicaid and community service boards, and commercial providers. How does this affect models of health care delivery across the market?
Dr. Alexis Aplasca: “It makes it a little bit complex, from a provider standpoint, to know which individuals should I serve, which payers should I receive that makes my business model sustainable, and also allows me to provide the best care possible. And then it also makes it really difficult, at the end of the day for the person receiving the care. I have to call my insurance company to know what I actually have access to and who within that service network can provide it. So that’s really the platform there, and the changes we’re really working on at the state level is how to decrease that gap between what’s available in the private space versus the public space, and how do we better align the services that are offered, so that the type of care and services that are available regardless of payer is really accessible to every Virginian.”
NP: How can agencies ensure their providers are aware of the trends and goals of their health care delivery models?
AA: “In the past 20 years, there’s been more research about mental health and behavioral health and there has been in the past 100 years. And our system really hasn’t caught up with the science, in terms of, ‘These are the evidence based treatments that work and have proven outcomes.’ So if you have a diagnosis, let’s say of depression, these are the treatments that would improve your depression within the next three to six months. And we don’t really have great insight to the extent those evidence-based treatments are actually being utilized in a system.
One, it’s costly. We have to train people on those practices and not everybody has access to that training. And, the more that we sort of move the system towards models that we know works, the less ambiguity there is for the person to choose a type of provider. So, for all the providers, if you’re looking for treatment of depression, and you’re looking for an evidence-based treatment like cognitive behavioral therapy, it should be pretty evident in the provider’s description of what they offer. CBT, or cognitive behavioral therapy, is not the only treatment. And then, it would come down to, ‘Alright, at least I know that this is a treatment that I’ve heard of, it works.’
And now I just want to make sure that this is the right provider in terms of the relationship and interpersonal relationship, which is really important also in behavioral health care, as you can connect with this person that’s providing the treatment. So, we are trying to move towards infusing more evidence-based or standards of care into the behavioral health services that are offered in the States, to be able to kind of close that gap and infuse all the science that we know and have the state catch up a bit.”
NP: What actions from the state legislature have addressed gaps in health care delivery models? What work would you like to see from the General Assembly next session?
AA: “There’s been a ton of activity from the state, and the General Assembly and governor’s office providing support. I think we’re talking about behavioral health now more than probably we’ve ever talked about it, partly due to a number of crises that happen, but partly because people are ready to address stigma in a more meaningful way. And so some of the things that we really advocated for is the transformation of the services within our community services boards through the STEP Virginia system…we do a lot of analysis around how much it needs to get up to speed to be the vision that we want it to be.
And then the other piece is really transforming the services in the Medicaid behavioral health space. Because those services have not been updated in about 20 years. And so they’re a reflection of a lot of practices that we have not had a good way of tracking how the evidence has been infused into those practices, and so that is being implemented through a project called Project Bravo. It stands for behavioral health redesign for access values and outcomes. And it really represents the ‘north star’ of what a really high-functioning behavioral health system looks like that drives away from costly, inpatient, crisis-driven care to that which is timely, preventative and really catches problems early.
So those are the things that I think will help support what our post COVID world would look like. We started this work before COVID and we were able to get support from the General Assembly and the governor’s office to implement six new services through the Medicaid behavioral health space, starting this July 1. The implementation will be throughout the year, but that is six of several [services]. The next thing on the horizon are some of the questions that we are getting from other stakeholders who are interested to know other than these six services, what else can we look forward to.”
NP: One possible way to reduce emergency room admissions and other potentially unnecessary costs is to look at and address non-medical factors, such as job security and access to sufficient food markets. How can agencies better incorporate the social determinants of health?
AA: “We really have to incorporate aspects where we ensure stability and safety and things from a population health perspective about keeping communities healthy. [It’s] making sure things like the minimum wage is a livable one, making sure that housing is available or making sure that the community that you live in is safe, or that your interactions with various agencies is equitable and the way that you access care is equitable. And so, we have a racial equity group that we’ve started, also as part of Project Bravo, to look at some of those factors that have played into the disparate nature of how people access mental health services and for different racial and ethnic groups.
We also bring forth the discussion, especially over the past year, around cultural competency and cultural humility and listening to each other about what you need, what people need. That might not be a mental health intervention at all. It might be [lack of] stable housing that’s driving the crisis, and so we have a number of programs at DBHDS that look at that as well and support people’s stability in the community.”
NP: Looking forward, how can agencies move towards value-based care as we move past the COVID-19 pandemic?
AA: “The post-pandemic state is tough. The post-pandemic state for mental health is tough. We did see a huge rise in the number of overdose deaths in the Commonwealth. And so we know that we have a lot of work to do to address substance use disorder, and substance use disorder treatment, [and] make sure it’s accessible. We had already gone through a transformation for substance use disorder services in the state through Medicaid and I can’t imagine this state of Virginia without that transformation, given what we know now of how much that impact was. We know that we have a lot of work to do there.
And then, even though we have these implementations on deck for this year, we know that the behavioral health services were pretty significantly affected by the pandemic, as some providers really just didn’t make it. A lot of behavioral health services are focused and built on group models of care, which we just couldn’t operate in the middle of the pandemic. So, we are trying to get a handle on what is still afloat and how people shifted their models and how do we bring them back into the space to provide these group models in a safe way, knowing that the pandemic is not completely gone…and to implement these new models of care. So, where we thought we would have a robust participation and influx of new providers into our system, I think we’re just cautiously optimistic about how robust the implementation can actually be in this post-pandemic state.”
This interview has been edited for clarity and length.