Dr. Robert Trestman

Behavioral Health

Board Support Essential to Behavioral Health Access

Carilion Clinic’s Robert L. Trestman discusses trustees’ role in advancing community health

By Sue Ellen Wagner


Hospitals and health systems provide essential behavioral health care services to millions of Americans every day. Yet there are a number of barriers to accessing mental health care, including inadequate reimbursement, provider shortages, fragmented behavioral and physical health systems, and stigma. Improving access to behavioral health and mental health services is a priority for many hospitals and health systems across the country.

Since COVID-19 began, the number of people in need of behavioral health services has increased. Governing boards should have a good understanding of the behavioral health challenges and needs in their community. Then they can work with the leadership team to develop strategies to reduce stigma, implement prevention and early intervention initiatives for individuals with behavioral health disorders, and improve access to all levels of behavioral health care.

I recently talked with Robert L. Trestman, M.D., about the behavioral health issues and challenges that continue to impact our communities, hospitals and health systems. We also discussed strategies that boards can use to address behavioral health issues. Dr. Trestman is professor and chair, psychiatry and behavioral medicine, at Carilion Clinic and Virginia Tech Carilion School of Medicine. He also is chair of the American Psychiatric Association’s Council on Healthcare Systems and Financing and of the American Hospital Association’s Behavioral Health Council.

Sue Ellen Wagner: Would you provide us with a general overview of the behavioral health challenges our hospitals, health systems and communities are facing?

Robert L. Trestman: Before the pandemic hit, we already faced a shortage of access to care, a shortage of adequate psychiatric beds in terms of number and subspecialty, and difficulties for our community members to access the needed levels of care. The system of care has been fragmented for many years and over the last few decades with managed care, authorization requirements, and medical necessity criteria, as well as with reduced budgets at the federal, state and county levels. As a consequence, pressure has been put on hospitals and health care systems to provide some of the stopgap and safeguard here that, unfortunately, has always been limited.

Additionally, which has been complicating things, the training of psychiatry has been inadequate in terms of numbers for years. We were really bad at predicting the necessary number of psychiatric-trained physicians and having CMS [Centers for Medicare & Medicaid Services] fund them appropriately. Further, the reimbursement for psychiatric care has always been cost minus over the last few years.

We rarely were adequately compensated — and certainly, at the level of the health care system, there has been limited capital and investment. It’s been a real challenge for health care systems to provide the level of care that people know is needed.

Then the pandemic hit. To complicate everything else, hospital systems are now faced with substantial income losses, capital decreases and lack of access to adequate funds; many critical access and smaller systems face closures. And those are our patients, our communities who are suffering. Many of our patients and their families have been faced with loss of income, and they’re facing eviction from their homes. In addition, even if they do have a job, [they’re] feeling so isolated.

All of those different factors are combined to create a perfect storm of despair. As we’ve seen from published data, there is a tripling of the baseline rate of depression, increases in substance use disorders and increases in overdoses, and the level of anxiety is reaching unheard-of levels. So that’s what’s going on right now in terms of the pressures on the system and the transformation that’s needed.

In most of our hospital ambulatory psychiatric systems, we have had to transform — essentially overnight — to a teletherapy platform. And on our inpatient units, where in-person care is still needed, it has been extremely difficult. The need for protective equipment, social distancing, and limiting interaction is a real conundrum in environments that historically were congregate and milieu based. So those are enormous challenges, just at the time when our services are most needed.

Wagner: What has your hospital done to advance behavioral health services for your community?

Trestman: Carilion has a long history of partnership with our communities, and in that context, we had already been expanding our ability to work with our community partners to reduce the wait for services. We have already been planning expansions utilizing new capital investments. The hospital has supported the application for a certificate of public need expansion of psychiatric beds and has essentially given us all the resources we need in terms of telehealth and in terms of financial support to do everything we can to expand our services.

For example, we are in the western part of Virginia in the Appalachians. Many of our patients are very poor, and it’s very difficult for them to travel to get to us. With all of the challenges, our ambulatory, hospital-based services have converted to about 80% telehealth. And in that, the majority is delivered now by telephone. Our system is committed to allowing and supporting us to deliver that care, even not knowing up front what kind of compensation we might receive. That’s a profound commitment on the health system’s part to dedicate that much resource, not knowing what the compensation would be. It’s been a critical component because we’re at about 110% of our access compared to the beginning of the pandemic. We’ve been able to actually reach more people because of these changes.

Wagner: What was the board’s role in advancing behavioral health as a strategy to address your community’s behavioral health issues? Does the board have any outcomes for the strategies?

Trestman: The board had empowered us several years ago to review what the actual needs will be for the future. Working with our planning group and with the input from our community health assessments, it’s clear that the future of our region is going to require even more psychiatric services. Although the board had already committed substantial capital for the replacement and expansion of facilities, we are now in a situation where we’re pausing, as are most facilities, as we review the timing on making those needed capital investments.

But in some important ways that’s actually quite beneficial. Now we have the opportunity to revisit those architectural designs, both of our future ambulatory and inpatient facilities, to be resilient to potential future infection, diseases and pandemics. We are now recognizing the need to be more resistant to the consequences of natural disasters. So board members have been forward thinking. They have looked to the community health needs. They have committed capital to the necessary infrastructure. And many have committed to our department the ability to continue to hire psychiatrists, psychologists, social workers and nurses, which is a wonderful commitment during these financially uncertain times. That requires strategic thinking, as well as the commitment of the organization at the level of the board to give guidance to management, saying “this is the direction we need to go to meet our community’s needs.”

Wagner: What leadership role and steps can trustees take to address behavioral health issues at the hospital board level?

Trestman: There’s an old saying that is basically “no money, no mission.” So hospital trustees have an obligation — a fiduciary responsibility — to the system. They also have profound responsibilities to the communities that we serve. And so their role in strategic planning is to think through the balance: Where can the investment come from to meet the needs? And so from their perspective, the relative costs of psychiatric care in the overall scheme of things — compared to the investment of new radiology equipment, a new operating room and other very intensive services — is fairly modest. But, indeed, the compensation is similarly modest. Even though the return on the investment may be small financially, it takes a commitment at the level of the board to say the return on investment in the community’s health and well-being is profound and substantial. And they will be able to give guidance to management to say “this is what we will need to do, and we have your back.”

Wagner: Are you aware of and can you discuss other examples of boards being the driver of improved access to behavioral health services?

Trestman: Without naming names, others have used the opportunity of mergers for community benefit. As part of the merger, they have committed many millions of dollars to endow wellness initiatives dedicated to the health of communities. Others have focused on building partnerships with community organizations and making those investments. Others in states with Medicaid expansion have been able to take some of their community investment and invest in building the infrastructure necessary to support ongoing collaboration with the communities and to really target some of the social determinants of health. To build on the quality of care and the quality of living. To help make it easier for people to live in affordable housing. To be able to support pathways into higher paying jobs, so they can support an improved workforce not only for their own health systems but for the community.

And so that kind of forward thinking has been a reflection of many boards of trustees around our nation. Hospitals have been good stewards of the finances of their communities and invested in the community, in collaboration, as many of us are working to transform. Instead of thinking of ourselves as hospitals, we think of ourselves as health care systems — and now, not only as health care systems but genuinely as health systems. As we move incrementally in fits and starts to value-based compensation, to capitation and then to population-based care, those investments become critical to making those kinds of risk-based approaches really work. So with the investments that are being made now, the partnerships are going to serve us extremely well in the months and years ahead.

Wagner: Any words of wisdom and advice for your peers across the country in terms of encouraging their boards to tackle these important issues?

Trestman: The data is unambiguous. Patients with serious mental illness die at increased rates from suicide and they die early from comorbidities. People with serious mental illness, depression and anxiety disorders have co-occurring medical disorders at disproportionate rates. Mental illness may compromise the ability of people with diabetes to adequately partner with their endocrinologist or primary care physician in their own care. Substance use disorder in individuals leads to many other complications.

We need to acknowledge and directly focus on reducing the stigma of mental illness. The degree to which we do that is the degree to which we can more openly, honestly and effectively treat our patients as whole individuals, and really help them advance their own health care. Those of us at hospitals and health care systems that are successful at doing so will be seen as critical members of their communities, and will be very well placed for the future.

So it’s an exciting opportunity, but I really want to encourage people to continue to advocate, to continue to demonstrate the benefits of psychiatric care. And as we work, we will find that we’re making a difference in the lives of our colleagues, our patients and our community.

For additional resources, visit the American Hospital Association’s Behavioral Health webpage.

Sue Ellen Wagner (swagner@aha.org) is vice president, trustee engagement and strategy, at the American Hospital Association.