Episode Transcript:
Eva Borden
Maybe someone I know has an issue. But it's a whole other ballgame to say, ‘I'm struggling.’ That's a really personal thing and how we meet people and encourage them to say that doesn't say anything bad about you.
Robert Traynham
So welcome to the program, Eva. You know, we all live really busy lives, we're constantly juggling between our phones, our family, and work — especially post COVID with so many things going on. One of the things that I love asking people is, okay, when no one else is looking, when you're spending good quality time with yourself, and or with your family and friends. What do you like doing? What's your favorite hobby, music, book that you're reading?
Borden
So, a couple of things, I would say, if I'm just by myself, I often call the books read ‘Mind Candy’ because that's just what I do for fun. And I really read a lot of murder-mystery novels — that’s one of my absolute, most enjoyable things to do. But if I had to pick a book that was . . . there's a mix of ‘you do that for fun,’ and then you also have the, alright, what do I do when it's like, ‘what do I read to help myself think professionally?’ And I think the book that I'm reading right now that I really appreciate is “The Obstacle Is the Way.” And I think it's just so in keeping with all that's going on in the environment right now. There are so many obstacles around us that to be able to say, ‘Okay, how do we actually use those obstacles as a point of overcoming as opposed to letting them be the things that hold us back?’
Traynham
So, let's unpack that. So, an obstacle can be an opportunity, right? In many ways.
Borden
Absolutely.
Traynham
Stepping back, you can also step forward and what I mean by that — they call it an ‘after-action review’ like ‘what went wrong and what went right.’ But let's focus on what went wrong because that's a learning opportunity. Right? Is that Is that how you look at that?
Borden
Absolutely.
Traynham
Yeah. And I want to go back for a second in terms of the murder mystery, because I'm not one of those people. But I enjoy, I really enjoy biographies where you can almost live another world, you can live another person's life. So, help us understand the whole murder mystery aspect of this. Why is it interesting to you?
Borden
I think a few reasons that I find it particularly interesting is one, the challenge of not knowing.
Traynham
Yeah, so it's almost like discovery.
Borden
Yeah, like you get a chance to understand that something's happened and try to figure out the different pieces. And if you read them enough, you're like, ‘Okay, I think I've got it almost figured out.’ But then I always love a good, good book where you end up going, ‘I thought, I got to figure it out. And you've thrown a great twist,’ and you go, ‘Well, so much for thinking I knew it was happening.’
Traynham
So, let's talk a little bit of work if we can. So, you are the President of Behavioral Health at Evernorth. What is that?
Borden
So Evernorth is the health services arm of the Cigna group. And so, our focus is really on how do we help bring all different kinds of services, whether it's pharmacy, medical, behavioral, together in support of health plans, employers, the government, whatever's needed. And so that's really what our focus is.
Now, when you think about the behavioral-health specific component, my job is to be able to provide — so, let's start with ‘What is behavioral health?’ So, behavioral health is really that focus or the discipline on everything from mental health to emotional well-being, and how do we think about the mind in relationship to the body and our environment and those around us?
And so, my job is really to make sure that the people who need access to care, who need to be able to get support — particularly when it's focused on the mind — are able to do that.
Traynham
Is it fair to say, Eva, it's almost like you're a navigator, and you're helping the patient navigate, in many ways, their own selfcare when it comes to the mind?
Borden
Oh, absolutely. And when you think about how people manage their behavioral health, I think there's such a big opportunity. Because unlike medical… So let's talk about what happens if someone is not feeling well, if I have a cold or a sniffle. I often, ‘Alright, do I need to go to the doctor or not?’ If I fall and break my ankle, I know what to do.
Traynham
Yeah, it's pretty concrete. You pretty much know what to do. Right? It's pretty prescriptive, almost.
Borden
Definitely, versus when your mind is struggling. One, are you aware of it? Two, even if you are aware of it, what do you do? It's not easy.
Traynham
Yeah. It can also be overwhelming. And I would assume, speaking on behalf of myself, you're almost paralyzed. It's almost, I call it ‘fear of fear.’ You just simply don't know what to do. And you create this environment around you where it's like, ‘oh, my gosh, I'm so paralyzed. I don't know exactly what to do because I don't recognize myself.’
Borden
Right. And it's also the one, if you think about it, it's one of those conditions that we, that people, struggle with, where we ask them to use the same part of their body that's struggling…
Traynham
…to be logical…
Borden
… to be the one to take the actions, right? It's like, okay, you broke your ankle now go run a marathon, right?
Traynham
That's a perfect analogy.
Borden
We would never say that to someone!
Traynham
That's right. So Eva, it is it is abundantly clear that you are passionate about what you do. What motivates you to do this work?
Borden
I'd say there's three things that motivate me or make me say, ‘Why do I get up every day and come to my job?’ One of them is I'm an actuary by background. And so, I'm really passionate about measurement. And if you think about mental health as a space, where we have not spent nearly enough time measuring the outcomes, measuring, what's the difference. Imagine a medical world where we said, ‘You know what, we're not going to bother having lab tests or other things like that. We're just going to trust that it's okay.’
Traynham
Why is that okay? It's almost like this low expectation. And you can make the argument that the brain is arguably the most sensitive, the least understood organ in our body. So why the lack of investment?
Borden
Well, I would say a lot of it was not knowing what to do. And so that's actually some of the advancements in the innovation and technology has become so important, because that's where a lot of the money is going into, on how do we actually put technology in play to begin to evaluate?
So, I can't take blood, urine, or tissue to determine if someone’s getting better? However, there are tools, whether it's face scanning, voice recognition, other pieces like that, that we can start to bring together to evaluate, you know, are we seeing a difference? There's also plenty of room for opportunity on how we do studies to say when someone's getting the right type of treatment. Maybe it's not exact causation, but we can absolutely go to correlation relative to, ‘If I had this action, what do I think is going to happen?’
So, I think a time is coming very imminently, where that's going to be something we're going to really go after.
The second part as to why I'm passionate is because I had done some work when the Affordable Care Act launched. I spent a lot of time working on our government business. I was our chief risk officer. And one of the things I had a chance to see that was really quite sad was that there was a lot of fraud that was happening in the behavioral health space. People were being taken advantage of. People were going and trying to get treatment or sending their loved ones to get treatment, and they were completely getting defrauded.
If you think about medical, I can go in network or out of network, if I go out of network, I'm still probably going to get good care. In behavioral health, the difference between in network and out of network can be getting good treatment, and literally being taken advantage of.
And the third reason why I'm so passionate about this is because I experience the system as a mom. So, I have three teenagers. And my daughter, who is 16, has some really significant mental health challenges that we've been dealing with her whole life. And so, all of the things that we talk about when it’s “What does it mean to get access to care? What does it mean to be the parent? What does it do to the siblings?’ I live that every day. And so, there's a piece of knowing that I think about. My privilege is the fact that I get to come to work and after I've experienced something, I actually have the opportunity to change it. And those are the three reasons why, for me, my job is so important.
Traynham
Let me be brutally frank with you for a moment, I just had an ‘aha moment.’ And the aha moment is when you're walking, you're really walking the walk. And you're also, you dare to ask the question. And what I mean by that is you're daring to ask the question. ‘This is not okay, what else can we be doing better when it comes to mental health?’ And second, to my first point, and that is walking the walk, thank you for sharing your story, because you can also relate to other moms or other humans that are trying to navigate this very, very difficult maze. Which, by the way, we don't have a map for, which, by the way, because no one's asked a question, which, by the way, because no one has researched, at least in detail.
Borden
You got it. Well said.
Traynham
So, walk us through why we're here. You know, why are we in this moment? My question is where people like Eva are asking the question, but we still have yet to make significant progress or, correct me if I'm wrong, maybe we've made significant progress.
Borden
I think we are making significant progress.
Traynham
Is that measured in baby steps? Or is that measured actual, in steps?
Borden
Well, I think it's not a direct path. So, if I think about steps, that's a very linear way of thinking.
Traynham
So, is it more like this? [makes wavy, zig-zag motion with hand.]
Borden
It can be that or even exponential. So, once you start making, once you start breaking through, it's kind of like the first time someone ran, you know, a sub- two-hour marathon or whatever the number is, you know, it took the first person to do it. Before that, people would have said, ‘Oh, you could have never run a marathon that fast.’ Or,‘You could have never broken the four-minute mile. Nobody can run faster than a four-minute mile.’ Until the first person does it. And then you start to see this exponential growth that's happening.
Traynham
Can we put a pin in that for a second? Because oftentimes with my family, with my friends, and I should also say, I believe a lot of this is cultural, a lot of this is religion based, a lot of this is maybe gender based. But it’s like, 'I'm not feeling so well.' 'Okay, well, let's talk about that.' 'No, no.'
Borden
No.
So, there's a stigma with just talking about it, right? And I get it, you have to be a little vulnerable, you have to be really honest about yourself, you have to be really open about perhaps maybe a struggle that you're dealing with, and that's sometimes not okay, especially if you're a man, maybe if you're a person of color, you know, maybe if you are a significant member, a prominent person in the community talking about your mental health. ‘Why would you talk about something like that? Just, just sleep it off?’ You know, that's, that's really part of the stigma, no?
Borden
Absolutely. Absolutely. And I think getting people willing to talk about it — so there's this having a champion, someone who's willing to say, 'It's okay to talk about it.' Two, making that map or the resources easy to get. And then three, making sure that there are resources that meet the needs in a way that can be very private.
So, if you think back to how we want to go about getting someone into care, you have to make sure that those resources are available, and they have to meet the needs. So sometimes people don't want to go, ‘I don't want to drive to someone's office and park my car, especially in the community where someone could know what I'm doing.’ Because they're still very much a private part of this. We've gotten away from what was ‘them over there, they have those issues,’ to now, maybe someone I know has an issue. But it's a whole other ballgame to say, ‘I'm struggling.’ That's a really personal thing, and how we meet people and encourage them to say that doesn't say anything that's bad about you.
Traynham
Yeah.
Borden
I also think one of the things that's challenging, particularly when you think about adolescents who are struggling, sometimes employers will say, ‘Why should I worry about this? Like, it's not my employees.’ It's like, I can show up to work and I can be a little sick, and I can go on and make okay, decisions. [shaking head] If my daughter is having a bad day . . . .
Traynham
Your whole self is not there.
Borden
Not even close.
Traynham
Right, because I'm making the number up, but if your daughter is home sick, maybe 20% of Eva's at work, meaning mentally, because you're preoccupied, you know, you have other more important issues going on, that you're probably more focused on. So, you'll make the decision. But are you thoughtfully making that decision? That's the question. Are you thoughtfully showing up in a way that’s 100%? So, to your point, absolutely, the employer should be caring about this.
Borden
Yeah. And there's a piece the employer should care about it because you can't see these things. So, it's not like everybody's standing on an assembly line and you can tell the person with the broken leg, and you say, ‘Go home and get better.’ When someone's had a fight with their spouse, or struggling with their child, or there are stressors going on, you can't, they don't walk in and have like a sign that says, ‘I'm not okay.’
I think the other interesting part, too, is we don't spend enough. Like there's the value on making sure people show up with our whole selves at work. There's also, there's real money tied to this. And so, unlike the fact that years ago, people didn't pay attention, because it was one of the lowest line items from a cost perspective, the reality is when you cross sect that with all the other medical conditions, all of a sudden, you're now talking about the majority of your medical costs are actually touched by people who have behavioral health needs. And so, when you don't address those, they're still going to seek out help. But they're going to seek it out in the medical care setting. They're going to seek it out by, ‘how do I go to my PCP?’ And they're not going to use words like ‘I'm depressed.’ They're going to use words like, ‘I'm not okay,’ or, ‘I'm just I'm not sleeping well,’ and helping them to know where to go becomes really important.
Traynham
So, Eva, we've been talking a lot about the problem, which is huge in many ways. Before we talk about the solution, we see a United States senator dealing with mental health in a very, very public way. Last time I checked actually the number spiked a little bit with respect to people Googling and doing some searching around their own mental health, which I thought was really interesting. We also have heard many celebrities talk about their own mental health — I call it just navigation, not challenge, per se. I think challenge has a little bit of a stigma to it, but that's my bias. Do you believe that when more and more household names come out and say, ‘Listen, this is the me you can’t see. This is me being my authentic self by being open about my own challenges.’ Is that helpful?
Borden
Definitely. And I think because it gives that willingness — we talked a little bit earlier about stigma — it gives that willingness to say ‘it's okay’ and normalize it.
So, when I think about different personas of people who are struggling, I kind of think about it in four buckets. One of them are willing engagers. And so, these are folks who say, ‘I think something's not okay.’ It doesn't mean that they're posting it on Tik Tok, or Instagram or whatever it is, but they're willing to actually go and try and navigate the system, whether it was a medical provider and or find a counselor. And it was one of the things that we found interesting is actually the younger generations have more willing engagers than the older generations. And if you think about from onset, most of the time, the first time someone's going to experience symptoms, the majority of them are going to experience them in their teens or early 20s, the first symptom set. And so, the more that we get people knowing how to navigate the system sooner, who know and can develop the right coping skills, you know, you're talking about generational impacts. Like, these are deposits and investments that we are making in our future.
Traynham
That we're going to pay forward. Right? So that leaves that 20-something — I’m being a little bit pejorative here — but that 20-something possibly will be a parent. And then thus the process, pay it forward with their kids in terms of how to show up in a way by saying, ‘Let's talk about this. Let's talk about how you're feeling. Let's process what you just saw, or what you're experiencing. And let's openly talk about this so that you can be in a better place.’
Borden
Yeah. So, you have the right coping skills. And so, you know how to navigate or know when I’m going off to a place that's not as healthy as I need to be. And how do I redirect as opposed to waiting for it to get to a place that someone's really struggling in a big way?
And I think as you go through, so you have your willing engagers and on the opposite end of the spectrum, nearly 40% of people are silent sufferers.
Traynham
Forty percent!?
Borden
Forty percent. Now, these are of the people who have behavioral health needs, which is about a quarter of the population. But still, imagine if you had a condition like diabetes, and you said 40% are silent sufferers. That would be horrible. We would never tolerate that. And so, one of the things that I think is incredibly important, is being able to help identify who these folks are. And not the 11 years that typically, on average, from symptom onset to treatment is about 11 years. And so, if you can help identify these folks sooner, and help them get into care in a much earlier way, so I don't need to wait for the acute event. Instead, I can help and find therapy now. Or if I need drugs, or if I need whatever it happens to be. And the beauty is, there are so many emerging solutions relative to how someone can get care, that there's loads of opportunities. And so, like when I really think about it, one of our most important things we can do is find people sooner. It's almost like finding the people who are wandering and say, ‘I have a map for you. You're not alone.’
Traynham
Navigation. It's helping the person walk their journey, in many ways. At least that's how I take it. So, if I do not have a PhD or an MD, or doesn't matter, let's just say from a health insurance perspective, what does this look like in terms of some of the solutions, Eva?
Borden
Yeah, so one of the roles that we have an opportunity within the health insurance space to really enact change in behavioral health is making it affordable. And so, if you think about right now, less than half of all the behavioral health providers out there actually work with a payer. And so, that's all about disparities, and who can afford it. Those who can afford it, get care. The less I can afford it, the less I'm going to prioritize it. So, when I think about my responsibility, it's enabling that access, affordable access, that people can actually get to. And so, I think whether it's making sure that it's affordable, making sure that people can find the providers that they need, making sure that we help them know they have a benefit. It's one of the most forgotten things! I still have people who come to me and say: ‘Ah, you know, I really wish my employer provided mental health help or support through benefits.’
And I say, ‘So you have medical benefits?’
‘Well, yes, I do.’
‘Then you have behavioral health help.’
Traynham
So, it's the awareness, it's the education, it's whatever you want to call that. It's making sure they know they already have this.
Borden
You have it available. And it's something you can afford. And there's also that protection. I think earlier I'd mentioned there's a lot of fraud in this space. And so, I think my responsibility isn't just making sure that someone has access, that they can afford it, but that it's actually good care. And there, they can trust that if you go to see a provider that we're endorsing, that you're going to get good quality care.
Traynham
Let’s talk for a few moments about the future. What is the future of mental health, from your perspective, from where you sit in Iowa, and being the president of this organization?
Borden
So, I think there's a few things that I think about with the future with mental health. One is, we are going to continue to see a prevalence, we went from about 20-to-25% prevalence of behavioral health — so this is a diagnosable behavioral health condition. So, I fully anticipate the normalization of what it means for us to get coping with our mental health. So, if I think about it, pre-pandemic, the CDC comes out and says 87% of people are not in optimal mental health. So only 13% are. The remaining 87 people, you can think about 25 of them have a diagnosable condition. The remaining people need coping skills, just like you would imagine we would say, ‘oh, I should be, I can eat better,’ or, ‘I should exercise,’ more things like that. We need to begin to normalize how to have those conversations with those folks.
But of the remaining people who have true needs, things that I would say are most important: One, identifying people, helping them know if they have a need — and we have plenty of data to inform us. Now it doesn't mean you pick up the phone and call someone and say, ‘Hey, all my data is telling me you're depressed.’ We'd never do that.
Instead, there are ways to say, if you're struggling, if you're feeling down, if you're fill-in-the-blank with whatever is culturally appropriate, and really sensitive to where that person is coming from. And it's more of so they have the maps and when they choose to use it. It's there. So, the early identification.
Two, is the navigation. It is unacceptable that we don't make it easy for people to know how to get care. Think about we normalized urgent care versus an ER, what's a PCP, when do I need to go with a specialist? If I said ‘cardiologist,’ most people would go ‘heart doctor.’ Most times if you said you have a behavioral health need, what doctor should you go to? I still have people who say, ‘I think I need a shrink.’ “Shrink” is not actually — there are no such things as shrinks. There are psychiatrists and psychologists and therapists. So, I think that navigation component becomes really key. And that's where I know at Evernorth we're really focused on the digital navigation piece. But also, how do I make it easy for an individual to come in and say, ‘I have a need,’ and then know where to take them across the entire spectrum? So, everything from autism through more acute needs to therapy for depression, anxiety, etc.? That would be the second.
Traynham
Can we put a pin in that for a second, and that is the digital piece. So, what role does, you kind of answered this a little bit, what role does technology play in all of this? Because in my mind, it's a really, really, really positive that technology can play. But we have to be careful and put some guardrails around it, right? So, it's like, okay, we have this car. But let's make sure that we have a speed limit so that everyone recognizes that if we go a little bit too fast with this, to use this analogy, people can get hurt.
Borden
Yeah. So, I think technology has two really important roles it can play. One is enabling access. It becomes really important. If we had to rely just on humans, there aren't enough, there aren't enough trained psychiatrists, or other therapists. So, in some ways, there's an augmentation. It’s also helping to reach people. So, for example, I live in a really small town in Iowa. In order for me to go to a therapist, I have to drive 45 minutes away. Sometimes that's feasible. Sometimes it's not. And so being able to do telehealth or other things from an “opening up access” becomes incredibly important.
In addition to technology enabling access, which is vitally important, the second really has to do with measurement. And so, when you think about having technology in place, whether it be to collect information on regular screenings, like your PHQ-2s, 9’s, GAD-7s industry accepted measurements, or to be able to do some of the facial or the voice components become really important. And so, when we are able to use technology to drive measurement, we can really begin to see what interventions are working or not, or what interventions do we need to tweak because we're not getting the right types of results that we actually need?
I think the third part that becomes really important is to protect people's privacy. It's vitally, vitally important that people feel safe in sharing their information and knowing that when they share, they are going to be protected.
Traynham
Right. Eva, last question. The next big thing in health, from your perspective, what do you think that is? What does that look like for you?
Borden
So, for me, I think the next big thing really involves the defragmentation of the system.
So right now, we live in a world that everything operates separately, whether it's financially, whether it's architecturally — literally buildings being separated out in the health care system. And I think one of the things I'm most excited about is, as we begin to normalize behavioral health, it’s almost this . . . we've arbitrarily disconnected the mind in the body. And I see for me the next big thing in healthcare is actually re-bringing those things together and giving behavioral health, giving our mind health, a really prominent place in addressing a really unaffordable health care system and addressing people feeling good about where they are in society, and who they are, and just overall making all the things that we've promised — just making this all be what it should be.
Traynham
Eva, it sounds like your prediction is breaking down silos, normalizing behavior. Basically, just making this whole experience equitable for all.
Borden
Very well said.
Traynham
Thank you very much for joining us. Really appreciate it.
Borden
Thank you. I enjoyed it.
