This Mental Health Consumer Helped Bring Peer Support to Top US Health Insurer. Why? It Saves Money, Lives
Interview with Susan Bergeson, former Optum VP
For much of her life, Susan Bergeson has suffered from debilitating depression, as have many members of her family. She tried to take her own life on more than one occasion, and she knows what it’s like to be hospitalized against her will. But out of her own suffering — and with the help of other people who have been through similar experiences — she learned coping skills and ways of recognizing and managing her moods and her triggers.
She also has learned to use her experiences to help others, helping develop and expand a growing field known as peer support.
The term peer support specialist describes the work done by people like Bergeson who have direct lived experience with mental health challenges and are sharing that experience and knowledge to guide others as they try to navigate the slippery shoals of the health, mental health and social support systems in the U.S.
Many peer support specialists work at the grassroots level in wellness centers and support programs run by nonprofit groups or local clinics and health departments. Bergeson, on the other hand, spent eight years working for the largest health insurer in the U.S., UnitedHealthcare, helping design programs that incorporate peers. She did that work as Vice President of Consumer Affairs for Optum, United’s behavioral health division. Much of her work was with Optum’s managed care programs.
Managed care organizations exist to find more efficient and less costly ways to deliver care, including behavioral care. They have learned that early interventions and supports can reduce the need for more expensive treatments such as day treatment and hospitalization. Until she retired in 2017, Bergeson was involved in bringing peer-based programs to fruition and helping gather evidence about the impact those programs.
I spoke with Bergeson this week after California legislators — on a nearly unanimous, bipartisan vote — passed a bill, SB 803, to set up a statewide certification process for peer support specialists and sent it to Governor Gavin Newsom. He voiced support for an expanded role for peers when he ran for governor in 2018 but last year vetoed similar legislation. SB 803 would allow counties in California to train and certify peers and bill the federal Medicaid program for part of the cost of their services. Newsom has until the end of September to sign or veto the legislation.
Our interview has been edited for length and clarity.
To start with, tell me a bit about your own your own mental health history and background.
I’m a person with a lived experience of mental health issues. I have been hospitalized and have attempted suicide. Everyone in my extended family has lived with a mental health or addiction recovery issue. When my eldest sister died by suicide, I said, “Hey, I’ve got to take my nonprofit experience” — I had been working in nonprofit management for many years — “and do something with that in mental health.” I lived in Chicago, and there’s a large advocacy group there, the Depression and Bipolar Support Alliance. I moved my experience from nonprofits into that arena and became vice president and then CEO. Along the way, I learned a lot about recovery. I learned a lot about self-management, about figuring out what my triggers were. If I’m walking into a situation that might be triggering, here’s what I can do. Like coronavirus right now — lots of anxiety, right? Here are my triggers, here are things I can do to get ahead of a crisis and not end up in the hospital.
At the Alliance, I was lucky enough to work with researchers, legislators, think tanks, several presidents. I parlayed that into a job in managed care because I think that has a big impact on how people access care. Optum is the behavioral health arm of United Healthcare. I was hired as national vice president of consumer and family affairs and got to work with lots of great people thinking about how to set up our systems so they’re reflective of a more recovery-oriented framework.
At what point did you recognize the value of peer support?
Pretty fast. These are illnesses of isolation, and you just feel so alone and weird and awful. And that was one of the things I was dealing with. Having the chance to talk to someone and say, I’ve been there, too — it was such a relief. I love my therapist. I thought my psychiatrist was great — listened to me very carefully, and we worked in a collaborative way. But they could not give me that sense of, ‘Oh, I’m not alone. Somebody else knows what I’m going through.’ I connected to some other people living with this, then moved into more formal peer support — going first to support groups, then more of a coaching relationship. Support is great. But comes a point where you also need to hear some practical things you can do when you feel your anxiety coming up, when you notice you’re going to be triggered. Going for a walk, getting sleep, making sure you’re drinking water, doing the ten things I’m grateful for, reaching out. All of these really practical things can really help. That was one of the magical things about peer coaching.
How does Optum make use of peer support specialists?
I left Optum in 2017, so I cannot speak to their current state of play. When I was working there, we had several ways of working with peers. Oftentimes, we’d go into a market and contract with a consumer-operated service to deliver peer coaching. We’d identify hotspots where people were cycling in and out of the hospital. We’d target people with three or more hospitalizations in a year. When I started, we focused on mental health and then moved into addiction recovery. Depending on the state, we would either use mental health coaches or addiction recovery coaches or both. Some states were not really set up to do that so we’d contract with provider systems, who would hire the peers, and we’d implement peer services that way. As I was leaving, we were looking at peer support services more aligned with coaching over the phone both for addiction and for mental health.
What kinds of training and credentialing did Optum require to hire peers?
We ensured that they met the state guidelines for training. We also needed to align with Medicaid guidelines. In Wisconsin, for example, we looked at the credentialing, the state guidelines, and we ensured that services using peers abided by that. We’d look at the peers to ensure that they were meeting those state guidelines, had that state training, and were doing the continuing education. In some cases, Optum used peers as a way to reduce rehospitalization. It really drove down their costs. In some cases, there was no Medicaid reimbursement but the return on investment was so great, it was totally worth them doing that.
Optum and UnitedHealth are in the business of making money. If Optum was employing peers, there must have been a real return on investment.
One thing people may not know about managed care is we employ researchers. We started a program in New York, and we saw a 47.9% decrease in the use of inpatient services by using peers. We cut that expense almost in half. And actually, our decrease in overall behavioral costs spent per person went from almost $10,000 to $5,292 — a 47 percent decrease in overall health spend when we added peers. The average number of inpatient days dropped from 11.2 days to 4.2. So even people who did go in ended up with fewer days. We were able to get ahead of the issue of hospitalization and decrease inpatient services. Those were huge numbers financially.
Of course, that’s the way a company would look at it. Plus, people were getting better, right? They were moving towards recovery more effectively. In one state, there was a person who would go into the hospital, be released, and within a day or two, attempt suicide again. She had seen every clinician, gone to every program, and nobody knew what to do anymore. So we tried peer support. We provided her with several days of peer support each week. And in a five-month period, she had no hospitalizations and there was a reduced cost for that one person of over $110,000.
Often a peer can reach someone that no one else can. That doesn’t mean clinicians aren’t amazing. It just means that someone like me or this woman is able to go, “Oh, I get it, I’m not as ashamed now. The stigma is not reducing me to tears and I can open up a little more.” A little bit of light comes in, and the clinicians can get some response and help her move forward. Often, the peer opens the door.
Tell me about Pierce County, Washington, where Optum manages behavioral health for people on Medicaid.
Pierce County was really great. Optum came in and they hired people with lived experience who, by the way, might also have experience doing quality management. They made the system more recovery-oriented, engaged peers in a more aggressive way, created opportunities for peer coaching. They put in some crisis management systems that were heavily staffed by peers. When you’re in a crisis and you actually hear someone say, “Yeah, I’ve been there too,” — Oh my god, there’s hope. They had a 31.9 percent reduction of hospitalizations over five years. That was huge — not a one-time, six-month sort of thing; this is a five-year period. And they were 22.5 percent below the state average for inpatient days per thousand. It’s a model where peers are embedded in the managed care system and also hired by providers within that county. They’re seeing massive outcomes. It is a for-profit company, so it has to have a good return on investment. And we had that in Pierce, and in every place where we used peers.
What would you tell California officials about why certifying peers and expanding their use is good policy?
When a peer enters the workforce, they move to a place where they can get off Medicaid. That’s a big cost savings. Having meaningful work is central to the concept of recovery, giving people a sense of purpose and meaning.
Secondly, we can keep them healthier because they have purpose and meaning, which means they’re not spinning and going back into the hospital.
Third, most places around the country have pretty severe behavioral health workforce shortages. Peers don’t do everything. But when you aim them toward activation — helping people do practical things, understand their triggers and act in advance — you keep people out of the ER. You help solve the healthcare workforce shortage not by making peers into therapists but by helping them do what they can do uniquely — reduce stigma, reduce isolation, and empower people to be active in their own health. Then they can keep moving towards recovery.
