Essential Infrastructure for Healthcare Integration & Insurance Coverage
Hello, I’m Lia Mix, CEO of Enthea [now CEO of Delphi]. Thank you for your interest in the promise and practicalities of bringing psychedelic-assisted therapy (PAT) into the U.S. healthcare system and making these therapies available at scale, safely and affordably, to everyone who can benefit. In this session, you’ll learn about the essential organizations and activities we must focus on now to ensure psychedelics can be brought to scale as soon as possible after FDA approval.
We’ll begin with brief introductions from our panel of experts, followed by foundational information about the healthcare payer landscape and how the psychedelic ecosystem can effectively interface with it. This awareness will lead us to a crucial decision point, and I have every confidence that those gathered here are the right people to receive this information and make this decision in service to humanity and the planet.
Today is the Winter Solstice, an inflection point. While it’s the darkest day of the year, it’s also the turning point from which every subsequent day grows brighter. So today, we celebrate illumination and witness the path forward for pragmatically implementing psychedelic therapies into the U.S. healthcare system and achieving insurance reimbursement so they may reach all who can benefit.
Introducing Our Expert Panel
The experts gathered before you collectively possess almost 200 years of experience in healthcare administration and managed care. My colleagues—Jim, Henry, Dan, Charlie, and Mike—are among the top 1% of people in the country who understand how the healthcare system works, specifically how insurance reimbursement happens for new therapies. I am blessed to have them as collaborators and advisors. We who are interested in seeing safe, broad, affordable access to psychedelic therapies are incredibly fortunate to have their wisdom, experience, and skillfulness brought to bear on achieving insurance coverage for these treatments.
Meet the Experts
- Jim Roosevelt: A healthcare lawyer with extensive experience, including over 10 years as CEO of Tufts Health Plan (now the largest in New England) and former Associate Commissioner of Social Security for Policy.
- Henry Harbin: A psychiatrist with four decades in the field, deeply involved in the managed care industry and, more recently, in policy reforms to increase access to effective mental health and substance abuse care. Henry also works with Brain Futures, a nonprofit dedicated to disseminating best practices and new technologies for mental health.
- Dan Rome: Co-founder and Chief Medical Officer of Enthea. In addition to practicing clinical psychiatry, Dan has served in numerous physician executive positions (Medical Director, CMO, VP) in both for-profit and not-for-profit healthcare organizations, on both the payer and provider sides.
- Charlie Gross: A psychologist with 30 years of combined clinical and senior health insurance management experience, including roles at Kaiser Permanente, United, and most recently as National Vice President for Behavioral Health at Anthem. He now consults, including work with Brain Futures on the payer perspective of PAT.
- Mike Cotton: Former owner and operator of Meridian Health for 20 years, focusing on Medicaid and Medicare programs and working with marginalized communities. Since selling his companies in 2018, Mike has been deeply involved in the psychedelic therapy space as a senior advisor to Enthea and working with the Psychedelic Science Funders Collaborative (PSFC) to identify areas for philanthropic funding.
And I am Lia Mix, founder and CEO of Enthea, a health plan administrator dedicated to psychedelic healthcare. I am also a licensed family therapist and certified by the psychedelic therapies and research program at the California Institute for Integral Studies. I’ve been participating in the psychedelic field for six years, collaborating with MAPS, elders, and other wise leaders. It’s through their grace and generosity that I, with these experts, can offer this information today.
Understanding the Payer Landscape: The Master Key
Let’s get oriented. While training and care delivery infrastructure are critical to insurance coverage for psychedelic therapies, the policy piece is the master key for interfacing with the payer infrastructure.
At a high level, approximately 90% of the U.S. population has health insurance at any given time. About half are covered through government-sponsored plans, and the other half through commercial plans.
Upon closer examination, we observe various plan types that represent different funding buckets, covered populations, and decision-makers. On the commercial side, self-funded plans (in which individual companies make benefit decisions) and fully insured plans (where carriers make decisions for populations they hold risk for) add layers of complexity.
Visually, the payer landscape resembles an exploded, shattered pie chart. Each of these payers operates with different processes, stakeholders, mandates, motivations, and often different information when deciding on coverage for new treatments. Crucially, these payer segments don’t communicate well with one another, if at all.
The disjointed nature of our healthcare payer system is a significant cause of inequities in access to care and health outcomes in the U.S. This is why new therapies, even those with robust efficacy in clinical trials, struggle to gain broad, swift coverage. With psychedelic-assisted therapy, the challenge is compounded: it’s not just about getting a new drug covered, but also new clinical services, which is often more difficult.
The complexity of our payer landscape, combined with the complexity of psychedelic-assisted therapy, presents the realities we must face to achieve insurance coverage and access at scale. This undertaking is largely unprecedented.
The Path Forward: Building Coherent Infrastructure
So, what’s the plan? Experts in healthcare and reimbursement know there’s a way to potentiate coverage adoption sooner rather than later, powerfully, and it’s surprisingly inexpensive, especially compared to single drug commercialization (which can run into hundreds of millions of dollars). However, this solution requires harnessing the will of practitioners and a community of stakeholders to support them. That’s the tricky bit.
Think of the U.S. healthcare system as a brain. Human neurons have an evolutionary advantage: they can coalesce energy and send powerful, focused signals through select pathways. Similarly, we can communicate with the healthcare “brain” by creating structures it recognizes and from which it will receive messaging.
Essentially, we need to build structures that can coalesce the consensus of the field and communicate effectively with the healthcare system. When these structures are in place and functioning well, the field of psychedelic therapy becomes coherent and trustworthy to the healthcare system and its payers. The “will of the field”—or policy recommendations—communicated reliably through these pathways, will then be reflected in healthcare policy decisions, like insurance coverage. Resources from the healthcare system can then flow back into the psychedelic ecosystem.
Creating this “neural pathway” infrastructure is a significant undertaking, not in the purview of any single organization. Multiple companies sending weak, mixed signals can create incoherence, ultimately impeding access. An example of this incoherence is many pharma companies acting as if getting their drug to market is as simple as getting a new drug approved for coverage. Getting a new drug on formularies is relatively simple compared to launching an entirely new clinical specialty into the U.S. healthcare system and getting those services reimbursed, which is what’s truly needed for psychedelic therapy products to reach patients.
To move psychedelic drug products from the manufacturer to the patient via psychedelic therapy, this infrastructure is essential. It must be built to harness the will and wisdom of the entire field, not just a few pharma companies with competing interests. Without a robust infrastructure connecting the psychedelic ecosystem to the healthcare system, communication will fail, and insurance coverage will be impeded.
The Core Infrastructure Projects: Already Underway
The good news is that the plan is already underway. Core infrastructure projects for the field have been established, largely through the grassroots and volunteer efforts of doctors, academics, researchers, attorneys, MBAs, and many others over several years.
These core projects are:
- A Practitioner Certification Board
- A Professional Association
- A Health Plan Administrator
These are the three essential nonprofit infrastructure organizations we must have to potentiate insurance coverage and access to psychedelic therapies at scale. Fortunately, these organizations have been thoughtfully developed to coalesce the will of the field and are structured to be readily recognized by the incumbent healthcare system and its payers.
The Roles of the Core Organizations
- The Board of Psychedelic Medicines and Therapies (BPMT): A consumer protection entity designed to achieve national accreditation, the gold standard for clinical specialties, which will be recognized by insurance carriers for reimbursement.
- The American Psychedelic Practitioners Association (APPA): Essentially the “AMA for the field,” this organization sets standards of care and can interface with institutions like the AMA and NIH on behalf of the field.
- Enthea: Designed to streamline insurance coverage adoption by solving challenges larger carriers will face, demonstrating how coverage adoption is possible and financially wise.
To play their unique and essential roles optimally and synergistically, these organizations must be nonprofits. However, they all have tried-and-true, self-sustaining business models once they are up and running.
BrainFutures also deserves an honorable mention. While not technically a psychedelic infrastructure project, it’s an excellent established healthcare policy organization that can help amplify the policy recommendations of the field as expressed through these infrastructure organizations.
The Decision Point: An Inflection Point for the Field
We are at an inflection point with the development of these three core infrastructure projects. They have been built out as much as possible by volunteers and skeleton crews. We are currently at the point of greatest potential for insurance coverage and access to PAT post-FDA approval.
However, to continue on this trajectory, these core infrastructure projects must be funded and cared for by a community of supporters. If they are not supported in the immediate term, progress will decline, and the vision of broad, safe, affordable access to psychedelic therapies may become dim and less certain. The difference between these two paths can be measured in the time it takes to achieve broad insurance coverage, potentially decades in the worst-case scenario.
We have everything to gain by funding these organizations, plus BrainFutures, right now. The more robust this infrastructure, the greater headway we will make towards accessible psychedelic-assisted therapies.
The cost to launch and get all of these organizations turning revenue is $6 million. This sum is relatively small because these projects have already done, and will continue to do, most of the heavy lifting: organizing and professionalizing the field, interfacing with the healthcare system, and running self-sustaining businesses. But they need the help of this community to get off the ground. And the time for that is now.
If you are invested in achieving insurance coverage and access to psychedelic therapies at scale, this is the highest-impact philanthropic giving opportunity available today.
A Story of Impact: The Courage of Community Bankers
My grandmother, in her early twenties during the Great Depression, tried to save the department store her father had built, an anchor of commerce in her town south of Detroit. Banks weren’t giving loans, especially not to young women. But a loan was issued. The store remained open, anchoring the community, providing employment, and hope. As the economy improved, the store thrived. Eventually, my grandfather, an attorney, could focus on philanthropy and helped found the Wayne County Community College District, now the largest post-secondary educator in metro Detroit.
Who is the hero of this story? In this telling, it is the bankers. My grandmother did what was necessary, my grandfather what he loved. But the bankers, in their courage, wisdom, and desire to help their community, secured not only the community’s economic well-being but ultimately created prosperity beyond their imaginations with a single action.
There are moments when a single decision, a single action, can have a resounding positive impact beyond what we imagine.
Our Commitment, Our Future
If we remain true to our commitments and follow through with supportive actions, I believe the decision made today by this group will lead to psychedelic healthcare being implemented into the U.S. healthcare system. I believe we will achieve insurance reimbursement and thereby create safe, affordable access to psychedelic-assisted therapies at scale.
On behalf of myself, my colleagues here today, psychedelic therapy practitioners, and all people who will receive the benefits of psychedelic-assisted therapy, thank you. As the days grow brighter from this Winter Solstice, may it be a reminder to you of the decision you made today and the light that choice will bring into the world.
