When she first started showing symptoms in high school, Amanda’s primary care physician didn’t know any mental health providers who were taking on new patients, and Amanda’s parents weren’t able to find any qualified therapists or psychiatrists covered by their insurance. Out of pocket costs were staggering, and it wasn’t until a change in a 2008 law that required mental health parity did the family’s insurance cover the cost of a stay in a psychiatric hospital. The family struggled financially and emotionally to get Amanda the best possible care, fighting against an outdated health system that is failing those with behavioral health needs.
It shouldn’t have to be that hard.
For too long, treatment for mental and substance use disorders has taken a backseat to traditional medical and surgical services. As much as 40% of our health outcomes are determined by our behavior, yet our health system has minimized the importance of behavioral health.
This is particularly concerning, since mental health disorders are highly prevalent in the U.S. One in four adults experience a mental health issue ranging from depression and anxiety to chronic mental illness. Studies have repeatedly shown that untreated mental illness leads to worse health outcomes, and increases costs to the health system in the long term. In my own experience as a cardiothoracic surgeon, a patient’s mental health meaningfully impacted the success of his or her recovery following an operation.
However, more than half of people with mental health disorders do not get treatment. Mental illness is driving hospitalizations and costs, translating into a $450 billion loss for the U.S. economy. It’s among the top ten leading causes of death in the U.S. And—this even surprised me—it’s the leading cause of disease burden in the U.S. according to the Kaiser Family Foundation.
How did we get here?
Over the past half century, the nation’s policies on the treatment of mental illness and substance abuse have shifted radically. The civil rights movement was accompanied by a move to deinstitutionalize, encouraging the transition of the mentally ill from long-term psychiatric institutions into clinics and community settings.
State psychiatric facilities closed, but community centers and clinics lacked sufficient financing and infrastructure to properly meet the needs of its new patient population. This left some of the most severely mentally ill falling through the cracks.
Community hospitals began seeing an influx of mentally ill patients in their emergency departments, while others ended up on the streets or incarcerated. These individuals repeatedly fell into the prison-homelessness-hospitalization cycle.
As a result, our nation’s jails and prisons have become our largest mental health care facilities. In state prisons, 73% of women and 55% of men have at least one mental health problem; in federal prisons, it’s 61% of women and 44% of men. Of those who are chronically homeless, 30% have mental health conditions, and 50% have co-occurring substance use problems. Cycling through the prison system, the emergency department and homelessness is not an effective solution.
New Laws Affecting Mental Health Treatment
During my time in the United States Senate, Congress passed the 1996 Mental Health Parity Act, which began to lay the groundwork for the transformative Mental Health Parity and Addiction Equity Act of 2008. The 1996 law was largely symbolic, but succeeded in kick-starting research that demonstrated preemptive treatment of mental health disorders saves dollars in the long run. When lawmakers realized mental health benefits could generate a cost savings, it helped propel the 2008 legislation into law, with the requirement that mental health and substance abuse benefits be equal to medical/surgical benefits. Mental health parity meant the co-pays and deductibles couldn’t be higher for behavioral health treatments than for more traditional medical care.
The Affordable Care Act of 2010 built on parity by defining mental health and substance use treatment as one of 10 essential health benefits. As a result, all health insurance plans in the individual and small-employer market must include coverage for the treatment of mental health and substance use disorders.
Addressing the Access Issue
These recent changes resulted in a new wave of consumers receiving coverage. But coverage does not equal access to care, and the nation faces a very real shortage of mental health providers. If we’re closing the coverage gap, what can be done to address the access issue?
First, we need to address the fragmented care system. Some of those most in need of treatment find today’s system overwhelming to navigate. Solutions should focus on evaluating patients for mental health needs whenever and wherever they come into contact with the healthcare system, an approach called Screening, Brief Intervention, Referral to Treatment (SBIRT). Consider, for example, an alcoholic patient who continues to injure himself and present at the emergency department. Treating only his physical injury will not keep him safe—or keep him from driving up excessive and unnecessary medical costs! Referring the patient to substance abuse counseling or treatment during that ER visit could break that cycle.
Other higher-touch methods that reduce fragmentation and improve access include co-locating physical and behavioral health care at the same site and health homes. A successful model of care integration can be seen in the Collaborative Care IMPACT study. The Collaborative Care model integrates physical and behavioral health services implemented within a primary care-based Medicaid health home. Patients have a primary care provider and a care manager in the clinic who closely monitor patient progress. The progress is overseen by a psychiatric consultant who advises on care, and can make adjustments to treatment if the patient isn’t responding. Because of the scaled care model, this allows a single psychiatrist to oversee a much larger patient population. And it has been shown to be successful: the largest trial of collaborative care to date, the IMPACT study, included 1,801 adults age 60+ with depression, in 18 primary care clinics in five states. Patients experienced a substantial improvement in their depression over 12 months, and reported improved physical health. It also boasted a meaningful return on investment with an average annual patient savings of $841.
Finally, we should leverage technology to address workforce shortages. With the increased coverage provided under the Mental Health Parity Act and the ACA, we’ve seen demand for mental health services increase, but we do not have adequate providers to meet that demand. One solution is using the growing field of telehealth, which allows patient-consumers to connect with providers over phone or video chat in numerous settings, including from the home, a hospital or clinic, the VA, or a prison facility. Telehealth can reach underserved patient populations in rural areas, and can be an around the clock resource. In the Nashville metro region, the Vanderbilt University Medical Center is piloting the use of telemedicine to provide child psychiatric services to the 38 schools it’s contracted with. This model allows VUMC to provide more services to more kids across more schools when they don’t have the bandwidth to visit all 38 school sites.
Meeting the patient where he or she is, extending parity, and leveraging technology are steps we can take to change the effectiveness and availability of today’s mental health services. Recent federal laws have spurred change, but our field leaders such as the IMPACT study sites, are operating in silos. We must collectively develop a broader strategy to bring mental health and substance abuse into the mainstream of health care quality improvement, so that families like Amanda’s are no longer left out in the cold.
(Disclosure: I sit on the board of Teledoc, a telemedicine company, but the opinions expressed here are mine and do not necessarily correspond with those of the company.)