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Multiple factors are moving mental healthcare to a front burner issue in managed care.
Mental health is a costly branch of healthcare that has for years been neglected and swept aside. People-particularly in older generations-don’t like to talk about mental health, and there generally isn’t as much funding available for mental health services as for medical services. To add insult to injury, when people do seek help and can afford services, many find that they lack access to qualified providers.
But that’s all changing, according to several industry experts, and a new report from PricewaterhouseCoopers (PwC). The report, “Top Health Industry issues of 2016,” predicts that this will be the year momentum shifts toward better addressing mental and behavioral healthcare issues.
IsgurBenjamin Isgur, director of thought leadership at PwC's Health Research Institute and coauthor of the report, says the increasing focus on mental healthcare is driven by multiple forces, including greater enforcement of mental health parity laws and regulatory changes. But that’s not all, he says.
“There is more recognition that the brain requires as much thought around treatment as medical needs,” Isgur says, adding that many large employers are recognizing that general health issues are connected to mental health issues. “You see both of those coming together in 2016 to really move mental and behavioral health to more importance,” he says.
Isgur adds that the timing is also right for mental healthcare to benefit from technological advances. Mental and behavioral health clients respond well to telehealth and virtual health treatment modalities, which offer easier access in a less-expensive format than traditional care, he says.
“We know that there are many geographic areas where there are shortages of mental health workers, but think of the efficiencies where you move to a virtual health model,” Isgur says. “We believe that will counterbalance some of the issues we have around lack of access.”
According to a recent report from The Kennedy Forum, one in four Americans struggles with mental health or substance abuse during their lives, and mental healthcare consumes about 25% of disability costs. Inadequate access to care and medications, noncompliance with care plans or treatment recommendations, ineffective care coordination, and poor care quality increases these costs even more.
It’s estimated that only 40% of people with mental health or substance abuse problems get the care they need, and only 22% of them get it from a mental health specialist. That means that 60% of people in need of mental healthcare don’t get it, and about 23% are cared for by primary care or general medical providers rather than mental health professionals. In addition:
There are similar results for mental healthcare, with only 25% of the 30 million people who receive antidepressants from a primary care physician each year showing substantial clinical improvement, according to The Kennedy Foundation’s report.
GreenbergPamela Greenberg, MPP, president and chief executive officer for the Association for Behavioral Health and Wellness, and former deputy director of federal affairs for America’s Health Insurance Plans, says several circumstances have created something of a “perfect storm” in mental healthcare.
She points to a December 2014 Government Accountability Office report that revealed poor coordination among government agencies in providing mental health services, and “significant challenges” for individuals with mental health problems to get the care they need.
Still, she says, several movements are underway to improve care and access, such as the proposed “Helping Families in Mental Health Crisis Act” in the House that has generated some controversy over its provision for assisted outpatient treatment.
The House bill, and another bill in the Senate, the “Mental Health Reform Act of 2016,” offer different philosophical opinions about the amount of control patients with acute mental health issues should have over their own care, Greenberg says.
RosenbergIn addition, Linda Rosenberg, president and chief executive officer of the National Council for Behavioral Health, says no longer are problems such as depression and anxiety to be kept hushed, instead they are openly discussed, particularly among younger demographics.
“With the younger populations, many of them are growing up believing, as they should, that mental illness and addiction are diseases,” Greenberg adds. “There’s been a lot of attention paid to the stigma and to encourage people to talk about it. Sandy Hook and wars have brought these issues to people’s attention in a way they haven’t before.”
Mental health is even getting more attention from payers. Rosenberg says there is more coverage from payers for mental and behavioral health than ever before thanks to the Affordable Care Act, and Medicaid managed care companies are doing well in states that have expanded coverage.
“One of the things we’re seeing is companies like United, like Anthem, who never were that interested in the Medicaid managed care market are interested in it now,” Rosenberg says.
Still, she says, the structure of ACA exchange plans has resulted in some slowed momentum, since many have high costs, high copays, and high deductibles. “It’s really the working class person that’s being killed in our health system,” Rosenberg says. “We wanted mental healthcare to be part of the marketplace. What we didn’t realize is that healthcare is becoming more of a competitive business.”
Eight states are currently in the planning stages to open community behavioral healthcare clinics for people with serious mental health and addiction issues as part of the Certified Community Behavioral Health Clinic (CCBHC) demonstration program, says Rosenberg, adding that the program could expand to 24 states.
“For us, these certified behavioral health clinic make a lot of sense in that they standardize care,” she says. “Right now it is different in every state.”
As Isgur noted, leveraging technology to improve access and cost issues could also improve how mental healthcare is provided. The PwC report recommends expanding access through telehealth, and says employers and health groups need to dedicate appropriate time and resources to mental healthcare because regulators and consumer groups are becoming more aware of its importance.
The report also notes increased interest and opportunity through the ACA in mental healthcare services coupled with access problems. “More than half of U.S. counties-all rural-have no practicing mental health clinicians,” according to the report. “At the same time, many more individuals requiring mental health services now have coverage through the ACA, increasing demand for already-strained resources.”
According to the report, the U.S. Department of Veterans Affairs conducted 325,000 behavioral telehealth visits with more than 100,000 veterans in 2014, and ended up reducing psychiatric admissions by 24%. The private sector is taking notice, with startups like Lyra Health and Doctor on Demand connection consumers with mental health clinicians over smartphones, according to PwC.
Telehealth is also helpful in treating mental health issues that make it difficult for patients to get to their appointments, such as depression or substance abuse, Greenberg says, adding that mobile apps can help, too, particularly with adolescents and school-aged kids. “I think we’re going to see a lot more apps with social media, where you could tweet to someone if you’re feeling depressed or possibly suicidal,” she says.
Rosenberg says she is optimistic about the changes ahead in mental healthcare, not just in telehealth, but in new models and treatment messages.
She says there is also a push to teach better mental health first aid, similar to the way Americans have been educated about recognizing heart attacks and strokes, and there are pilot projects underway to examine the benefits of combining Medicaid dollars with social services. She notes a high prevalence of socioeconomic stress among those with acute mental health issues.
Still, the system must undergo other changes to ensure mental healthcare coverage continues to improve, says Rosenberg. For example, patients tend to move from plan to plan, and even in Medicaid, every few years a new company takes over the plan in each state. Because of this, payers often only have a short-term vision of care.
“It’s cheaper often just to let people go into the emergency room once in a while. We complain about it, but for an insurance company, they are a business and they have a lot of power in healthcare right now,” Rosenberg says.
And, in a system where many payers want to shell out as little as possible for services, and providers want to earn as much as possible, and consumers want the best healthcare possible, there is conflict, Greenberg says. “At some point, that dynamic is going to break.”
Rachael Zimlich is a writer in Columbia Station, Ohio.