The U.S. mental healthcare system remains plagued by inadequate funding, poor access, and ongoing workforce shortages. Panelists at a recent meeting hosted by the University of Pennsylvania Leonard Davis Institute of Health Economics detailed the depth of the crisis and offered some potential paths to improvement.
Prof. Rachel Werner, M.D., Ph.D., executive director of the Leonard Davis Institute, asked the panelists to begin by describing some of the main drivers of the crisis in mental healthcare.
Jamie Dupuy, M.D., a Boston-based psychiatrist and medical director of clinical services at Optum Behavioral Care, said that people feel that they are up against big systemic problems that are hard to define and therefore hard to know how to manage.
“One of the important things in this crisis is acknowledging that there are so many factors that are well beyond the control of individuals, whether providers or patients, certainly the pandemic and the losses that came with it, but all those other things that existed before, during and after, like poverty, discrimination and systemic racism, health inequities, violence, food insecurity, the impacts of climate change — all of those and many more things are contributing to this general sense of unease and distress, as well as a real feeling of a lack of agency that we can do something to change it,” Dupuy said. “At the same time, it feels like we're losing that connection from community support that might help ease the burden. All of that feels bad enough on its own, but we also know that chronic stress biologically can contribute directly to the onset of an exacerbation of mental illness.”
“From a provider’s point of view, we're well aware of the need that's out there to help people directly and we feel that responsibility to step up,” Dupuy said. “We're seeing those same stresses in our own lives, and also those same obstacles. There's this real sense of futility and frustration that's contributing to burnout and turnover for mental health providers. Many providers are choosing to leave the system altogether, or reducing their challenges by going into something like a private practice.”
She said we have systemic factors leading to a chronically stressed population and stressed providers, huge changes in how people are perceiving mental health and preferring to access care, and changes in the workforce itself. “All of this in the context of really confusing and fragmented pathways to help as well as real barriers to engaging in healthcare of good quality. All of that and probably lots more adds up to what we're all experiencing as this national mental health crisis.”
Werner asked Dupuy what changes need to happen to address this crisis.
“I think we can take substantive steps toward improving access to help right now,” she responded. “It doesn't have to be treatment. We can invest in prevention, like mental health education for young people. We can support integrating behavioral healthcare and screening into medical care settings to support people who are struggling and to find and identify them early enough to intervene. We can invest in community-based organizations to expand the reach of trusted individuals who are not professionals. For those who do ultimately need to end up in specialized care, we really do have to improve access. We can do that by expanding the mental health workforce. We also need to expand diversity and representation in the workforce because we know this makes differences in quality outcomes for patients. But I think what's really key is not just adding tons of newly trained people to the already fragmented s stem as it exists and then quickly losing them to burnout to private practice or fee for service settings.”
Madhuri Jha, L.C.S.W., M.P.H., director of the Kennedy Satcher Center for Health Equity at the Morehouse School of Medicine, said we need to increase investment in mental and behavioral healthcare. “A lot of historically invisible communities will access mental healthcare from places like their OB/GYN, their primary care provider, or kids being referred from school because their school guidance counselor or their teacher has identified a problem,” she said. “We need to become more culturally centered and culturally empowered in the way that we administer mental and behavioral health services.”
Haiden Huskamp, Ph.D., Henry J. Kaiser Professor of Health Care Policy at Harvard Medical School, noted that the workforce shortage and poor distribution of providers across areas is a big problem in our system now. “Training new personnel up, particularly a diverse group of new personnel to enter the workforce, is really important, but it won't get us to the numbers we need anytime soon,” she added, so we need to continue to support the sustained implementation of care models that exploit the personnel resources we have in the system already in the short term — things like collaborative care consultation models, for example.
Huskamp noted that a long-term issue is that traditional fee-for-service payment doesn't reimburse for all of the components you need to make those models work and to really integrate mental health treatment into primary care. For example, Medicare introduced a handful of codes for paying for integration of behavioral healthcare. Uptake of those codes hasn't been huge for a lot of reasons, she said. “One problem we have in our system with the plurality of payers is that, when Medicare does this, it may represent a small proportion of someone's practice. That doesn't really allow providers to invest in the infrastructure that they need to run those models and build those codes. I think the same is true to some extent in Medicare's newer, office-based Opioid Treatment Bundle. You need a lot of services and infrastructure to do that, and you need to ensure that the resources are there to fund that investment.”
Workforce shortages are compounded by low participation of mental health specialists in insurance networks, Huskamp added. “We need to reassess provider network requirements and the federal parity law’s role in guiding reimbursement for behavioral health specialists and other clinicians who are billing for these kinds of services. Obviously, reimbursement and coverage policy that would continue to facilitate the use of telehealth is an important way to get at these issues. Medicare has made a very strong statement saying we will continue to cover behavioral health via telemedicine, but how things play out with other payers is going to be really important, I think, in determining this way of accessing care and helping to reallocate providers across areas, even the providers that we have.”
Werner noted that we talk about value-based, purchasing a lot in other sectors of healthcare, yet it is lagging behind in mental healthcare and hasn't been as widely adopted. She asked Huskamp whether she sees that as a potential solution for some of the payment-related challenges in mental health.
Value-based payment is challenging across the board, but it can be particularly challenging in mental health, Huskamp responded. “I do think there's still a role for it. We still have a ways to go in terms of having a full set of mental health quality measures that clinicians and everyone will feel capture what we need to capture,” she said.
“You have to worry about it anytime you're moving towards outcomes as opposed to just process measures of quality,” Huskamp said, adding that it poses concerns if risk adjustment isn't adequately accounting for differences across patients. “Historically, our risk adjustment systems, while improving over time, haven't done as well on behavioral health as they have on much of the rest of healthcare. That is an issue that certainly makes providers concerned about being rewarded or penalized on the basis of their outcomes for things they may not have full control over.”
Another issue involves what happens to the outcomes you're not rewarding, she added, because the outcomes that there has been agreement on in mental health focus on a narrow set of clinical areas. Also, the lack of capacity in the system creates challenges for this anyway. “There just isn't much excess capacity, so it's a little bit harder to implement systems with strong rewards and penalties for low quality when we need everybody we have in the system. There are a lot of challenges, but I would like to see our field continue to move in that direction and try to counter those as we go.”
Mai Pham, M.D., M.P.H, is president of the Institute for Exceptional Care, a nonprofit organization dedicated to helping people with intellectual and developmental disabilities thrive–by promoting radical, empathetic inclusion of IDD issues in healthcare, and for integration with other social supports. Previously she was vice president, provider alignment solutions at Anthem Inc., responsible for value-based care initiatives, and before that she served as chief innovation officer at the Center for Medicare and Medicaid Services. She stressed that there's a desperate need to integrate not just physical and mental healthcare, but also with home and community-based service supports.
“This is not something that the traditional professions are good at doing — one, because they've never been asked to do it; and two, they aren't given the resources and the flexibility to do it,” Pham said. “It is not about the clinical side of the house solving every problem. It's about them having access and knowing how to help patients reach those resources when they need them. For good or bad, primary care is going to be a major component of the mental healthcare delivery system, and for both those providers and for mental health providers, we need to think about some very different ways of paying. You need to get them off the fee-for-service wheel and give them more resources. I'm talking about at least a hybrid payment structure that is a little bit more majority capitation and less so fee for service, but capitation priced in a way that is significantly higher than what we have paid historically. That is what allows for the investment and the flexibility because you cannot address social drivers of health if you cannot reach out to those social service organizations if you're constantly watching the clock. People have a hard time connecting the dots from capitation higher pricing to the infrastructure but that's what it is. You need the flexibility freed up from your revenue source to think about that.”
In closing, Werner asked the panelists if they had 10 minutes with a U.S. legislator, what would they identify as a must-do piece of federal legislation for improving the mental healthcare delivery system in this country?
“I always am an advocate for expanded mental health access housing,” Jha said. “I think it's a true barrier to decreasing high utilization of primary and emergency care services for folks experiencing severe mental health crisis. People ask me ‘what do you see as a primary public mental health crisis’ and I say the housing shortage is a primary mental health crisis. If somebody doesn't have access to housing, there's no way they can make an appointment. And yet then they get deemed by our system as a high utilizer. We use terrible phrases like frequent fliers, which I've heard so many times by various providers, and then they're stigmatized and those things live on their medical records. My altruistic aim is always to say, give someone a place to live and think about their hierarchy of needs. And then appreciate that someone who might be a primary care provider can have a better space to understand those needs.”
Dupuy said expanding the telehealth provisions would be really important to maintaining access and then also expanding the interstate licensing provisions that can allow providers to reach underserved areas that are not in their state.
Huskamp said she would push for a bill that would expand system capacity in multiple different ways — funds for training and recruitment of a diverse group of providers; expanding those telehealth policies to make sure that it's accessible broadly; and pushing on network adequacy requirements, which would force reimbursement rates higher. “I would also address ways to help fund infrastructure development in primary care.”
Pham said she would ask for two things: robust primary care with partial capitation, and a nationwide investment in community health workers. who would go door to door and ask people how they're doing and whether they would like to come to a place where they can be connected with others.
