Originally published in The American Journal of Managed Care
Addressing the mental health crisis in the United States warrants innovation in treatment and recovery, and the development of mechanisms to provide and pay for them accordingly.
When assessing the current state of mental health in the United States, the issue is often described as an epidemic, and one that's been magnified by the COVID-19 pandemic. I would argue against such a label. We do not have a mental health epidemic. Rather, what the pandemic has done is opened people's eyes and created a sudden realization about mental health, which is that it's a crisis—and a crisis that's been with us for a long time.
Everybody, at every level, in every sector, in every section of the country has a mental health need. The crisis is not mental health and illness. Rather, it's our ability—or really inability—to meet that growing, universal need.
Leveling the Physical and Mental Health Playing Field
One of the reasons we're in the crisis the nation currently faces is mental health has never received the same attention as physical health. That's largely because of a lack of understanding of the brain compared with all other parts of the human body.
Consider that we understand the heart and can replace the heart. We don't understand the brain well and we can't replace it. We can effectively treat blood sugar, but we don't effectively treat behavioral health disorders. While we may know some treatments that can work for behavioral health, we don't apply those treatments with the rigor and objectivity that we do treatments for physical health disorders. We've invested heavily into understanding neurologic diseases and can now treat some of them, yet we don't have great funding or science around behavioral health disorders.
What must happen if we hope to begin getting the mental health crisis under control is to start discussing mental health disorders with the same candor, understanding, and focus that we do physical health disorders. We can begin to focus on mental health disorders as a component of every individual, whether that person has physical disorders or mental disorders. That's a crucial way to destigmatize mental health conditions.
Meeting the Challenge Head On
In addition to establishing an equal playing field concerning the perception of and approach to mental health compared with physical health, we must work to provide better access to behavioral health care. In some cases, the use of technology is improving and will continue to improve access. But we must focus not just on access, but on availability. Access and availability go together. One may have the opportunity to receive mental health treatment but may not have the availability—or vice versa. Access and availability are both greatly limited in rural areas, inner-city areas, and other already underserved areas.
There's no question that improvement in mental health will require a focus on measurement-based care as well. That's not only for measuring value from a payment standpoint but also quality of service delivered. This commitment to measurement-based care and its role as a driver of payment and quality is largely missing in behavioral health today.
If we hope to improve access, availability, and outcomes, there's another area we must focus on: managing cost. That's going to require the same attention we must give to the other areas neglected in mental health. We must commit to improving access, availability, and the measurement of the outcomes while ensuring treatment is also cost-effective and of the highest quality available.
We must acknowledge that there requires a focus for mental health on the potential for recovery, not just symptom treatment. In other words, how do we help someone recover from a behavioral health disorder rather than just treat the symptoms of the disorder and hope this individual never gets worse? Research has shown us that about 2 out of every 3 people living with a serious mental illness experience partial to full recovery.
Finally, if we hope to move the needle on mental health sooner than later, we must recognize the treatment model for mental health is different than the treatment model for physical health and adjust our payment mechanisms appropriately. What we pay for, and how we pay, in behavioral health is different than physical health. We generally don't pay for what's needed for mental health. We pay for diabetes education treatment. When was the last time an insurance company paid for depression education treatment?
Thomas Insel, MD, former head of the National Institutes of Mental Health, said it takes 3 things to effectively treat mental illness: people, place, and purpose:
By people, he argues for the importance of ensuring those with mental illness have people in their lives who can provide support. We don't pay for individuals who can fill these roles.
By place, he argues those with mental illness need a place to live—one that provides comfort and security. We don't pay to help reduce homelessness and improve an individual's housing situation when it's detrimental to their well-being.
By purpose, he argues about the importance of giving a purpose to people, such as a job. We don't pay for individuals to help those with mental illness achieve purpose as part of their treatment.
The reason none of these are paid for as part of mental health treatment is because they are not paid for as a facet of physical health treatment. If we're ever going to address the mental illness crisis in this country, we must look at these facets as integral to treatment and recovery, and develop the mechanisms to provide and pay for them accordingly.