In 2017, there was only one mental health provider for every 426 people in the United States. An analysis by the Kaiser Family Foundation revealed that nearly 124 million Americans are living in a mental health shortage area, and only 35% of the total need for care is being met in the U.S., leaving many people without access. There are a myriad of barriers to obtaining behavioral health services, such as inadequate funding, shortages of providers, cultural stigma, lack of insurance coverage, and absence of specialty services. Rural, low-income, and minority communities have a disproportionate lack of access to mental health providers, in particular.
In addition to challenges in access, epidemiological data from the 2001–2003 National Comorbidity Survey Replication showed that 34 million American adults, or 17% of the adult population, had comorbid mental and medical conditions within a 1-year period. For example, the risk of self-reported depression among people with diabetes is two times the risk of individuals without diabetes. This 2008 study found individuals with cardiovascular disease to be nearly 1.5 times more likely to have a lifetime anxiety disorder. The high rate of these comorbidities, the complex connections linking medical and mental health, and a fractured system lead to problems in quality and costs than can be even more troubling than the problems related to the conditions alone. Whatever the causality may be, there are elevated costs observed in claim data that result in an opportunity for improved clinical care programs and potential for cost savings.
The good news is that providers are piloting new models of behavioral health care, ranging from access to care in retail clinics, utilizing technology-assisted care, and integrating behavioral health into primary care. Below are a few emerging examples of the industry’s response to the unmistakable gaps in care for many Americans:
Walmart
As we mentioned in this post, thousands of health clinics have opened in retail stores, pharmacies, supermarkets, and big box stores across the U.S. like Target and Walmart. Many retailers are poised to enter the healthcare market or have already done so, however few have waded into the realm of behavioral health. The world’s biggest retail giant, Walmart, piloted a third-party mental health clinic in a Texas Walmart in 2018. Last month, the retailer opened a new health clinic in Dallas, Georgia. Along with regular vision tests, hearing tests, x-rays, labs, or other services, patients can now attend 45 or 60 minute counseling sessions for certain non-acute needs such as stress, anxiety, or grief. Patients are able to pay up-front and all costs are transparent. According to a ranking by Mental Health America, Georgia ranked 47th in access to behavioral health care out of the 50 states. Given Walmart’s large rural footprint in Georgia, this decision was strategic; Walmart is positioning itself in areas where healthcare is scarce, or where medical care (without insurance) is cost prohibitive. While they are testing the concept with the one initial clinic, Walmart could open more in the future if it proves to be profitable.
Telehealth
While some companies are meeting consumers where they’re already shopping (Walmart), another method is to use a remote computer to interview/assess patients and provide treatment via videoconferencing or telephone. The utilization of telehealth among behavioral health providers is on the rise, particularly in rural or otherwise isolated communities. There is a growing body of evidence that supports the effectiveness of telehealth at facilitating positive health outcomes. One review by the Agency for Healthcare Research and Quality found evidence supporting telehealth for psychotherapy. In a study mentioned in this review, trauma-focused cognitive behavioral therapy (CBT) was provided via one-on-one videoconferencing, resulting in statistically significant clinical improvements and high satisfaction ratings from both providers and patients. Telephone-related care programs have also been shown to improve treatment compliance and to help monitor recovery from substance use disorders (SUDs).
There are still many barriers to implementing telehealth programs, among them being the lack of reimbursement, maintenance costs, organizational support, training, and workflow challenges for staff. Reimbursement, in particular, is being addressed at the legislative level and will hopefully serve to alleviate some of these challenges. In 2017, 200 telehealth-related bills were introduced in the legislative session, most of which had to do with reimbursement in Medicaid or private payers, establishing professional board standards, or cross-state licensing. There is still a long way to go with implementing telehealth programs for behavioral health care, but it shows great promise for increasing access while reducing costs.
Magellan
Magellan’s Complete Care model combines experience with physical health, behavioral health, pharmacy benefit management, and specialty services into a highly integrated approach. The company currently operates in Arizona, Florida, Massachusetts, New York, Virginia and Wisconsin. Magellan is deploying an integrated approach to identifying at-risk patients early, enhancing coordination of care, and tailoring educational tools to the needs of each patient. By integrating medical and behavioral health rounds, they can close the gap in behavioral care and identify patients while they are in the primary care environment. According to Magellan, this method saved a 1.4 million life commercial health plan a total of $41 million over a 4-year period, or 12% of their total behavioral health costs.
Searching for the Silver Bullet
The best model for addressing gaps in behavioral healthcare remains to be seen; however, mental health must be taken seriously and treated at parity with physical health if we plan to make meaningful improvement in quality of care and patient outcomes. HIRC's recent research with Accountable Care Organizations confirms that behavioral health is of high priority and that often there is an underlying behavioral health diagnosis behind inpatient and ER utilization statistics. ACOs are actively developing and piloting new care models to address access to care for their own populations, mirroring some of the strategies above. Among these approaches include embedding behavioral health staff in primary care practices, piloting telehealth/virtual care, investing in additional dedicated space, and prioritizing screening and identification initiatives.
For years, HIRC panelists have underscored the importance of pharmaceutical manufacturers bringing holistic solutions that address entire disease states rather than a sales-based approach that emphasizes specific branded products. Behavioral healthcare is a challenge large enough that collaboration industry-wide will be crucial. With ties to provider quality metrics in a time of transition towards value-based care, making behavioral health part of the conversation can be a significant differentiator in building partnerships.
