Breaking Through Gridlock in the Mental Health Care System

The mental health care system is broken.

One in five people has a mental health condition, but it’s harder than ever to find effective care. 163 million Americans live in a mental health professional shortage area, and if you can find a provider who accepts your insurance, you are often left waiting months until the next appointment. As a result of this and related trends, people of all ages are presenting with more severe mental health conditions, emergency department visits for mental health-related issues have increased dramatically, and suicide rates have risen 30% in the past 20 years.

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With so much need for mental health services, why hasn’t the market responded by supplying more and better care? While we commonly talk about the limited supply of mental health providers, the truth is that there’s more to the story.

Mental health care’s unproductive cycle

The mental health gridlock that we’ve been struggling with for decades can be distilled down into three key factors:

Mental health care delivery has lacked necessary rigor.

Symptoms of mental health conditions are self-reported or observed by a provider – there is no diagnostic blood test. Additionally, mental health conditions are highly heterogeneous, and classifications in the Diagnostic and Statistical Manual (DSM) are certainly imperfect. As a result, diagnosis and treatment are inherently subjective.

This level of subjectivity and variability creates a scenario where most therapists practice with nearly full autonomy and little transparency or accountability, trusted to adapt to whatever they perceive a given patient needs in a given session. As a result, mental health treatment has failed to adopt the type of standardized clinical pathways that have driven quality and efficiency improvements in other chronic conditions. Additionally, fee for service payment has created a scenario where providers lack incentives to effectively treat and discharge a patient, leading to longer care cycles than may be necessary.

Similarly, antidepressant prescribing mostly follows an ineffective guess and check convention that assumes any medication will do. This has made it so that any clinician is empowered to prescribe these medications with little training or insight and that Primary Care providers (not psychiatrists) prescribe the vast majority of mental health medications.

But the fact that our care has been falling short has been hidden by an astounding lack of outcome measurement. Fewer than one in five mental health providers practices Measurement Based Care, which means we’re practicing mental health care like an endocrinologist treating diabetic patients without ever measuring their hemoglobin A1C. Imagine that.

As a result, payers are flying blind and playing defense.

Because so few providers measure and report outcomes, payers have no idea whether the care they are paying for is helping people get better. So rather than risk spending exorbitant amounts of money on treatment with unclear clinical or financial impact, payers can only assert control by keeping reimbursement rates low and managing utilization.

The rate dynamic shows up clearly in national Medicare reimbursement, where primary care MDs and NPs receive up to 33% more per minute for an established patient office visit than their behavioral health colleagues receive for the same type of appointment.

At the individual state level, the delta can be even greater. For example, according to the 2019 Milliman Research Report, “Addiction and mental health vs. physical health: Widening disparities in network use and provider reimbursement,” as of 2017, primary care rates were 50% higher in 11 states (an increase from nine states in 2015), between 30% And 49% higher in another 13 states.

Some payers are also actively limiting the size of their behavioral health networks by excluding virtual care providers.

This creates a supply/demand imbalance that only worsens the problem.

The combination of high demand for services and low reimbursement has created a dynamic where mental health care providers can make more money (and have less stress) by charging cash for their services rather than accepting insurance. As a result, more and more mental health care providers are leaving or never even joining payer networks, exacerbating the growing mental health provider shortage.

In many ways, this has left employers holding the bag. Every day, they see the direct impact of mental health challenges among their workforce and pay for it in lost productivity and output. And because their health insurance providers haven’t effectively supported the mental health needs of their workforce, employers have been forced to pay substantial amounts for ancillary mental health services that they rightfully expected from their payer partners.

In the end, patients are the ones who lose. These systemic barriers to care result in a growing number of patients delaying or avoiding care altogether, making their mental health challenges even worse.

So how do we break through this gridlock? The answer isn’t as hard as it may seem.

Breaking through the gridlock

Changing these mental health care dynamics will take three key steps: 1. Providers must raise the bar.

Despite a lack of physical biomarkers, the science of mental health care provides robust structure, guidance, and measurement to enable rigorous and effective care delivery.

Line therapy should adhere to the evidence.

We need to move beyond delivering “evidence-based” care (a term so vague and overused that it really doesn’t mean much of anything anymore) to providing “evidence-adherent” treatment – therapy that rigorously follows the handful of protocols that decades of evidence have shown to be effective. Structured and proven approaches that have specific content, exercises, and practice to be completed through a defined program usually lasting about 12 weeks. Therapists must be given the training and tools necessary to effectively deliver these programs, then be held accountable for consistently doing so.

At the same time, we must move beyond the guess-and-check model of antidepressant prescribing (which accounts for the vast majority of prescriptions today) and embrace data-driven precision prescribing, which research suggests can yield substantially better outcomes.

In addition, 100% of mental health care providers must practice measurement-based care, utilizing validated rating scales to monitor and measure longitudinal outcomes for every patient.

Anything less is unacceptable. The concept is simple, and the impact will be substantial, as outcome data is the foundational ingredient to progress.

Payers must look at behavioral health reimbursement with fresh eyes.

This enhanced care model will allow payers to calculate ROI across populations and within specific member segments – including chronic condition comorbidities, emergency department and inpatient stays and readmissions, youth, etc. With that insight, payers will finally be able to (1) offer reimbursement that appropriately rewards providers for delivering high-quality, effective care, and (2) incentivize proactive mental health management – from screening and population health programs to targeted interventions that support at-risk individuals.

Finally, payers must update their policies to ensure that virtual care providers can provide the care their members need.

The industry must move to value-based care.

With an accountable, measurement-based care model in place, the logical next step is to support value-based payment models. These models enable payers to enhance their investment in the behavioral health needs of their member populations while effectively managing risk, and they reward providers for delivering cost-effective and high-quality clinical care. Value-based payment models also open the door to effective stepped care models and appropriate asynchronous care delivery that can help mitigate the growing provider shortage.

Now is the time for change

This market has been gridlocked for too long, and our healthcare system is letting our families, friends, and communities down by failing to provide timely access to effective and affordable mental health care. It’s time to usher in a new era of mental healthcare delivery and payment.

So what is the first step to breaking the gridlock?

Payers have the scale and influence to move the market most quickly. And they can start with the following policy changes and strategic initiatives:

Implement robust guidelines and requirements for mental health providers to report structured outcomes. Provide incentives to drive rapid adoption of measurement based care across all mental health providers.
Establish performance benchmarks (with risk adjustments) to compare outcomes across providers.
Invest in updated cost studies to better understand and justify mental health interventions at the population and targeted individual levels.
Share the risk with providers who are following best-practices through value based arrangements, setting a template for the industry to follow.

Fortunately, we are seeing early signs of this trend. Certain organizations, teams, and individuals are pushing forward to break through the gridlock, but it needs to move from the outlier to the norm. Our communities need us, and the time is now.

Photo: Cheunghyo, Getty Images

Brad Kittredge

Brad Kittredge is the CEO and co-founder of Brightside Health. He has spent over a decade pioneering evidence-based and consumer-driven health care solutions, including building the Product teams at 23andMe and Lantern. Inspired by the challenges of a close family member with lifelong depression, Brad’s mission is to ensure that everyone has access to life-changing mental health care with measurably better outcomes. He holds MPH, MBA, and Psychology degrees from UC Berkeley.