Taking Action Against the Rising Mental Health Crisis: Efforts From Health Plans, Congress, and More

The mental health crisis in the United States has shown staggering increases in rates of mood disorders and suicide-related outcomes among adults and adolescents. Along with COVID-19, issues such as social media use and the intensifying danger of climate change have been associated with symptoms of depression, anxiety, suicidality, and other psychiatric conditions, particularly among youth.

According to recent data from the CDC, more than a third of high school students reported experiencing poor mental health during the pandemic, and LGBT and female youth were disproportionately affected.

Moreover, research from a myriad of organizations, such as the National Alliance of Healthcare Purchaser Coalitions (National Alliance), Lyra Health, and Ginger, has only further distinguished mental health as an epidemic in vital need of nationwide intervention:

• 80% of US workers indicated in a poll by Lyra Health and the National Alliance that they were experiencing mental health issues during the early months of the pandemic.
• Nearly 7 in 10 employees indicated in a Ginger survey that the pandemic was the most stressful time of their entire professional career.
• An analysis by Blue Cross Blue Shield of Massachusetts showed that use of outpatient mental health services, including psychotherapy, increased nearly 20% during COVID-19, and spending on substance use disorder treatment increased by 10%.

At the community level, these concerns have garnered expansive initiatives from employers and those involved in health benefit design, who have largely had to play catch up to fill the gaps of inadequate mental health coverage cited just before the pandemic began.

However, Michelle Thomas, LCSW, associate vice president, Behavioral Health, UPMC Health Plan, highlighted in an email exchange with The American Journal of Managed Care^® (AJMC^®) that there remain significant barriers continuing to limit the integration of behavioral health care services in the United States.

“Integrated behavioral health care, to me, is the blending of care into one setting for medical and behavioral health. In a more fully integrated practice, there may be a care team that consists of the primary care provider, a behavioral health clinician, and a consulting psychiatrist,” she explained.

Thomas noted that despite pockets of great success in behavioral care integration, barriers such as the lack of assessment for behavioral health conditions, inability to link at-risk patients with behavioral health care, and reimbursement models continue to widen the access gap practice by practice and state by state.

“Funding for [an integrated model] is often a challenge.…Securing funds for a behavioral health clinician in the practice and/or a consulting psychiatrist can be difficult. It’s important to have engaged primary care practice leadership who are willing to dedicate resources to build an integrated model,” said Thomas.

“Care needs have increased, but patients are having a difficult time finding providers with openings in their schedule. Appointment wait times are longer than they were prior to COVID-19, and though telehealth has certainly helped with that, access needs persist, for all people, not just at-risk populations.”

Ellen Beckjord, PhD, MPH, vice president, Population Health and Clinical Optimization, UPMC Health Plan, discussed with AJMC^® what beneficiaries should expect from their respective single/family health plans in meeting the behavioral health care needs of people nationwide.

In designing behavioral health care programs at the community level, Beckjord stressed the need for respective health plans to place greater value on what the community needs, prefers, and values, rather than their own interests, to build a partnership on a foundation of trust.

“Beneficiaries should expect that their health plans will offer evidence-based services in a variety of modalities that make receipt of behavioral health care convenient and affordable, and beneficiaries should expect that health plans will architect their offerings in ways that improve health equity and ensure the most vulnerable have sufficient support to receive the care and services they need,” she added.

Echoing sentiments from Thomas, Beckjord cautioned that the threat of a “digital divide” may impede the widespread use of telehealth for behavioral health care needs. But use of digital tools, as well as new models of care and advances in pharmacological options, still show promise to provide robust and safe virtual communities for the provision and receipt of peer support, she said.

Along with health equity concerns, efforts to address stigma associated with behavioral health and receipt of treatment were also mentioned.

“​​Because the pandemic was a universal stressor, there’s been some positive impact on destigmatizing mental and behavioral health concerns; however, we have a long way to go to truly eliminate stigma and the disproportionate ways stigma affects those who are already vulnerable, thereby exacerbating inequity,” noted Beckjord.

“Keeping behavioral health in the shadows doesn’t protect us from shame and embarrassment, it robs us of opportunities to observe—and celebrate—our resilience. Making real changes regarding how we approach mental health challenges won’t expose our weaknesses—it will expose our strengths.”

Novel initiatives to address mental health have also found their way to Congress who recently introduced the 988 Implementation Act. Set to take effect July 16, 2022, at least 11 states have enacted legislation to fund and implement 988, a 3-digit designated hotline for people experiencing a mental health crisis to speak with trained counselors part of the established National Suicide Prevention Lifeline network.

Margie Balfour, MD, PhD, chief clinical quality officer, Connections Health Solutions, and practicing psychiatrist, spoke with AJMC^® on the preventive impact that 988 will have on managing the growing mental health crisis.

“Having a 3-digit number like 988 makes it easier and less stigmatizing to ask for help. It sends the message that a mental health crisis is a legitimate health emergency like other kinds of emergencies. And most importantly, it connects the individual to someone who can provide clinical assessment and intervention,” she said.

Moreover, Balfour explained its potential implications for minority communities who may have been discouraged to call 911 for mental health emergencies in the past due to the involvement of law enforcement. Nearly a quarter of all people killed by police officers in America have been shown to have had a known mental illness, with the risk of death magnified 10-fold for people of color.

Understanding how 988 will be implemented in each respective community will be of utmost importance for local stakeholders, providers, and advocacy groups, noted Balfour, as the hotline will be used primarily for suicide-related concerns in some communities, whereas in other areas, 988 will connect to a crisis line that provides access to dispatch mobile teams and crisis stabilization facilities.

“In addition to telephonic counseling, callers will need a similarly robust crisis system with mobile crisis teams to respond instead of police and specialized crisis stabilization facilities where people can receive care they need instead of boarding in emergency rooms. We need to build that crisis system of care and that will take time,” she said.

As the rollout of a national mental health crisis hotline will influence demand in psychiatric services, the lack of an adequate emergency response infrastructure in some communities may continue to direct patients to emergency rooms that are poorly equipped to manage mental health emergencies.

To assist in the rollout of the 988 hotline, Colin LeClair, CEO of Connections Health Solutions, said in an email exchange with AJMC^® that there are several things hospitals and health systems, as well as health plans and insurance companies, can do to encourage the development of a high-functioning continuum of psychiatric care.

With many hospitals and health systems likely to be caught off guard by the increase in behavioral health care demand, LeClair said that what hospitals should do is work together with government agencies, community stakeholders, and competitive health systems in their communities to develop a high-performing center of excellence for emergent and urgent psychiatric care.

As opposed to competing to hire scarce mental health professionals to staff their emergency departments, which will still result in insufficient coverage for mental health emergencies, the design of a center of excellence that can provide high-quality, interdisciplinary psychiatric care, at scale, and supports all patients and all of those health systems agnostically, was touted by LeClair.

Furthermore, he cited 3 strategies for health plans and insurance companies in the rollout process:

1. Plans should cover crisis services equally—currently, original Medicare and most Medicare Advantage plans don’t cover many urgent and emergent crisis services, and commercial plans provide spotty coverage. These services are principally available to Medicaid-eligible populations, leaving most of the population with very few options if they’re in a psychiatric emergency.
2. Plans can help standardize the metrics that we use to measure quality and access, and the expected outcomes from each service, to ensure that we don’t increase the volume of services at the expense of quality.
3. Plans should insist on contracting with providers through value-based payment models that incentivize improved quality, access, patient experience, and sustainability so that new mental health services always put the patient first and do so in a sustainable, cost-effective way for the long-term viability of the mental health system.

Ultimately, optimizing an integrated approach to mental health and physical health management will reap significant benefits for employers and those involved in health benefit plan design. Currently, the greatest source of waste for health plans is in inpatient care, where nearly 40% of every behavioral health dollar is spent.

“Of course, our number one priority should be to improve timely access to preventive outpatient psychiatric care. But doing so requires a long-term workforce development strategy. In most markets, it also requires that significantly more funding be directed to those services,” said LeClair.

Nearly 70% of inpatient admissions can be replaced by high-quality emergent or urgent psychiatric care, at a fraction of the cost and with far better outcomes for patients, he added, which include lower readmission rates, better medication adherence, better primary care, and psychiatric outpatient care engagement following the mental health crisis.

“This is how we achieve all of the critical aims of a modern mental health system—improved access, quality, cost, patient experience, and sustainability.”