Fixing the Broken Mental Health System
For millions of people, mental healthcare has not been accessible for years due to a lack of mental health resources. Compounding the problem, many insurance policies do not offer coverage for mental health, limit the coverage of therapy, and/or pay a substantially lower percentage of the cost than they do for other forms of medical treatment, all of which can make seeking treatment financially unattainable for many patients and their families.
Obamacare attempts to rectify this, starting January 1, 2014, when all Americans become eligible for mental health services and addiction treatment. Under this plan, insurance companies will be required to reimburse for mental health services if the individual has an eligible policy. Moreover, they will not be able to limit visits for outpatient therapy any more than they do for other medical outpatient visits.
While the intention to offer better care to patients is admirable, there will be unintended adverse consequences to this change if it proceeds as currently planned. It is anticipated that there will be an additional strain on a system that is already at its breaking point due to a lack of mental healthcare resources in many communities.
As it stands today, there is a severe shortage of mental health care professionals and facilities, both inpatient and outpatient, in the U.S. Under Obamacare, we do not expect to see the addition of new physicians or facilities to accommodate the millions of new patients expected to seek treatment – therefore exponentially adding strain on a system already stretched to the breaking point. The result of this lack of treatment in the pre-Obamacare system is easily evidenced by the number of mentally ill patients in jails (a.k.a. “new mental asylums”) and homeless shelters – many of whom desperately need treatment for their illnesses, as opposed to being housed in jails or shelters, but never receive treatment due, in large part, to a lack of psychiatric treatment resources available in their communities. For example, there are almost three times as many mentally ill individuals in the country’s three largest jail systems (Cook County, L.A. County, and New York City) than there are inpatient psychiatric beds in these three large states. In New York City alone, mentally ill prisoners comprise 37% of the prison population, up from 24% in 2005. We also see the result of the lack of care of our country’s most mentally ill in the increase of school shootings, “suicide by cop”, and other incidents of violence by individuals who, under better circumstances, would have received the care they need.
In addition, according to a recent Wall Street Journal article, the U.S. Department of Health and Human Services reports that almost 91 million adults live in areas where shortages of mental health professionals make obtaining treatment difficult. A departmental report to Congress earlier this year reported that 55% of the nation's 3,100 counties have no practicing psychiatrists, psychologists or social workers. In 1955, there were over 300 inpatient psychiatric beds per 100,000 people in the United States. Today, according to the Treatment Advocacy Center, there are 14.1 beds per 100,000 people – the same number as in 1850, and a 95% reduction over 1955, leaving many patients and their families to fend for themselves.
The continual decline of insurance reimbursement rates and increased bureaucratic hurdles has led many providers to stop accepting insurance, which creates an even greater lack of resources – especially for those patients in lower socioeconomic communities who are not able to pay out of pocket. A study recently published in the JAMA Psychiatry found that only 55% percent of psychiatrists accept private insurance, compared to 89% of other physicians. Under Obamacare, while more patients are expected to receive coverage for mental health treatment, reimbursements for psychiatrists will decline further, and the network of providers that patients can access will be restricted, all of which will lead to a deterioration in the quality of care patients can access. The cheapest care is not usually the best care – especially in complex and complicated cases. It is unacceptable that our country is migrating towards the lowest common denominator in psychiatric care. We should strive for adequate care for our mentally ill patients, not just basic treatment.
This shortage of mental health resources is also a contributing factor to the unnecessary prescriptions of antidepressants, psychostimulants, and anxiolytics in individuals who do not meet criteria for major depression, ADHD or an anxiety disorder. It is easier and more “time efficient” for a busy clinician to write a prescription and the insurance companies to reimburse pennies for generic psychiatric medications than it is to reimburse for a thorough diagnostic evaluation by an experienced clinician and pay for therapies that may be as efficacious as medications but more time intensive.
The time for change is now. We need to reorganize and strengthen the infrastructure of the mental health field. We need to increase inpatient psychiatric beds. The government needs to stop subsidizing organizations and advocacy groups that “help” the mentally ill refuse treatment. The standard for inpatient commitment should be broader than the “imminent danger to self and others” standard which prevented the Adam Lanza’s of the world from receiving adequate treatment. Involuntary outpatient commitment laws like “Kendra’s law” should be adopted nationwide. As things stand, we have a very fragile house of cards. Obamacare is going to lay a brick on top of those cards and hope it holds out.
We need to increase training in mental health care within the entire medical establishment. Family physicians, nurse practitioners, physician assistants and other extended care providers handle more than 90% of psychiatric care in the U.S., yet only receive six to 12 weeks of training in psychiatry over their entire medical school, residency and training careers. We can increase training through accessibility to MOOCs (massive open online courses) which serve as an effective way to educate professionals and is also becoming more widely accepted as a means of continuing medical education. Mental healthcare professionals can have access to the best teachers in the country (think Khan Academy) rather than simply being taught by mediocre local teachers who consider teaching a chore. In this regard, the announcement in September 2013 of a partnership between EdX and Google to expand availability of this kind of platform and tools to individuals and institutions is a step in the right direction.
We also need to make sure that there is more emphasis on the detection and treatment of psychiatric illnesses in the early stages. The sooner a patient receives the correct diagnosis, and the quicker treatment is initiated, the better the outcome. Screening for common psychiatric illnesses in primary care practices should be part of the initial differential diagnosis, along with other medical illnesses, rather than an afterthought like it currently is for patients who do not respond to medical treatments or in whom the myriad of unnecessary tests are negative. Too many patients are bounced around the system until they receive a proper diagnosis. For example, studies have shown that it takes about a third of bipolar patients almost 10 years to receive a correct diagnosis.
Beyond that, we need to reprioritize the structure of the new insurance policies. Reimbursement for psychiatric care should be commensurate with higher reimbursements for providing evidence based care. There should be no expectation that dwindling payments will produce better results.
Long term, we should be increasing training slots for psychiatry residents, increase training in primary care, nurse practitioners, and physician assistant programs for treating common psychiatric illnesses.
Mental health is key to our overall health. As a society, we are more aware than ever that staying mentally fit is just as important as maintaining our physical health. Yet, overall, the mental healthcare field has been neglected, which is unacceptable. The costs involved in maintaining the resources needed to support an adequate system are insignificant when compared to the dividends that will be returned to us in productivity, safety, and a better quality of life for society as a whole.
Dr. Prakash Masand is the CEO of Global Medical Education, a free online medical education resource that provides timely, unbiased, evidence-based medical education and online medical information from the world’s leading experts to health care professionals around the world. GME provides answers to medical questions, from the common place to the most critical, in concise three to four minute medical education videos, available on-demand on all major digital devices.