Your brain is definitely a part of your body.
So why do tens of millions of Americans find it so hard to get help for brain-based problems, from depression and anxiety to addiction and eating disorders?
Currently, the nation doesn’t have enough mental health care specialists to meet the rising need for this care.
But even if you find someone to guide your treatment, or that of your child, and get an appointment, you may find that your health insurance won’t cover the cost of your visits or the treatments that your specialist recommends.
Or you might start by calling clinics on your insurance company’s approved in-network list, and run into long waiting times or discover they aren’t in-network after all.
Or you may decide to book an appointment with a mental health provider who doesn’t take your insurance, or doesn’t take insurance at all.
That can mean spending hundreds or thousands of dollars out of pocket, perhaps with a chance of getting some of that money back if you press your insurance company for reimbursement.
Meanwhile, getting help for a longterm physical issue like asthma, heart disease or diabetes doesn’t usually come with nearly as many barriers.
This inequality – what experts call a lack of parity – has led many children, teens and adults to go without specialized care or ongoing therapy for mental health conditions.
Now, it has inspired a range of new federal rules, announced September 9, 2024 by the Biden administration.
Lack of access to mental health care can impact every part of a person’s life, from work and school to relationships and finances. It can also mean people won’t seek help until they have a mental health crisis, even a suicide attempt or overdose.
And that can send them to places like the Michigan Medicine psychiatric emergency department directed by Victor Hong, M.D.
This rising demand for such emergency care, and inpatient care, feeds long waits nationwide, and fueled 5 million inquiries to the 988 phone and text mental health and addiction crisis help line last year.
“For many years, clinicians, hospital systems and most importantly, patients, have suffered the consequences of continued lack of mental health parity, despite there technically being a law enforcing this issue,” said Hong, a clinical associate professor of psychiatry at the University of Michigan Medical School.
Parity laws and new proposals
That mental health parity law he’s referring to is now 16 years old, though some of its strongest provisions only took effect a few years ago. That 2008 law tried to go further than the 1996 law that preceded it, though it doesn’t apply to Medicare or Medicaid, which cover tens of millions of Americans.
All the while, mental health needs have risen steadily, accelerated recently by the stress of the pandemic and 2020 economic downturn.
That’s why the Biden administration has just finalized a new set of federal rules to require insurance companies to follow the letter and spirit of those earlier laws. The rules, issued by three federal agencies, underwent a public comment period starting last summer and will begin taking effect in January 2025.
“Numerous studies have demonstrated that even modest levels of out-of-pocket cost are associated with lower use of clinically necessary, high-value mental health services and treatments,” said A. Mark Fendrick, M.D., who directs the Center for Value Based Insurance Design and is a professor of internal medicine at the Medical School.
“This can lead to downstream consequences including worsening of illness and increased need for acute care and hospitalization. Parity in insurance coverage can address the need to balance appropriate access to essential mental health services with growing fiscal pressures faced by public and private payers.”
Any new provisions, he adds, need to have enough enforcement “teeth” in them to change the landscape.
More providers needed
But the new rules won’t affect two other key parts of this problem: A national shortage of mental health care providers, and uneven distribution of the psychiatrists, psychologists, psychiatric nurse practitioners, clinical social workers and other licensed therapists our nation does have.
Srijan Sen, M.D., Ph.D., director of the University of Michigan Eisenberg Family Depression Center and the Frances and Kenneth Eisenberg Professor of Depression and Neurosciences at the U-M Medical School, said “I think the specific changes are worthwhile, most notably reducing prior authorizations and gathering data. But I do think the impact of these changes will be limited without concurrent changes to expand the capacity of our mental health care system and changes to reduce the number of people who develop mental health challenges in the first place.”
States like Michigan have tried to spur more people to enter mental health-related professions or practice in shortage areas by promising student loan forgiveness, while other federal proposals have been put forth or put into place.
Experts say higher pay and better benefits for mental health professionals of all kinds will be critical to encouraging more people to pursue these professions, as well as a clearer career ladder for advancement.
Another key area of promise: training people who have handled a mental health illness of their own, or in their child, to work as ‘peer providers.’
But training any type of behavioral health provider takes time, as described in a report from a national medical school group.
Shrinking distance through telehealth
One silver lining in the situation: the fact that a lot of mental health care and addiction treatment can be provided over a video link or even a phone connection.
In fact, pandemic-era rules from insurers and the federal government have made telehealth mental health appointments easier to take part in for many more people. Not having to drive long distances, or take as much time off from school, work or family obligations removes barriers.
But will that virtual care option continue after 2024 when current special rules expire?
That’s on the mind of Chad Ellimoottil, M.D., M.Sc. He’s the medical director of virtual care for Michigan Medicine, and lead author of a report on telehealth in Michigan commissioned by the Michigan Health Endowment Fund and the Flinn Foundation:
“Our recent report on telehealth use in Michigan showed that half of all Michigan counties have less than 10 mental health specialists, and 1 in 5 Michigan counties have one or no such providers,” he said.
“In the 38 counties with the most dire shortages, 57% of all visits with such providers take place via telehealth for patients with traditional Medicare, and 47% of all mental health visits were with providers in other counties. These data show that telehealth meant greater access to mental health care for people living in areas that lack providers of such care.”
Supporting primary care
Another key factor in addressing mental health needs is improving the care that people can get from their regular primary care health providers – doctors and nurses in family medicine, general pediatrics, general internal medicine and women’s health clinics.
“The vast majority of mental health care in the U.S. is provided by general practitioners, who often lack training in psychosocial interventions,” explained Briana Mezuk, Ph.D., director of the Center for Social Epidemiology and Population Health at the U-M School of Public Health.
“To support them, it is essential that healthcare systems and payers embrace coordinated team-based care models,” she said. “Team-based care – which typically involves a general practitioner, nurse, and a mental health specialist working together to support the patient – not only generates better clinical outcomes for patients with co-occurring mental and physical health problems, it is also cost-effective for managing such complex health needs. Payers and healthcare systems need to invest in these types of structural and personnel solutions to complex patient care.”
Outreach programs from psychiatry departments like Michigan Medicine’s offer these primary care providers a “lifeline” for specialized support in caring for patients with specialized needs, as well as training.
Joanna Quigley, M.D. helps run Michigan’s program, called MC3. She’s the associate medical director for child and adolescent outpatient psychiatry and addiction treatment at Michigan Medicine.
“Moving toward true parity for mental and behavioral health care continues to be elusive for many, and we need and welcome interventions that remove barriers during a time of unprecedented demand for mental health care,” she said. “It will be very important to monitor implementation of these changes, particularly around the goals of limiting the scope of limits set through prior authorization processes and limits on length or type of treatment settings.”
Another U-M-led study showed success in supporting rural primary care providers in caring for complex issues in adults.
More research needed
While the race to increase clinical access and remove barriers accelerates, researchers at universities and think tanks continue to study the issue and quantify how big the problem is and what impact policy changes are having.
Kyle Grazier, DrPH, is one of them.
As the Richard Carl Jelinek Professor of Health Services Management and Policy and a professor of psychiatry, she conducts research on payment models and their incentives to create and sustain access to high quality mental health services that are delivered through integrating primary care with community systems.
Grazier sees progress and reason for optimism in this latest federal proposal, and others in recent years.
But she also knows the improvements meant to repair the current system of mental health care and insurance will take time.
“While there is a general shortage of behavioral health providers, the challenges of finding care are exacerbated by the lack of affordable and available access,” she said. “Even among those who have private health insurance and despite the state and federal parity laws in the past 15 years, group health plans and health insurers that provide mental health and substance use disorder benefits continue to impose less favorable limitations on those benefits than on medical or surgical benefits.
“For the consumer, the out-of-pocket cost for therapy or medication management can be prohibitive, and much more expensive than equivalently complex or time-consuming medical procedures, even if a provider is in an insurer’s network. The stark imbalance between needing care and receiving care has led to a call to respond to the behavioral health crisis.”
A recent paper by a team led by Kara Zivin, Ph.D., of the U-M Department of Psychiatry, evaluated the impact of the 2008 mental health parity law and the Affordable Care Act of 2010 on the care of patients who had mental health concerns during pregnancy and the postpartum period. It found that while the percentage of patients receiving psychotherapy for their pregnancy-related depression, anxiety or other condition increased, still only 10% of those with a diagnosis received this talk-based mental health care.
But even as research continues, experts like Nasuh Malas, M.D., the director of child and adolescent psychiatry at Michigan Medicine, welcomes the new federal policies as a key step toward a larger goal.
He said, “I believe this is a good step to seeing mental health and substance use care and treatment as an important component of overall health, and as critical as physical health to the well-being of our patients.”
