Although the White House, Congress, and state governments have launched various new initiatives designed to improve the U.S. mental health care delivery system in recent years, a panel of experts convened by the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) concluded that, overall, the system is worsening at a faster pace than it is improving.

“The percentage of U.S. adults who receive mental health treatment is increasing,” said Rachel M. Werner, MD, PhD, moderator and LDI Executive Director, as she opened the virtual seminar focused on payment and policy solutions for the crisis. “There aren’t enough providers to meet existing needs and to ensure equitable access to treatment. Over 75% of U.S. counties don’t have a prescriber and wait times for treatment can range from weeks to months. For younger people, the situation has become dire enough that the Surgeon General of the U.S. issued an advisory for protecting youth mental health.”

The cited 2021 advisory reported: “Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor life outcomes in young people, with up to 1 in 5 children ages 3 to 17 in the US with a reported mental, emotional, developmental, or behavioral disorder. From 2009 to 2019, the proportion of high school students reporting persistent feelings of sadness or hopelessness increased by 40%; the share seriously considering attempting suicide increased by 36%; and the share creating a suicide plan increased by 44%.”

Brought together by LDI to discuss the state of mental health care delivery were panelists Jamie Dupuy, MD, Medical Director of Clinical Services at Optum Behavioral Care; Haiden Huskamp, PhD, Professor of Health Care Policy at the Harvard Medical School; Madhuri Jha, LCSW, MPH, Director of the Kennedy-Satcher Center for Mental Health Equity at the Morehouse School of Medicine; and Hoangmai (Mai) Pham, MD, MPH, an Adjunct LDI Senior Fellow and President of the Institute for Exceptional Care.

Obstacles and Insufficiencies

The panel discussion touched on a wide range of obstacles and insufficiencies that have combined to leave so many mentally ill patients without adequate care for so long. Included were the current contentious tangle of social, economic, political, crime and health issues that have created an unnerving national sense of unease and distress; severe mental health workforce shortages; maldistribution of those clinicians who are in practice; long-term lack of investment in the fragmented mental health care system at all levels of government; siloed practices that keep primary care and mental health care rigidly separate; insurer and government payment and administrative restrictions that thwart access; failure to enforce the Mental Health and Addiction Parity Act of 2008; data collection and policy metrics systems that grossly underrepresent minorities, homeless, and incarcerated populations that have the highest levels of mental health illness and needs; lack of the provider diversity required to adequately address the mental health needs of people whose first language is not English; and concern that one of the most effective new innovations in mental health care delivery — telehealth — may be curtailed when the relaxed pandemic regulations that enabled it end with the expiration of the national health emergency declaration.

“Our mental health system feels like it was designed for mid-last century because so much of the world around us has changed,” said Pham, a former Chief Innovation Officer at the Centers for Medicare & Medicaid Services (CMS). “On the one hand, reduced stigma around mental health has allowed for earlier self-disclosure and better diagnosis and screening. On the other hand, reduction of that stigma, combined with the availability of guns and drugs, has led to this epidemic of suicide as well. It just feels like the milieu has changed and policy makers have always been behind.”

Big Systemic Problems

“Providers and patients feel alone up against big systemic problems that are hard to define and therefore difficult to know how to manage,” said panelist Dupuy. “There are so many factors that are beyond the control of providers or patients — the pandemic, poverty, discrimination and systemic racism, health inequities, violence, food insecurity, the impacts of climate change. More than half the people who need treatment are still not receiving it — and for Black and Latino adults, that number is probably closer to two thirds.”

Noting that accurate data is crucial to health care policymaking, Jha, whose organization recently issued “The Economic Burden of Mental Health Inequities in the United States Report,” lamented the populations left out of care because of insufficient data availability.

“Populations are generally left out of these discussions because it’s overwhelming to think about the solutions to families that live in shelters, or are transient,” Jah said. “They’re not getting counted in the system. Yet, we know these kids have very high rates of anxiety, depression, and traumatic stress. And if we’re counting things like adverse childhood experiences (ACEs), we have to think about this outside of just a mental health service delivery thing.”

Workforce Shortage

On the critical issue of workforce shortages, health economist Huskamp pointed out the non-obvious complexity of a problem that has no real short-term fixes.

“Payment plays a large role in the workforce shortage and maldistribution of providers,” said Huskamp. It’s a big, big problem in our system now. Training new personnel — particularly a diverse group of new personnel to enter the workforce — is really important but it won’t get us to the numbers we need any time soon.”

She noted that although Medicare has expanded payment codes to incentivize current providers to take on more patients, it doesn’t cover the investments required for those providers to achieve that physical expansion.

“Medicare may represent a small proportion of someone’s practice and that doesn’t really allow providers to invest in the infrastructure that they need necessarily to run those models and build those codes,” said Huskamp. “The same is true to some extent in Medicare’s newer office-based opioid treatment bundle. You need a lot of services and infrastructure to do that, and you need a different way to ensure that the resources are there to fund that investment. Another issue is that workforce shortages are compounded by low participation of mental health specialists and insurance networks. And so, we need to reassess provider network requirements and the federal parity laws’ role in guiding reimbursement for behavioral health specialists and other clinicians who are billing for these kinds of services.”

All panelists agreed that the single most promising new development in treatment capacity expansion is telehealth. As in many other areas of health care, remote access mental health treatment via interactive web video, text messaging, and phone has been a dramatic success story since it was made possible by pandemic-driven waivers and temporarily lifted regulatory restrictions.

Success of Telehealth

“Telehealth was one of the most dramatic shifts in health care during the pandemic — something that we always thought we couldn’t do well in mental health became immediately essential, and we all just did it, which is really extraordinary,” said Dupuy. “The really wonderful thing is that it looks like outcomes were just as good or comparable, and that it really could improve access to care. So, I think patients are finding it essential and providers are finding it essential as well and we are reluctant to go backwards. I do worry about the end of the public health emergency and those expansions of telehealth that I think are critical to protect.”

However, Dupuy also noted there were limits. “We weren’t able to use telehealth in the same effective ways for more intensive treatment settings,” she said. “It certainly can’t reach people if they don’t have access to the devices they need or the internet service that could deliver it. So there had to be some adaptations in terms of moving to phone calls or even bringing devices to people in need. For example, there are some really innovative programs — one in Harris County, Texas puts iPads with police so that when law enforcement officers go out on a call, a mental health professional can be available on the screen to hopefully intervene in a way that diverts people from more interaction with law enforcement or even hospitalizations.”

As the seminar ended, Werner asked each of the four panelists to imagine they had 10 minutes with a congressional legislator to brief them on a must-do piece of legislation to improve mental health care. What would that be?

Madhuri Jha: “My answer is not a typical one. I say the housing shortage is a primary mental health crisis. If somebody doesn’t have access to housing, there’s no way they can make an appointment. And yet when they are deemed by our system to be a high utilizer or ‘frequent flyer,’ they’re stigmatized. We need to give someone a place to live and think about their hierarchy of needs, and then appreciate that a primary care provider can have a better space to understand those needs if that patient is actually able to see them.”

Jamie Dupuy: “Investing in basic safety and health, and supporting infrastructure is extremely important. If the legislator could do something right now, I think expanding the telehealth provisions would be really important to maintaining access as well as expanding the interstate licensing provisions that can allow telehealth providers to reach underserved areas that are not in their state.”

Haiden Huskamp: “I would push for a bill to expand system capacity in multiple different ways: funds for training and recruitment of new providers in a diverse group of providers, making telehealth accessible broadly, pushing on network adequacy requirements that would force reimbursement rates higher, and finding ways to fund infrastructure development of primary care.”

Hoangmai (Mai) Pham: “I would ask for two things: robust primary care partial capitation and a nationwide investment in community health workers who actually go door-to-door and ask people how they’re doing and whether they would like to come to a place where they can be connected with others.”

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