Strategies to Improve Access to Care

Over the past several months, my columns have described some of the barriers that people encounter when they try to access mental health care and the underlying causes. The 2017 National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration found that 13.55 million adults reported an unmet need for mental health services. In addition, 1 in 5 adults was unable to obtain treatment because of barriers to getting the help they need. Unless we have personally tried and failed to get treatment for a friend or family member, it’s hard to imagine the scope of the problem.

After my election as president of APA, I received the most upsetting telephone call of my career. It was from the leader of an advocacy organization who discussed the problems their members had experienced accessing care from psychiatrists for their seriously ill family members. Among the complaints were how psychiatrists do not want to treat people with schizophrenia in their private offices and their refusal to accept insurance coverage whether it be commercial or Medicaid. I started to explain some of the reasons so many psychiatrists cannot treat these individuals in a private office because of their need for additional services, which most private-practice psychiatrists cannot provide or cannot afford because of unrealistically low and discriminatory reimbursement rates from Medicaid. In the end, I decided to just listen as this person was telling me why so many families and patients are frustrated and angry with some aspects of our profession.

We can all list the reasons for poor access to mental health care: poor enforcement of the Mental Health Parity and Addiction Equity Act; workforce shortages, which will severely worsen over the next decade; discriminatory reimbursement; absence of adequate funding for needed housing, vocational, occupational, and peer support services; and so on. Nonetheless, APA and psychiatrists must try to improve access to and the quality of care that patients deserve. We have to marshal the entire workforce who cares for people with mental illness. That includes social workers, advanced practice nurses, psychologists, mental health counselors, and peer counselors. It comes down to collaboration and putting aside some of the guild issues about which we all have valid concerns.

I believe everyone who enters a mental health discipline is motivated to provide the best care to patients. The skill sets, expertise, and training are different, but together we can work to improve access to treatment. Technology can play an important role, whether it is through telepsychiatry or the creation of virtual team-based care so that if a psychiatrist needs cognitive-behavioral therapy or peer support services for a patient, another clinician on the virtual team can engage that patient in a seamless manner.

Collaboration will become even more essential as the primary care workforce is expected to fall short of demand by 21,000 to 55,000 physicians by 2032. Primary care physicians provide a lot of mental health treatment to patients with mild to moderate mental illness. If their number is insufficient—and it looks like it will be—we are all in trouble. These projections take into account that advanced practice nurses are expected to increase by 125% over the next 10 years. So let’s figure out how to more effectively work together to help people get quality treatment.

In a future column, I will discuss efforts that APA will be undertaking to improve collaboration and the education of the workforce. ■