Let’s Build a Better MH Care System

Parity: Parity is an important design element of the mental health system. We have parity in commercial insurance plans, now by law. As evidenced by the November 2017 Milliman report titled “Addiction and Mental Health Versus Physical Health: Analyzing Disparities in Network Use and Provider Reimbursement Rates,” however, we have a long way to go with regard to enforcement of parity. Milliman found that patients’ use of out-of-network services is extremely high for behavioral health compared with general medical and surgical services and that psychiatrists are paid less for the same codes than other physicians. So while parity is an important design element for expanding access to mental health care, implementation and enforcement still fall far short of the law. The design is not fully implemented.

Transitional-age youth: In the realm of mental health conditions, particularly serious mental health conditions, there is no more critical time period than the transitional stage of youth, generally between the ages of 16 and 26. This is a period wherein individuals transition from childhood into adulthood, and during that time, many serious and potentially disabling mental illnesses such as schizophrenia, mood disorders, and addictions develop. Our delivery system includes several recent developments that are designed to increase access to effective treatment for this age group. Currently, commercial insurance plans are required to allow children up to age 26 to remain covered on their parents’ plans. Recently, Congress created another design element to address the identification of early psychosis and treatment. Through the Substance Abuse and Mental Health Services Administration, federal money was added to each state’s Mental Health Block Grant to implement first-episode psychosis programs. These funds have supported the creation of nearly 200 first-episode psychosis programs in the United States, enabling us to at least begin to scratch the surface of the need. Whether these programs can be sustained, however, is yet to be seen. Research shows that the most effective programs involve wraparound services for which commercial insurers and even Medicaid are not required to cover. So while we know these programs are an effective design element of the mental health system, their future is imperiled by a lack of resources. Here again we see a good design element that is not fully implemented.

Safety Net. With regard to safety-net design, a foundation is the Emergency Medical Treatment and Labor Act (EMTALA), which requires emergency departments (EDs) to diagnose and stabilize all comers. Yet we all know that far too many EDs board individuals with mental illnesses, waiting for beds that they may not actually need if safe alternatives were more available. We also know that for many persons with psychiatric crises, traditional EDs are often not the best place for the diagnosis and treatment of psychiatric crises. Many communities have designed crisis services so that safe alternatives to EDs and inpatient treatment exist. Again, we see good design elements that are not fully implemented.