Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services

Increasing the quality of health care in community settings is a primary focus of public health policy. Recently, federal and regional organizations have invested heavily in the implementation of evidence-based practice (EBP) to reduce the variability in service quality and outcomes in health care. The face validity of this approach is appealing. Ultimately, however, these efforts may fail for the same complex reasons that drive the variability in service quality and outcomes in the first place. We argue for prioritizing policy reform and increased funding to improve the quality of community mental health and substance use services.

This perspective stems from decades of work in partnership with Philadelphia’s public mental health and substance use system. We have collaborated with system leadership to advise on and study EBP implementation with a suite of approaches, including observations, interviews, and surveys. Studying the rollout of system-wide policies and initiatives designed to increase EBP use has enabled us to uncover the stressed financial infrastructure of mental health and substance use services (1, 2). Despite inspired leadership and dedicated policy makers, payers, agency leaders, and clinicians, we have not overcome the systemic challenges in the business of delivering mental health and substance use treatment. Community agencies are in dire financial straits (3), causing many administrators to make the difficult decision to shift their workforce from salaried clinicians to independent contractors (4). We know little about the consequences of this change, although organizational research from other work settings suggests that it will likely not result in better care. Agency leader and clinician turnovers happen frequently, which affects agency culture, patient engagement, and outcomes.

Agency leaders unanimously tell us, “EBPs are great, but I have to keep the lights on,” prompting us to consider Maslow’s hierarchy of needs as it applies to public mental health and substance use services. Maslow posited that basic needs, such as food and water, must be met before one can achieve higher-level needs. In a similar vein, the agencies serving our most vulnerable citizens are struggling to stay solvent. Implementing EBP is akin to a higher-level need—agency leaders endorse it as a priority, but in the same breath, ask how they can achieve this goal given their uncertain financial landscape and other organizational pressures. We are staunch believers in the value of EBPs; however, we have concluded that EBPs will not solve these financial problems, nor will any of the other many initiatives to improve the quality of care, such as performance contracting, measurement-based care, learning mental health systems, or value-based purchasing. These approaches often layer complex requirements onto already stressed environments. Initiatives to improve service quality shift with the times and with funder priorities, but the importance of adequate funding holds steady. The need to address these fundamental barriers to high-quality, evidence-based mental health and substance use services and the importance of adequate funding is not idiosyncratic to Philadelphia, where we conduct our research. Adequate funding is a key factor in most leading implementation science frameworks (5). National evaluations of EBP implementation and sustainability all have found that inadequate funding, particularly low reimbursement rates, is the single most critical factor in an organization’s decision to adopt, sustain, or discontinue an EBP (6).

At the time of this writing, the COVID-19 pandemic has been raging in the United States over the past 7 months. The suffering, tragic losses, and economic hardships are likely only beginning. The full impacts of the pandemic on individuals who have, or are vulnerable to, mental health and substance use problems are still unknown, but many of these individuals will almost certainly experience ramifications arising from the general medical and psychological impacts of this disease (7). A focus on funding for our community mental health and substance use treatment systems will be crucial in the aftershocks of COVID-19. Our hope is that the new acknowledgment of the importance of mental health in the United States in light of the COVID-19 pandemic may present an opportunity for reforming mental health and substance use policies and for delivering a large infusion of resources. Below we describe three policy directions and provide research recommendations for improving quality of care in community mental health and substance use, beginning with increased funding.