Among the many challenges inherent to the COVID-19 pandemic is the strain that social isolation is putting on people's mental health. According to Revel Health, more than 42% of Americans are reporting an overall mental health decline since the start of the global crisis, and yet historically, mental health hasn't been a central focus in healthcare. But the pandemic has laid bare some vulnerabilities in the system, and the mental health picture may be changing.
That's good news for those suffering, and a necessary realization for the industry as it eyes a potential wave of patients with mental health needs.
Sara Ratner, senior vice president of government programs and strategic initiatives with Revel Health, said that the number of people attempting suicide is similar to the number who have been diagnosed with COVID-19. It speaks to the need for a more streamlined and accessible mental health system.
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"If we look at mental health the way we were looking at COVID, you can see how big an issue it really is," said Ratner. "When you layer COVID on top of it, it's really exploded. It's created a butterfly effect."
The convergence is magnifying the issue and bringing it to the fore, and highlighting some sober realities. One of those realities: a shortage of mental health providers.
Even before the pandemic, there was a severe shortage of mental health services, in rural areas in particular, and that's due partly to mental health being treated differently from primary care in terms of reimbursement. The Centers for Medicare and Medicaid Services has ensured parity on copayments and cost-sharing for primary care services, but an equivalent framework for mental health treatment has yet to emerge.
Reimbursement is paltry. Mental health providers are paid at close to 5% below the Medicare allowable, according to Revel Health. By comparison, acute and hospital-based procedures are typically paid at 200% the allowable for commercial services – a stark difference.
"Because there aren't many providers, and coverage is poor, a lot of people have to go out of network for a provider," said Ratner. "So that cost is really expensive. People spend more money on mental health providers than on regular acute or primary care. The real concern is that providers will say, 'Forget it, I can't handle this anymore.' They're having to go against their Hippocratic oath to make decisions that are against their training on who lives and who dies. It's causing a massive mental health issue for the provider community."
Since the industry focus has traditionally centered more on acute and primary care, mental health sufferers are often left to wait until they have the cognitive or emotional equivalent of a heart attack before being treated. The prescription for the industry is to shift the emphasis to preventative mental healthcare so patients don't find themselves in dire situations. In that way, health plans can have a role in shaping the discussion, said Ratner – n part by acknowledging and highlighting the reality that mental health is the top medical condition that results in disability.
Health plans can also play a role in implementing mental health "extenders" such as health coaches, who work tactically to help a person through a difficult situation. It's not a long-term solution, but at the very least would provide a stop-gap of sorts.
Ratner said that, while a patient with physical issues is typically led through the healthcare system in a guided way, that has yet to happen in the realm of mental health.
"The system is set up to hold my hand," she said. "It gets me into a doctor immediately, gets me into surgery, and all of this is coordinated around me. I don't have to do a lot. These are high-margin services. In the mental health space, we leave people to their own measure to find a provider and find out if they're in the right network. We put them into the abyss of the healthcare system. If we hold their hand in a similar way to someone who's a surgery patient or someone who needs more acute services, I think we'd have a lot more success. We need to be more mindful and intentional about where the ball's being dropped."
There has been one silver lining during the pandemic: telehealth. While devices that monitor vitals such as heart rate and blood pressure are making virtual primary care visits viable, mental health is already a strong candidate for telehealth, since treatment tends to be largely conversation-based. And with CMS waivers that have allowed telehealth to be reimbursed at the same rate as in-person visits, there's more of an incentive for providers to implement the technology. The waivers are temporary, but the pandemic could prompt more lasting change through legislative action.
"CMS and private payers are reimbursing for this, whereas in the past many of them did not, or else it was a fraction of what somebody would get in person," said Ratner. "Insurers are now realizing you need to reimburse at the same rate.
"We'll see access become a little bit less of an issue," she said. "There's still an issue with the number of providers who are in-network, and reimbursement rates, and the time it takes to get an appointment. Plus, it's such a personal relationship, it needs to be the right fit. But I don't think we're going back."