Battered by two-plus years of Covid-19, soaring inflation, general financial worries and existential dread tied to Russia’s invasion of Ukraine, Americans are grappling with a dramatic rise in stress and anxiety. Combined with the ongoing opioid crisis, today’s pervasive mental health problems underscore the need to dramatically reimagine America’s fragmented, often-difficult-to-access behavioral health care system.
Overcoming major systemic deficiencies in pursuit of behavioral healthcare
Under the best of circumstances, behavioral health needs often go unmet. Just 50% of Americans who experience behavioral health concerns receive treatment and less than 20% of those with substance use disorders (SUD) get the care they need. Mental health problems and substance use frequently are intertwined: Studies show about half of those who grapple with mental illness face a SUD at some point, and vice versa.
There is good news, though. Population health strategies hold the promise of expanding behavioral care access for those who don’t receive care and improving efficacy for those who do. Data-driven frameworks that support clinical decision-making can improve telehealth and clinician consults. Better integration with primary care can increase risk screening, accelerate interventions, and enhance wellness.
Payer strategies consequently are increasingly focused on ways to more effectively blend medical and behavioral care in pursuit of greater continuity, improved patient experience, better outcomes, fewer emergency room visits, and lower costs.
The pandemic’s psychological toll
It’s no secret the pandemic and related economic and psychological hardships has triggered a substantial jump in mental health problems. Between January 2019 and January 2021, the percentage of U.S. adults reporting symptoms of anxiety and/or depressive disorders spiked from 11% to 41%.
Pandemic related-depression impacted younger Americans particularly hard, with 10.6% of youth, or 2.5 million people, experiencing severe depression in 2021, though fewer than 1 in 3 received consistent mental health care. Similarly hard hit have been women with children, Black and Latino adults and essential workers.
Global crises trigger new fears
Now new financial worries and the specter of war have reenergized America’s epidemic of angst. A March 2022 poll conducted by the American Psychological Association found that stress and anxiety among Americans have reached “alarming levels” due to soaring prices, supply chain worries, the invasion of Ukraine, and fears tied to potential retaliation by Russia, including cyberattacks and the threat of nuclear war.
Meanwhile, the opioid epidemic—supercharged by the proliferation of fentanyl—continues to ravage lives and communities nationwide. More than 100,000 overdose deaths occurred in the 12 months ending in April 2021, a 28.5% jump from the year-earlier period and the first time in the decades-long crisis that the number of lives lost exceeded 100,000 annually. More than 60% of the deaths were tied to synthetic drugs like fentanyl, which are typically 50-to-100 times more powerful than traditional prescription opioids.
Barriers to behavioral health care – a population health issue
While current circumstances have placed enormous strain on behavioral health resources, accessing behavioral health in the U.S. has long been hampered by structural problems that pre-date the opioid crisis or pandemic. The most significant of these include:
- Financial hurdles: 11% of Americans with mental illness are uninsured, and 8% of children have insurance that does not cover mental health services. For those with coverage, care is often costly: behavioral health care was five times more likely to be out-of-network than medical/surgical services in 2017, an 85% increase from 2012.
- Caregiver shortage and ignorance of available resources: A recent study found that more than one-third of Americans, about 122 million people, live in areas lacking mental health professionals. The report estimated that the country needs an additional 6,400 mental health providers to close these gaps. Even among those with access to providers, uncertainty about how and where to access mental health care is widespread.
- Lack of minority behavioral health practitioners: Just 2% of America’s approximately 41,000 psychiatrists and 4% of its psychologists are Black people. This disparity can make it more difficult for Black Americans to find a practitioner they’re comfortable with and trust. What’s more, White mental health professionals frequently misdiagnose Black Americans or don’t provide them with the same level of care afforded to White clients.
- Rigid, classification-driven diagnoses: The propensity to diagnose patients with specific psychological disorders based on the alignment of symptoms and fixed disease classification systems leaves little room for treatment flexibility. It also often ignores the needs of patients whose problems don’t rise to the diagnostic threshold. This later point greatly reduces opportunities for prevention and early intervention.
- Stigma and lack of knowledge: Long-standing social stigma and lack of knowledge surrounding both mental health and substance use issues foster a widespread ambivalence when it comes to seeking care. One survey found that 52% of respondents adopted a “grin and bear it” attitude when feeling depressed or mentally unstable and reported that fear of stigma was a deterrent to seeking care.
The promise of population health for behavioral health needs
Population health approaches identified by the Centers for Disease Control (CDC) can help mitigate some of these structural challenges by:
- Reducing the reliance on one-on-one care provided by specialists
- Easing the concurrent dependence on traditional disorder diagnoses
- Accelerating integration of behavioral health services with primary care
- Making care more accessible at work, school, and in the community
The American Psychological Association has developed a population health framework with underlying principles to support improvements in behavioral health access, prevention, and care. These principles include:
- Use data and the best available science to inform policies, programs and resources
- Prevent when possible and otherwise intervene at the earliest possible moment
- Strategize, analyze, and intervene at both the individual and community/population levels
- Reach broad and diverse audiences through partnerships and alliances
- Utilize a developmental approach (e.g. age-appropriate interventions)
- Consider the whole person and the structural/systemic factors impacting individual behavior
- Be culturally sensitive while also thinking transculturally
- Recognize that inherent in every community is the wisdom to solve its own problems
- Champion equity by addressing systemic issues, such as social determinants of health
“A population health approach has, as its goal, optimal behavioral health and wellness across the continuum of need,” according to the CDC. “This approach addresses the need to `get upstream’ as it promotes intervention before individuals need clinical services. It also shifts the goal of practitioners to behavioral wellness and not just the absence of psychopathology.”
Treat the whole patient
Integrating behavioral and physical healthcare is well supported. "For organizations that manage or deliver health care to individuals with behavioral health conditions, who frequently have co-occurring conditions and complex needs, implementing a PHM framework and strategy can lower costs and improve outcomes," according to literature published by the National Committee for Quality Assurance in the Population Health Management Resource Guide for Behavioral Health.
New population health model for additional behavioral health treatment
In California, the non-profit CA Bridge is pursuing an innovative, population health-based approach to help address the state’s burgeoning opioid crisis. The organization promotes rapid, low-barrier access in hospital emergency rooms to an FDA-approved medication that blocks opioid cravings and withdrawal symptoms while helping prevent relapse and overdose.
When the drug, buprenorphine, is administered in the emergency room and continued via primary care, patients have a 74% chance of remaining in treatment after two months, versus about 50% who receive traditional psychosocial interventions. The approach accelerates intervention, improves outcomes, and reduces the stigma associated with traditional methadone treatment. In so doing, it can reduce overdose deaths and help bring down the total cost of care associated with opioid disorders.
Payers extending member, provider outreach
Payers, for their part, are pursuing new approaches to more effectively meet behavioral health needs:
Blue Cross & Blue Shield of Rhode Island is working to reduce behavioral health hospital readmissions with a program that offers members counseling, medication management, and case management support on discharge.
SCAN Health Plan, one of the nation’s largest non-profit Medicare Advantage plans, in 2021 developed a program to help seniors overcome the loneliness and isolation associated with the pandemic. The initiative offered members classes, both in-person and virtual, on topics of shared interest, as well as regular telephone outreach by both employees and peer advocates.
Aetna launched an educational initiative designed to help its provider partners improve their knowledge and training on range behavioral healthcare issues, with an emphasis on suicide prevention. More than 280,000 providers can access evidence-based suicide prevention tools and resources at no cost.
Harnessing population health to address the behavioral health crisis
The CDC acknowledges that major challenges surround the implementation of population health models for behavioral care. These include re-training the workforce to adopt a population health perspective, developing new interventions, building the infrastructure to meet a wider range of needs, and developing the appropriate fiscal and regulatory framework.
Nonetheless, CDC says, using a population approach to behavioral health “holds much promise. It will allow us to address many long-standing issues that affect our current behavioral system by placing a greater emphasis on prevention and early intervention and by reaching underserved groups.”
Would you like to learn more? Contact RTI Health Advance for help developing a population health-based approach to support the behavioral health needs of your members.