To Address Mental Health Care Inequities, Look Beyond Community-Based Programs

If we learned one lesson from the past year’s events, it is that life is indeed fragile, even more so for those suffering from mental illness. The confluence of events in 2020 — the pandemic, the growing awareness of racial injustices and escalating socio-political tensions — have brought this inequity to the public consciousness for all to see.

The fact is mental health care has long been anything but equitable. Case in point:

• 2019 data compiled by the Medicaid and CHIP Payment and Access Commission found that psychiatrists accept new Medicaid patients at a much lower rate (35%) than Medicare (62.1%) or private insurance (62.2%).
• In a 2016 study, a white middle-class woman seeking an appointment with a therapist received a call back from a therapist 20% of the time while a Black working-class male received a call back approximately 1% of the time.
• Despite data showing substantial increases in mental health issues last year, use of mental health services actually declined dramatically in 2020 among people covered by Medicaid and the Children’s Health Insurance Program (CHIP). Despite their great need, large numbers of adults and children were unable to find or use mental health services during the pandemic.

Given the marked inadequacy of current networks of mental health therapists and psychiatrists, it is unlikely they will meet patients’ needs without substantial contributions from virtual-first and digitally-enabled care. There is now a compelling opportunity to do something truly meaningful about the inequities and injustices in mental health. The health care industry has a unique chance to make systemic changes that will bring quality, accessible mental health care to those most at risk and most underserved. But such changes are unlikely to happen unless both the federal Centers for Medicare & Medicaid Services and state Medicaid officials look beyond local community-based programs to resolve the limits of geography, transportation, workforce, and multiple languages and cultures.

The good news is, we already know what less resource-intensive care looks like. Consider new modalities such as the integration of virtual cognitive behavioral therapy and behavioral health coaching — which counsels patients on self-management, stress and coping strategies. Efforts such these are already rapidly expanding the numbers of beneficiaries who can be served.

Unfortunately, today many communities and individuals do not have access to telehealth. More than 25% of Medicare beneficiaries do not have broadband internet service, can’t afford data charges, don’t have the necessary devices or haven’t learned to use them. Digital access issues are even more acute among populations 85 or older, widowed, with a high school education or less, Black or Hispanic, on Medicaid, or living with a disability.  

A further challenge is historically inadequate federal and state coverage and reimbursement for telehealth services for underserved communities, particularly in Medicaid. Prior to COVID-19, federal reimbursement for telehealth was limited to rural locations, by type of provider and other constraints. Under the COVID-19 public health emergency, many of these restrictions were temporarily modified or removed. Restrictions and reimbursement policies have continued to vary greatly across state Medicaid programs: About half of the states have let their emergency orders expire, while some states have markedly expanded Medicaid coverage and reimbursement. These rapidly evolving state policies are tracked closely by the Center for Connected Health.

I believe the case for digitizing mental health care services is clear. Other segments of business and society, including commerce, transportation and financial services have done just that decades ago. Virtual care, I believe, will lead to significant gains in access, cost and improved patient experience. 

Access

In both urban and rural locations, the need for transportation and the lack of qualified providers are barriers to care. Moreover, there is a growing recognition of the need for providers capable of providing culturally competent care, and the staffing complexities required for appropriate patient matching. These underscore the need for virtually distributed capabilities. Virtual, on-demand mental health care can help meet these needs and increase access to care. By combining mindfulness, meditation, wellness and behavioral health coaching with options for video-based therapy and psychiatry when necessary, these models can effectively serve as many as 80% of people with mild and moderate mental health conditions, who do not need clinical support from therapy or psychiatry.

Cost

Virtual mental health can also reduce the cost of care. While the cost of live streaming (synchronous) care may approximate that of in-person therapy, combining  much lower-cost asynchronous care with the synchronous can make virtual mental health care more affordable than in-person — particularly so when coaching and computerized cognitive behavioral therapy are incorporated. These cost differentials are especially important for patients who must pay for mental health services entirely out-of-pocket, because approximately 56% of psychiatrists do not accept insurance. Recent data confirms, for example, that Black Medicare beneficiaries are more likely to have cost problems in accessing care. With the markedly lower cost of digital coaching and related forms of asynchronous care, plans and providers can rapidly narrow these gaps.

Improved Patient Experience

Virtual care is proving to be acceptable, even preferable, for many patients. Large numbers of behavioral health patients were first introduced to virtual care during the COVID-19 pandemic. This experience has been positive enough to spur a widespread acceptance of the practice, suggesting that improvements in access and costs may be achieved for some patients without sacrificing patient trust and confidence.

Next Steps And Signs Of Progress

To advance the adoption of these strategies, regulators should recognize the value of virtual mental health care and support enhanced access for Medicaid members and other underserved groups. In a first step, CMS proposed in July to loosen long-standing restrictions on behavioral telehealth services. In addition, they should support reimbursement for preventative, on-demand mental health care services.

The time has also come to let telehealth providers deliver services across state lines. As emergency telehealth expansions have begun to expire, one of the most pressing policy areas has become licensing and the state flexibilities that temporarily allow out-of-state providers to treat patients via telehealth during the pandemic regardless of location. A recent Kaiser Health News article reported that, as emergency orders wind down, licensing is becoming a major barrier to care as providers and patients now face cancellations. In Maryland, Johns Hopkins Medicine – which hosted more than a million telehealth visits during the pandemic, 10% serving out-of-state patients — had to cancel more than 1,000 appointments with Virginians due to the state’s expiring orders that had allowed interstate telehealth.

Addressing these licensure issues will also allow state policymakers to tackle reimbursement in earnest. Some states made progress during the pandemic; for example, New York State issued an executive order in March of 2020 providing for New York State Medicaid to reimburse for telephonic assessment, monitoring, evaluation and management services in cases where face-to-face visits may not be recommended. This and other similar emergency orders should be extended or made permanent.

Moreover, AmeriHealth Caritas District of Columbia (DC) recently announced that it is providing a free suite of virtual mental health services from the on-demand mental health company Ginger (I am a member of Ginger’s board) to 110,000 AmeriHealth Caritas DC Medicaid plan enrollees. 

But isn’t the move to digital mental health only serving to further grow the digital divide? The answer is no, it need not. Federal policy is intensifying its commitment to broadband access. The current administration’s national infrastructure plan will ensure massive expansions in broadband access to urban and suburban as well as rural communities.

While additional efforts will be needed to assure access to devices such as smartphones, tablets, and wireless personal health monitors, to pay data charges, support digital literacy, and to establish virtual and physical community programs to support adoption, large proportions of Medicaid populations have a smartphone or digital device — more than 86%, according to a Deloitte survey. For the approximately 5-15% of the Medicaid population who need assistance with these technologies, innovative health plans are developing ways to identify them and provide help with access to hardware, bandwidth and digital literacy.

In addition, acceptance rates for telehealth are high among Medicaid patients.

Concerns about fraud and abuse have been a longstanding argument against the viability of digital health. But traditional mental health counseling, whose results are also extremely difficult to measure, are just as vulnerable to those claims. In contrast, digital mental health programs could provide for greater documentation and measurable clinical evaluations of patient progress. 

Fear and mistrust of traditional health care institutions and practitioners among marginalized communities can be extreme. Community programs have limited resources. Qualified therapists, if they can be found, often refuse to accept Medicaid. Digital solutions are an obvious and perhaps the only real answer to begin to address the scale of the problem.           

Our growing awareness of the mental health challenges faced by so many underserved populations in this unique moment is an opportunity to make lasting, meaningful change. The time is now for health plans, providers, and regulators to step up and make the investments necessary to address the mental health inequities that are having such a tragic impact on the most vulnerable among us.