In February 2013, the Department of Health and Human Services announced that because of the Affordable Care Act and full implementation of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA), 62 million Americans would gain access to improved mental health and substance abuse (MHSA) care. Recent analyses, however, find that the two laws are falling short.
The National Alliance on Mental Illness (NAMI) surveyed over 2,700 individuals and families to compare access to MHSA with access to medical treatment. NAMI also contracted with Avalere Health to explore benefits in health insurance exchange (HIX) plans. The Pew Charitable Trusts studied state enforcement of MHPAEA.
NAMI found that many types of policies are exempt from MHPAEA, while Pew discovered that application of parity is thus far spotty. “Only California and New York consistently enforce the rules,” sources said.
NAMI reported additional barriers to MHSA care, some of which also applied to medical treatment, including: high deductibles and copayments; limited information about benefits and provider panels; higher rates of MHSA care authorization denials; and limited access to – and high costs of – psychotropic drugs.
The greatest hardship NAMI identified was respondents’ experience in trying to locate covered MHSA therapists “followed closely by difficulties accessing psychiatrists.”
For all those privately insured (through employers or through individual coverage on- or off-HIXs), 22 percent reported difficulties in finding an in-network therapist. For those in HIX plans, the number rose to 26 percent. Problems securing a prescribing provider were reported by 21 percent and 22 percent, respectively. Similar troubles were reported in accessing inpatient or residential MHSA treatment.
While ascribing part of these hardships to insurers’ new narrow and ultra-narrow provider panels, NAMI also cited “severe shortages in qualified mental health professionals in most parts of the country.”
Such a supply shortfall is no surprise. The Substance Abuse and Mental Health Services Administration (SAMHSA) told Congress in 2013 that “55 percent of U.S. counties, all rural, have no practicing psychiatrists, psychologists, or social workers.” In a 2009 study of adults’ needs, 77 percent of counties were characterized as suffering “a severe shortage of mental health prescribers or non-prescribers,” and over 565 counties “had at least some unmet need for non-prescribers.”
SAMHSA’s report described reasons for this shortage: “As a whole, the workforce is too few, aging into retirement, inadequately reimbursed, inadequately supported and trained, and facing significant changes affecting practice, credentialing, funding, and ability to keep up with changes in practice models.” These factors, along with MHSA providers’ perceptions of stigma, SAMHSA wrote, complicate workforce recruitment and retention.
The New York Times reports that a “deluge” of new Medicaid recipients is already straining community health clinics. “Ms. Hall has had to wait up to seven weeks between appointments with her therapist, Erin Riedel, whose caseload has more than doubled. ‘She’s just awesome,’ Ms. Hall said. ‘But she’s busy, very busy.’ ”
Spreading MHSA resources more sparingly will likely be one adjustment the field takes, especially as treatment is integrated into primary care settings. Physician Michael Miller, medical director of Wisconsin’s Herrington Recovery Center, told the outlet MainStreet that such delivery system reform would create “an inch deep and mile wide approach.” He added that “we do not have the workforce” to provide specialized care to all.
The New York State Psychological Association Health Reform Taskforce wrote about this approach in 2014. Since health reform is increasingly moving toward broader Population Health Management (PHM), “longer, open-ended treatments may not always be the best use of resources.”
Other proposed remedies to this shortfall include expanding professionals’ scope of practice to prescribe, use of telehealth technologies, and even the smart phone. The United Kingdom’s longstanding MHSA demands have led some to advocate use of Internet applications to augment, and reduce the need for, psychological care. A 2013 study found four sessions of cognitive behavioral therapy (CBT), combined with use of the Viary app, were as effective in treating depression as 10 CBT sessions alone.
Some argue that cash-only practices contribute to the scarcity of care opportunities. “Many mental health providers don’t take insurance,” New York City’s NAMI director Wendy Brennan told New York Public Radio. “With greater access to care, at least on paper, that problem is only going to get more severe.”
Recent research in Massachusetts, the birthplace of reform, finds continued barriers to care include “low insurance reimbursement rates and clinicians who increasingly rely on clients paying out of pocket.” MHSA providers “are intentionally taking on more private pay clients” with one in six refusing to accept any insurance. “More than 80 percent say they turn away at least one patient each month.”
Jeffrey Lieberman, former president of the American Psychiatric Association, urges MHSA practitioners to accept insurance reimbursement. “Providers need to change their way of doing business. The government’s done its part, bringing this legislation forward, as painful and difficult a process as it’s been, but we need to do our part, too.”
Professionals hoping to maintain their pre-reform income, he said, “will need to see more patients.”