Obamacare and Mental Health: Good News and Bad News

An article was published by US News and World Report yesterday, and it has mixed news about the Affordable Care Act and mental health treatment: the number of people with mental health conditions who are uninsured decreased in 2015, but the number of people who received mental health services using insurance plans obtained on the exchanges also decreased, when it should have increased. That’s very concerning, since it’s been shown consistently over time that “talk therapy” is the most cost-effective way to help people with disorders like depression and anxiety to improve their well-being and functioning.

I can answer the questions in the article about why, despite more people being insured, fewer are getting mental health care. I would love to provide mental health services to people with insurance plans from the exchanges, but the people who could use good private mental health care (especially for prevention or early intervention) don’t have the kind of access that people with employer-sponsored plans have. This is largely the fault of the insurance industry, which has done several things to make it harder:

1.) They carved out separate provider networks that are very limited. An example would be Aetna Better Health, which uses providers affiliated with large clinics, hospitals, and community agencies. So the patients end up on waiting lists with all the other people that these entities serve, including sliding scale and Medicaid patients.

2.) They force separate provider agreements onto their regular providers to save money, so that the providers get paid less for providing the same services, as with the new “Blue Choice” plans. If the patients go to a regular network provider they end up with a higher copayment. Not many providers are agreeing to these new “third tier” rates, which are about 15-20% lower than the regular contracted rates.

Of course, a big reason is built into the ACA plans themselves, in the form of high deductibles, even in the “silver” level plans. When it comes down to it, these plans are only slightly better than the old individual plans that people could buy directly from the insurance companies. They ‘re just a bit cheaper and don’t shut out those with pre-existing conditions.

I think the goals of “Obamacare” were and are admirable, but the big mistake (for mental health, at least) was that the people who designed it were cajoled into doing it in a way that lets the insurance companies call too many of the shots. That was a political decision, not a public health decision, and see how well that worked out… Republicans still called it “communism” and voted 70 some times to repeal it and deprive people of even the coverage that they now had.

In theory, single payer could work, but (a) the political climate we’re in currently could never support it, and  (b) if it were contracted out the same way Medicare is now to private companies (like National Government Services), we would need to be sure that these organizations did not create additional obstacles to access.

I think I have a fairly good sense of the best ways to provide services in the behavioral health area, having worked in an organization that offered integrated managed behavioral health benefits to employers. The EAP core model of offering free assessment, referral, and short-term problem-resolution, paired with a clinically savvy managed behavioral health plan, offers the best “bang for the buck” when it comes to serving a wide range of people with a wide range of problems, including mental health and substance use disorders, as well as everyday stresses and coping difficulties that don’t rise to the level of a mental health disorder.

My solution would be to amend Obamacare to allow for up to six free visits per year with any mental health provider who’s in the regular network, at regular network rates, without a copayment or deductible, and without the need to report a diagnosis. Then, for people who need more, there could be a managed mental health plan that would kick in and allow for visits up to 52 per year for psychotherapy (subject to case review for medical necessity every 20 sessions or so) and 12 visits per year for medication management (without any case management), using psychiatrists who are in network, with a modest copay. This would allow experienced and capable providers to assist people in preventing bigger problems, by making access to short-term problem resolution easy and free, while allowing people to receive longer-term services (and keeping some of that famous “skin in the game” to satisfy those who are offended by the idea of “free stuff”) for people with more serious issues, without bankrupting them. In addition to amending the ACA, we may need to amend the Mental Health and Substance Abuse Parity Act to allow for a different (though better) level of benefits for behavioral health.

Research has consistently shown that many people get what they need from a few sessions of mental health counseling (in fact, the modal number of sessions is about five). We also have models already in place (such as S-BIRT, for Screening, Brief Intervention, and Referral to Treatment) that could help create a successful integrated model that incorporates the ACA’s notion of the “warm hand-off” between primary care and behavioral health. These techniques can be used by mental health providers as well as primary care doctors and other health professionals.

Of course, this kind of plan would require some selling to providers (as well as insurance companies), which would include educating clinicians about the assessemt, referral and short-term problem resolution model. Another part of this task would be convincing behavioral health providers to overcome their tendency to see managed care as the enemy. By reserving managed care for those with more severe problems, this might be easier to do.

It would be very interesting to see some research by those in the behavioral health field on this type of a hybrid/integrated model, with a measure of outcomes to assess how well people are helped to avoid disabling or severe mental health conditions by the use of an EAP-like model.

 
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