POPULATION HEALTH MANAGEMENT · BEHAVIORAL HEALTH Experts Weigh in on Fixing Broken T
he U.S. mental healthcare system remains plagued by inadequate funding, poor access, and ongo-
ing workforce shortages. Panelists at a recent meeting hosted by the University of Pennsylvania Leonard Davis Institute of Health Economics detailed the depth of the crisis and offered some potential paths to improvement. Prof. Rachel Werner, M.D., Ph.D.,
executive director of the Leonard Davis Institute, asked the panelists to begin by describing some of the main drivers of the crisis in mental healthcare. Jamie Dupuy, M.D., a Boston-based psy-
chiatrist and medical director of clinical services at Optum Behavioral Care, said that people feel that they are up against big systemic problems that are hard to define and therefore hard to know how to manage. “One of the important things in this
crisis is acknowledging that there are so many factors that are well beyond the control of individuals, whether providers or patients, certainly the pandemic and the losses that came with it, but all those other things that existed before, during and after, like poverty, discrimination and systemic racism, health inequities, violence, food insecurity, the impacts of climate change — all of those and many more things are contributing to this gen- eral sense of unease and distress, as well as a real feeling of a lack of agency that we can do something to change it,” Dupuy said. “At the same time, it feels like we’re losing that connection from community support that might help ease the burden. All of that feels bad enough on its own, but we also know that chronic stress biologi- cally can contribute directly to the onset of an exacerbation of mental illness.” “From a provider’s point of view, we’re
well aware of the need that’s out there to help people directly and we feel that responsibility to step up,” Dupuy said. “We’re seeing those same stresses in our
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own lives, and also those same obstacles. There’s this real sense of futility and frustration that’s contributing to burnout and turnover for mental health provid- ers. Many providers are choosing to leave the system altogether, or reducing their challenges by going into something like a private practice.” She said we have systemic factors
leading to a chronically stressed popu- lation and stressed providers, huge changes in how people are perceiving mental health and preferring to access care, and changes in the workforce itself. “All of this in the context of really con- fusing and fragmented pathways to help as well as real barriers to engaging in healthcare of good quality. All of that and probably lots more adds up to what we’re all experiencing as this national mental health crisis.” Werner asked Dupuy what changes
need to happen to address this crisis. “I think we can take substantive
steps toward improving access to help right now,” she responded. “It doesn’t have to be treatment. We can invest in prevention, like mental health educa- tion for young people. We can support integrating behavioral healthcare and screening into medical care settings to support people who are struggling and to find and identify them early enough to intervene. We can invest in community-based organizations to expand the reach of trusted individuals who are not professionals. For those who do ultimately need to end up in special- ized care, we really do have to improve access. We can do that by expanding the mental health workforce. We also need to expand diversity and representation in the workforce because we know this makes differences in quality outcomes for patients. But I think what’s really key is not just adding tons of newly trained people to the already fragmented system as it exists and then quickly losing them
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hcinnovationgroup.com | NOVEMBER/DECEMBER 2022
Mental Healthcare System Panelists at University of Pennsylvania meeting describe need to address workforce, equity, payment issues as well as primary care integration By David Raths
to burnout to private practice or fee for service settings.” Madhuri Jha, L.C.S.W., M.P.H., direc-
tor of the Kennedy Satcher Center for Health Equity at the Morehouse School of Medicine, said we need to increase investment in mental and behavioral healthcare. “A lot of historically invisible communities will access mental health- care from places like their OB/GYN, their primary care provider, or kids being referred from school because their school guidance counselor or their teacher has identified a problem,” she said. “We need to become more culturally centered and culturally empowered in the way that we administer mental and behavioral health services.” Haiden Huskamp, Ph.D., Henry J.
Kaiser Professor of Health Care Policy at Harvard Medical School, noted that the workforce shortage and poor distribution of providers across areas is a big problem in our system now. “Training new per- sonnel up, particularly a diverse group of new personnel to enter the workforce, is really important, but it won’t get us to the numbers we need anytime soon,” she added, so we need to continue to support the sustained implementation of care models that exploit the person- nel resources we have in the system already in the short term — things like collaborative care consultation models, for example. Huskamp noted that a long-term issue
is that traditional fee-for-service payment doesn’t reimburse for all of the compo- nents you need to make those models work and to really integrate mental health treatment into primary care. For example, Medicare introduced a handful of codes for paying for integration of behavioral healthcare. Uptake of those codes hasn’t been huge for a lot of reasons, she said. “One problem we have in our system with the plurality of payers is that, when Medicare does this, it may represent a
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