Access to care matters: The need to better redistribute mental health services

Benjamin F. Miller, PsyD 
Taylor Koekkoek
Well Being Trust

Getting access to health care is challenging even in the best of times. While there have been substantial advancements in health coverage, access continues to be a highly critical issue for anyone seeking help for their health. What is access? How do we define it and how do we measure it?

To start, let’s define access. From one source: “Access is a complex concept and at least four aspects require evaluation. If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may ‘have access’ to services.” In addition to the adequacy of supply, true access to mental health services also depends upon the affordability, the physical accessibility, and the social acceptability of those services.

So yes, there are multiple factors that go into access. However, when we need services we are not likely to consider all those factors (we are seeking help, after all)!

In a now dated, but still highly relevant article, the Institute of Medicine (now called the National Academy of Medicine) Committee on Monitoring Access to Personal Health Care Services, made sure that we knew access was only one piece to a much larger puzzle.

“Access to services is not an end in and of itself. The purpose of gaining access to the personal health care system is to achieve one or more of an array of possible health outcomes — not only avoidance of untimely death and relief of acute symptoms but also maintenance of long-term functioning and relief from anxiety about the meaning of symptoms.”

We could spend a great deal of time talking about access in general; however, it is important to understand that not all access is created equally. Take for example access for mental health services. There may be no more prominent example of the challenges of access than with mental health.

Consider recent evidence, which shows some of the barriers around receiving care for individuals who have both a mental health and substance use need. As the authors conclude, “low perceived need and barriers to care access for both disorders likely contribute to low treatment rates of co-occurring disorders.”

Or what about the 6,600 primary care physicians who were surveyed and found that mental health was the most difficult specialty in health care to get access to? This is despite the fact that we already know that a great deal of mental health is seen only in the primary care space.

More than half of all adults in the United States living with a mental health need received no treatment in the last year. And of the adults that sought treatment, one out of five reported that they were unable to get the care they needed. The numbers are even worse for young people; even among youth who suffered from severe depression, more than 60% received no treatment whatsoever. That means that out of the 1.8 million teenagers who suffer a severe major depressive episode every year, only four out of ten receive treatment.

Is this fundamentally an access issue or is this an identification issue? Or perhaps this is both. Regardless, people — especially vulnerable populations — who would benefit from mental health care frequently don’t get it. They are hindered for many reasons including a) shortages and uneven distribution of clinicians; b) health insurance barriers and outdated formulas for payment for mental health treatment; c) obstacles to the seamless sharing of health information among clinicians; and d) continuing social stigma and cultural disapproval of people who seek mental health services.

As a result, people with mental health needs go without. In some cases, those individuals with severe mental health issues become sicker and die younger than others because of complicated chronic physical health problems. Until everyone who needs mental health treatment can access it easily, we will not be able to make the changes necessary to improve the nation’s overall well-being.

To address this country’s mental health need, we must work to make sure that people who need mental health treatment can get timely and seamless access to care. Because health care is fragmented, we must break down the barriers between mental health, medical, and community so that the person receives comprehensive, whole-person care in whatever setting they need. To do this will require our country to reform and integrate the way it delivers and pays for mental health services.

This is a fundamental shift from thinking of mental health only as a specialty condition requiring a specialty mental health setting to seeing mental health as something that should be identified and treated across our communities.

So what’s the goal? We need to be able to activate multiple points of entry for mental health and substance use services, under the principle “There’s no wrong door.” This is truly not such a foreign concept, but one that requires us to reconsider the role of mental health in only traditional mental health settings.

Imagine a world where any person with a mental health need is able to find treatment when and where he or she chooses, and to be matched with the right person or team at the right time. What would happen if we had a redistribution of our current mental health workforce and placed then in all the places we know people show up with mental health need?

And if you wonder about the importance of better addressing access, consider that the largest payer for mental health services, Medicaid, is currently being debated more now than it has in quite some time. Let’s apply a no wrong door framework to our states and their work on better addressing mental health.

Well Being Trust regards the Medicaid system as a good place to begin developing these approaches because it is the single largest payer for mental health services in the United States. By broadening and deepening resources from public providers, Medicaid agencies and other state programs, we can have the biggest impact in improving the way we treat mental health in America.

To this end, here are a few examples of the types of items that could be considered when we begin to look to improve access for mental health:

Prevention — Because mental health often goes unrecognized and untreated, individuals with need often do not improve and, as a consequence, are costlier to treat later. To stop this cycle, we must break down the silos that separate the way we treat, finance, and regulate physical health and mental health to focus directly on prevention. How can we better go “upstream” into the settings people first present with some mental health need?

Peer support — Research shows peer support can aid mental health and substance use recovery and maintenance, but it is not uniformly embraced by current provider and payment systems. We aim to standardize peer curriculum and reform the payment system to support the delivery of peer support services. This, in essence, allows for us to have more workforce out there distributed throughout the community.

Payment reform — Fragmented payment leads to fragmented delivery. Having more advanced alternative payment models that support teams over individuals could go a long way in allowing more timely access to mental health services in non-traditional mental health settings (e.g. primary care). We want a system that rewards quality and outcomes and is not dependent on just a single provider to take care of a person’s mental health need; this is about the person and having a team that can be paid to help keep them well in whatever setting is most appropriate. .

Integrated treatment — Because many people with mental health needs encounter the health care system through settings like primary care, the primary care team must do a better job of identifying and treating the whole person, recognizing when a patient would benefit from team-based mental health treatment and making appropriate referrals when necessary.

Isn’t it time we were more responsive to our communities’ needs? Let’s create a more user-friendly health system that takes into account the person who is seeking care. Let’s increase our access by being in the places people seek help for care — not just in our clinics, but in our communities.