Meeting mental healthcare demand

Mental healthcare is an essential part of basic healthcare in the United States. Throughout the country, we hear of underfunding or lack of resources in mental healthcare, access to care being extremely limited even in major cities, patients going untreated due to wait times in private sector and federal facilities, and much more.

The practice administrator plays an important role in forming solutions for increasing patient demand.

In 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) was passed, which generally prevents group health plans and health insurances that provide mental health or substance use disorder benefits from imposing less favorable benefits limitations on those benefits than on medical or surgical benefits.¹ The parity act’s passage was impactful as it was intended to ensure that insurance companies provided essentially the same benefits and coverage and out-of-pocket amounts for mental health services as it did for any other medical or surgical benefit.

So, why is there a lack of mental health services, non-covered mental health services, practitioners who do not accept insurance, higher copays, coinsurances, deductibles and plans that exclude mental health or substance abuse diagnosis?

Who can treat mental health?

Mental healthcare and treatment in the United States is provided by many types of licensures. Some of these include physicians, licensed clinical social workers (LCSW), licensed professional counselors (LPC), clinical psychologists (PsyD) and nurse practitioners who have completed a program of psychiatry focus (e.g., CRNP, PMHNP-BC). These licensures, along with others, work in various ways to provide mental healthcare. Most of these disciplines can bill for and receive renumeration for services from insurance payers; however, this varies by state. 

Similarly, the ability to diagnose and prescribe varies by state and licensure board. For example, LCSWs and LPCs in Alabama cannot necessarily diagnose a patient, simply list and focus on their presenting symptoms or use a diagnosis provided by a treating physician. In Alabama, a clinical psychologist cannot prescribe medication. In states such as Illinois, Louisiana and New Mexico, a clinical psychologist can prescribe medication, with appropriate additional training.

One of the barriers to consistent treatment is the varying access to care. As described above, some states and licensure boards provide more access and ability of care options than other states with the same disciplines. This paves the way for insurance coverages and benefits to vary per patient, per state. When insurance companies are based “out of state” or in a state other than the receiving patient’s treatment, variations of care and coverage options are a major obstacle. This can lead to non-covered services, diagnosis, and render to the patient, or treating facility, large out-of-pocket expenses.

Increase in demand: Where are the psychiatrists?

The demand for psychiatrists has risen, yet the number of newly qualified and trained psychiatrists has not met this increase.² One of the shortfalls of psychiatry is that reimbursement often lags for mental health providers, which leads most facilities to struggle to cover professional salaries. Unlike surgical or medical practitioners, psychiatrists do not have many, if any, ancillary or additional services they can perform for which they can bill and receive reimbursement. The professional service, E/M service and sometimes a small billable component of add-on psychotherapy is the extent of reimbursable services for a psychiatrist. They often spend 30 to 45 minutes with each general follow-up patient, and much longer if the patient is in acute crisis or requires a different level of care, such as hospital admission. At most, a psychiatrist might see two patients per hour. In an eight-hour day, that’s 16 patients maximum. 

Since most of these patients need biweekly or monthly follow-up, the ability for a psychiatrist to take on new patients is limited after only a short time. Most new psychiatrists in an outpatient setting can be at a max caseload in the first two to three months of practice. The burnout on physicians who treat mentally ill patients often takes a toll, resulting in a decrease in practice hours and availability or changing of specialty.

Several universities have increased recruitment of future psychiatrists.⁴ As the need for more psychiatrists has become prevalent, universities have improved the quality of their psychiatric clinical rotations, increasing mentoring efforts by providing future psychiatrists the ability to receive hands-on experience with the direct supervision of faculty. Some universities have increased the number of residency slots available for future psychiatrists.⁵ That number has been limited in the past by universities as Medicare froze stipends for residency positions in 1997 and hospitals have taken on the additional training costs themselves.

New models of mental healthcare are being implemented to improve use of psychiatrist time and work-life balance, such as telepsychiatry. Telepsychiatry, providing flexibility to work from home or fill in time slots of patient no-shows in outpatient clinics via videoconferencing, expands the workforce by increasing access. Telepsychiatry also extends treatment in rural areas to clinics where a primary care physician (PCP) has identified a patient who needs evaluation and/or treatment. A PCP office can help render service and arrange transportation to a nearby accepting inpatient facility, if needed, when an evaluation is performed by telepsychiatry.⁶

Steps in a corrective direction

MHPAEA was a huge step in preventing group health plans and health insurance that provide mental health or substance use disorder benefits from imposing less favorable benefits or limitations on those benefits than on medical or surgical benefits. The one underlining factor here — “health insurance that provides mental health or substance use disorder benefits” — became the barrier for equality. Not all plans provide for or allow mental health coverage. Self-funded or small company plans, for example, often exclude certain services.⁷ 

Some health insurance companies that previously provided for mental health benefits devised ways to deliver those benefits through third-party or subsidiary “benefits management” companies, whereby a patient’s mental health benefits through a large commercial payer are sold to and managed by a third-party company. Therefore, reimbursement and fee schedules can and are different from a psychiatrist’s primary care or medical counterpart. Often these companies limit the diagnosis covered, the type of treatment recommended, or have a tiered out-of-pocket fee schedule for the patient. They can also limit the number of approved visits for therapy and medication management.

One example of tiered benefits is when a patient has three initial sessions with a mental health provider, after which time there may not be any further benefits, or those benefits will come with a progressive copay or coinsurance. This wouldn’t be consistent with the medical or surgical benefits of the same plan; however, the plan was outsourced and the idea of parity doesn’t factor in, as the management company or benefits manager has no counterparts to make benefits comparable. This has long been a frustration for psychiatrists as reimbursement is lower and makes the field of psychiatry unattractive. 

The United States is already at crisis level for attracting, training and placing psychiatrists, and financial barriers make it increasingly more difficult.⁸ Many psychiatrists no longer accept federal or private sector insurances and have become “private pay” physicians. This provides a steady stream of income for the physician and no undetermined benefits, lack of benefits or restrictions on amount of time a patient can be seen. Unfortunately, for patients or families who are unable to pay out of pocket, the mentally ill go untreated and often are at the mercy of the endless cycle of inpatient temporary stays, homelessness and crime.

The administrator’s role

Given the financial barriers to treatment, decreasing access to providers for the mentally ill and the rapidly increasing demand for care from patients, the functions of a practice administrator are as follows for improving our national predicament:⁹

• Education: As an administrator, you should seek education about state and federal limitations for your area of practice, whether community agency, inpatient or outpatient. Being knowledgeable about the mental health crisis and availability of resources in your state is essential. Maintain an index for the payers you accept and form relationships with those payer representatives who can serve you in rallying for changes in benefits and fee schedule structures.
• Liaison: An administrator is already a liaison for the physicians and practice. Becoming a liaison for your patient demographic helps you understand the barriers and limitations they face. To be a liaison, it’s important to know your patient demographic and be able to make the right contacts for them. As an administrator, be knowledgeable about the MHPAEA, be able to ask for a payer’s compliancy status and speak fluently about your rights and responsibilities as the providing office. Additionally, know your practitioners’ value to the area served in handling payer contracts. If you are in a rural area, you could negotiate the fee schedule to value the work your practice is doing.
• Support: As an administrator, you need the support of your office and physicians, as well as other administrators in your area of practice. As there are few administrators in mental health/psychiatry, it is vital to form relationships through networking groups such as MGMA. You will also find support on your state level of medical examiners and any other state psychiatric association. By becoming active at the state level, you present your voice and knowledge to them from a “boots on the ground” level.

Mental healthcare is an essential part of one’s basic medical care. In lieu of ignoring or placing a stigma on treatment, acceptance is the first step in addressing the mental health crisis.

Physicians and administrators can be important players in creating environments that encourage open communication and accessibility for resources and care.

It will take a lot of moving pieces for the mental healthcare system in the United States to continue to improve, and psychiatric administrators are vital in improving processes. An educated and devoted voice can and will improve the standards of care access.

By the numbers: who’s suffering?

According to the National Alliance on Mental Health (NAMI), the increase in demand for psychiatric care has risen dramatically in recent years.³

• Approximately 1 U.S. adult in 5 — about 43.8 million or 18.5% of the population — experiences mental illness in a given year. 
• Approximately 1 adult in 25 — 9.8 million or 4% — experiences a serious mental illness in a given year that substantially interferes with or limits one or more major life activities.
• Approximately 1 youth (ages 13 to 18) in 5 (21.4%) experiences a severe mental disorder at some point during his or her life. For children ages 8 to 15, the estimate is 13%.
• 6.9% of adults in the United States — 16 million — had at least one major depressive episode in the past year.
• 18.1% of adults in the United States experienced an anxiety disorder such as posttraumatic stress disorder (PTSD), obsessive-compulsive disorder or specific phobias.
• Among the 20.2 million American adults who experienced a substance use disorder, 50.5% — 10.2 million adults — had a comorbid mental illness.
• Suicide — which is often preceded by a mental illness — is the 10th-leading cause of death in the United States. Access to care and treatment is essential to lowering or improving these numbers.

Editor’s Note

This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification: mgma.com/acmpe.

Notes

1. “The Mental Health Parity and Addiction Equity Act.” The Center for Consumer Information & Insurance Oversight, Centers for Medicare & Medicaid Services. Available from: go.cms.gov/2bzNOF5.
2. Bureau of Labor Statistics. Occupational Outlook Handbook. U.S. Department of Labor. Available from: bls.gov/ooh.
3. “Mental health by the numbers.” National Alliance on Mental Illness. Available from: bit.ly/2HwmXpJ.
4. Rimmer A. “Number of trainees choosing psychiatry is up by a third.” BMJ. 2018; 361:k253.
5. Moran M. “U.S. seniors matching to psychiatry increases for sixth straight year.” Psychiatric News. March 29, 2018. Available from: bit.ly/2SvCDBK.
6. “What is telepsychiatry?” American Psychiatric Association. Available from: bit.ly/2jp4ezy.
7. Center for Consumer Information & Insurance Oversight.
8. Japsen B. “Psychiatrist shortage escalates as U.S. mental health needs grow.” Forbes. Feb. 25, 2018. Available from: bit.ly/2DfKvxo.
9. Greenstein L. “9 ways to fight mental health stigma.” National Alliance on Mental Health. Oct. 11, 2017. Available from: bit.ly/2FXtsQX.