With May 31 marking the end of Mental Health Awareness Month, it is imperative to reflect on the state of mental health care in this country beyond just last month. Mental health in the United States is the midst of a crisis, and the recent pandemic has only exacerbated the situation.
According to Czeisler et al,1 40.9% of Americans reported having a mental health or behavioral health condition as of June 2020, which went up from 20.6% in 20192 and 17.7% in 2008.2 In a comparison with 2019, Leeb et al3 reported that hospital emergency departments treated 14% more cases of drug overdose, 6% more patients after a suicidal attempt, 24% more children, and 31% more adolescents experiencing a mental health crisis in 2020.
Anxiety and depression spiked drastically in 2020, nearly three times and four times higher respectively, than 2019. The suicide hotline run by Substance Abuse and Mental Health Services Administration received 891% more calls in March 2020 compared to March 2019.4
The root cause of the mental health crisis in this country lies deep within our health care infrastructure. Even though mental health illnesses are exceptionally disabling, many people cannot access health care or choose to opt out because of incremental costs. Millions of people who are uninsured or underinsured in this country shed light to the fact that health care is simply not affordable.5,6
The national average for a premium benchmark marketplace plan in 2021 is $452 per month, which increased from $273 in 2014 (66% increase).7 According to the National Alliance on Mental Illness,8 60% of youth with depression did not receive any mental health treatment in 2017-2018.
People suffering from mental health illness are less likely to have health insurance than those without mental health problems.9 Pearson et al10 found that the odds of having health insurance were 40% lower for people with serious psychological distress (SPD) than those without. Even though the Affordable Care Act has improved access to health care, similar findings were reported by Novak et al.11
People with SPD from low-income families were more likely to be uninsured, and to report delaying, foregoing, or being unable to afford mental health compared to their non-low-income peers with SPD.
Commercial insurance companies have their own mechanisms in place to deprive mental health patients of the care they desperately need. The continued trend toward increased cost sharing among the insured with mental disorders has led to substantial out-of-pocket expenditures that in many cases exceed 20% of family income annually.12
Commercial insurance plans are also notorious for paying mental health providers far less than other health care providers. In 2017, commercial preferred provider organizations paid in-network mental health providers 24% less for office visits than they paid other primary providers.
Payment disparities force mental health providers to withdraw from insurance contracts. Only 62% of psychiatrists accepted new, privately insured patients compared to 90% of other physicians participating in one or several insurance networks.14,15
Mental health provider shortage exists throughout the country. Outside of the core metropolitan areas, 80% of US counties have no psychiatrist, 61% have no psychologists, and 91% have no psychiatric nurse.16
This means patients with mental health disorders are encountering more out-of-network (OON) providers in inpatient (15.6 times higher) and outpatient (5.7 times higher) settings compared to patients with other chronic disease states (ie, diabetes and congestive heart failure).13,17
How does it translate to health care dollars? Patients with mental health conditions are spending $341 more for OON care compared to those with diabetes. Individuals with drug use disorders and alcohol use disorders had much higher cost-sharing payments for OON providers ($1242 and $1138) when compared to individuals with diabetes.
Furthermore, even if you happen to live in a metropolitan area with in-network mental health providers, it can be excruciatingly difficult to get an appointment in a timely manner. In a 2015 study by Malowney et al,18 investigators posed as patients attempted to schedule appointments with psychiatrists (N=360) within the network of the largest commercial insurance in three major cities (Boston, Houston, Chicago).
Researchers were successful only about 26% of the time in making an appointment with a provider in the network directory. In a 2017 study of providers listed as in-network with Blue Cross Blue Shield, Cama et al19 were able to secure appointments with only 17% of the child psychiatrists (out of 312) and 40% of pediatricians (out of 601).
Incorrect provider lists (commonly referred to as ghost/phantom network) and/or office phone numbers are often cited as the most common reasons for failure to secure an appointment.20 Commercial insurance companies have other tricks up their sleeves to restrict, limit, or simply deny crucial care to patients with mental illnesses.
A 2015 study showed that insurance claims regarding mental conditions were deemed “not medically necessary” twice as much as other medical conditions.21 Commercial plans tend to follow such stringent guidelines to deny necessary mental health and substance use treatment that courts have routinely forced insurance companies to reprocess previously denied claims.22
The verdict from multiple court cases have highlighted the fact that insurance companies are denying medically necessary coverage because of financial reasons alone.
Mental health parity is long overdue in this country and the implementation of a single-payer system (SPS) is the only way to achieve it.Apart from eliminating corporate greed and administrative waste, SPS will expand people’s access to health care and most importantly improve patient outcomes.
This is evident from a study conducted by the University of Minnesota. Publicly insured patients had greater access to care than those who were privately insured.23
SPS will provide the ultimate freedom to patients with mental illnesses to pick their own providers as every provider will be in-network. This means patients may have access to providers other than psychiatrists (ie, clinical social workers, licensed mental health counselors, psychologists, licensed marriage and family therapists).
If SPS is implemented on a fee-for-service principle, pharmacists may qualify for reimbursements based on clinical services provided. Pharmacy does have its own set of challenges when it comes to mental health care.
As pharmacy professionals battle with their own challenges regarding mental health, the optimal role of psychiatric pharmacists is yet to be defined.24-26 Pharmacy professionals need to actively work toward improving health care outcomes for their patients with mental illnesses.
This means engaging in health care legislation that constructs the SPS and ensures patients have access to health care. Without the voice of pharmacy, mental health parity will continue to remain a distant dream.
1. Czeisler MÉ, Lane RI, Wiley JF, Czeisler CA, Howard ME, Rajaratnam SMW. Follow-up Survey of US Adult Reports of Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, September 2020. JAMA Netw Open. 2021;4(2):e2037665. doi:10.1001/jamanetworkopen.2020.37665
2. Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf
3.Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental Health-Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic - United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(45):1675-1680. Published 2020 Nov 13. doi:10.15585/mmwr.mm6945a3
4.Levine, M. (2020, April 7). ABC News. Calls to US helpline jump 891%, as White House is warned of a mental health crisis. https://abcnews.go.com/Politics/calls-us-helpline-jump-891-white-house-warned/story?id=70010113.
5. United States Census Bureau. Annual estimates of the resident population for selected age groups by sex for the United States, States, Counties, and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2017 2017 population estimates. Feb 18, 2018. https://factfinder.census.gov/bkmk/table/1·0/en/PEP/2017/ PEPAGESEX (accessed Jan 4, 2020).
6. Collins SR, Gunja MZ, Doty MM. How well does health coverage protect consumers from costs? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016. Oct 11, 2017 http://www.commonwealthfund.org/~/media/files/publications/ issue-brief/2017/oct/collins_underinsured_biennial_ib.pdf (accessed jan 4, 2020).
7. KaiserFamilyFoundation. Marketplace Average Benchmark Premiums | KFF.
https://www.kff.org/health-reform/state-indicator/marketplace-average-benchmark-premiums currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%7D. Accessed April 28, 2021
8. Mental Health By the Numbers. National Alliance on Mental Illness. (2021, March 21). https://www.nami.org/mhstats.
9. Garfield RL, Zuvekas SH, Lave JR, Donohue JM. The impact of national health care reform on adults with severe mental disorders. Am J Psychiatry. 2011;168(5):486-494. doi:10.1176/appi.ajp.2010.10060792
10. Pearson WS, Dhingra SS, Strine TW, Liang YW, Berry JT, Mokdad AH. Relationships between serious psychological distress and the use of health services in the United States: findings from the Behavioral Risk Factor Surveillance System. Int J Public Health. 2009;54(Suppl 1):S23–9.
11. Novak P, Anderson AC, Chen J. Changes in Health Insurance Coverage and Barriers to Health Care Access Among Individuals with Serious Psychological Distress Following the Affordable Care Act. Adm Policy Ment Health. 2018;45(6):924-932. doi:10.1007/s10488-018-0875-9
12. Cunningham, PJ. Chronic burdens: the persistently high out-of-pocket health care expenses faced by many Americans with chronic conditions [Internet]. New York (NY): Commonwealth Fund; 2009 Jul.
13. PR Newswire. Milliman Report: Analyzing Disparities in Network Use and Provider Reimbursement Rates. PR Newswire US. November 30, 2017. Accessed May 16, 2021. https://search-ebscohost-com.libnet.swosu.edu/login.aspx?direct=true&db=n5h&AN=201711301306PR.NEWS.USPR.DC58702&site=ehost-live score=site
14. Holgash K, Heberlein M Physician acceptance of new Medicaid patients: what matters and what doesn’t. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20190401.678690/full/. Published April 10, 2019. Accessed May 7, 2019.
15. Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. JAMA Psychiatry. 2014;71(2):176–181. doi:10.1001/jamapsychiatry.2013.2862
16. Andrilla CHA, Patterson DG, Garberson LA, Coulthard C, Larson EH. Geographic Variation in the Supply of Selected Behavioral Health Providers. Am J Prev Med. 2018;54(6 Suppl 3):S199-S207. doi:10.1016/j.amepre.2018.01.004
17. Xu WY, Song C, Li Y, Retchin SM. Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions. JAMA Netw Open. 2019;2(11):e1914554. Published 2019 Nov 1. doi:10.1001/jamanetworkopen.2019.14554
18. Malowney M, Keltz S, Fischer D, Boyd JW. Availability of outpatient care from psychiatrists: a simulated-patient study in three U.S. cities. Psychiatr Serv. 2015;66(1):94-96. doi:10.1176/appi.ps.201400051
19. Cama S, Malowney M, Smith AJB, et al. Availability of Outpatient Mental Health Care by Pediatricians and Child Psychiatrists in Five U.S. Cities. International Journal of Health Services. 2017;47(4):621-635. doi:10.1177/0020731417707492
20. Holstein R, Paul DP 3rd. 'Phantom networks' of managed behavioral health providers: an empirical study of their existence and effect on patients in two New Jersey counties. Hosp Top. 2012;90(3):65-73. doi:10.1080/00185868.2012.714689
21. A Long Road Ahead--Achieving True Parity in Mental Health and Substance Use Care. Medical Benefits. 2015;32(15):12. Accessed May 19, 2021. https://search-ebscohost-com.libnet.swosu.edu/login.aspx?direct=true&db=bth&AN=108626904&site=ehost-live&scope=site
22. Highlights. ParityTrack. (n.d.). https://www.paritytrack.org/legal-cases/highlights/.
23. Rowan K, McAlpine DD, Blewett LA. Access and cost barriers to mental health care, by insurance status, 1999-2010. Health Aff (Millwood). 2013;32(10):1723-1730. doi:10.1377/hlthaff.2013.0133
24. Mospan CM, Gillette C. Student Pharmacists' Attitudes Toward Suicide and the Perceived Role of Community Pharmacists in Suicidal Ideation Assessment. Am J Pharm Educ. 2020;84(5):7588. doi:10.5688/ajpe7588
25. Douglass M, Moy B. Evaluation of the impact of a social media-focused intervention on reducing mental health stigma among pharmacy students. Ment Health Clin. 2019;9(3):110-115. Published 2019 May 10. doi:10.9740/mhc.2019.05.110
26. Silvia RJ, Lee KC, Bostwick JR, et al. Assessment of the current practice of psychiatric pharmacists in the United States. Ment Health Clin. 2020;10(6):346-353. Published 2020 Nov 5. doi:10.9740/mhc.2020.11.346