To address inequalities in mental health care, look beyond community programs


If we have learned one lesson from the events of the past year, it is that life is indeed fragile, even more so for people with mental illness. The confluence of events in 2020 – the pandemic, growing awareness of racial injustices and escalating socio-political tensions – made everyone aware of this inequity.

The point is that mental health care has long been anything but fair. Concrete example :

  • 2019 data compiled by Medicaid and the CHIP Payment and Access Commission found that psychiatrists accept new Medicaid patients at a much lower rate (35%) than Medicare (62.1%) or private insurance (62.2%). %).
  • In a 2016 study, a middle-class white woman seeking an appointment with a therapist received a callback from a therapist 20% of the time while a working-class black man received a callback about 1% time.
  • Despite data showing a substantial increase in mental health problems last year, the use of mental health services actually declined significantly in 2020 among those covered by Medicaid and the Children’s Health Insurance Program (CHIP). . Despite their great needs, large numbers of adults and children were unable to find or use mental health services during the pandemic.

Given the marked insufficiency of current networks of mental health therapists and psychiatrists, they are unlikely to meet patient needs without a substantial contribution from virtual and digital-first care. Now there is an overwhelming opportunity to do something really meaningful about inequalities and injustices in mental health. The healthcare industry has a unique opportunity to make systemic change that will bring quality, accessible mental health care to those most at risk and under served. But such changes are unlikely to happen unless the federal Centers for Medicare & Medicaid Services and state Medicaid officials look beyond local community programs to resolve the limitations of geography, transportation, workforce and multiple languages ​​and cultures.

The good news is that we already know what less resource-intensive care looks like. Consider new modalities such as the integration of virtual cognitive behavioral therapy and behavioral health coaching, which counsel patients on self-management, stress and coping strategies. Such efforts are already rapidly increasing the number of beneficiaries that can be served.

Unfortunately, today, many communities and individuals do not have access to telehealth. More than 25% of Medicare beneficiaries do not have high-speed Internet service, cannot afford data costs, do not have the necessary devices, or have not learned how to use them. Problems of digital access are even more acute among populations 85 and older, widows, with a high school diploma or less, blacks or Hispanics, on Medicaid or living with a disability.

Another challenge is the historically inadequate federal and state government coverage and reimbursement for telehealth services for underserved communities, particularly in Medicaid. Before COVID-19, federal telehealth reimbursement was limited to rural areas, by type of provider and other constraints. As part of the COVID-19 public health emergency, many of these restrictions have been temporarily changed or removed. Restrictions and reimbursement policies continued to vary widely across state Medicaid programs: about half of the states allowed their emergency prescriptions to expire, while some states significantly expanded Medicaid coverage and reimbursement. These rapidly changing state policies are closely monitored by the Center for Connected Health.

I believe the arguments for digitizing mental health care services are clear. Other segments of business and society, including commerce, transportation, and financial services, did so decades ago. Virtual care, I believe, will lead to significant gains in terms of access, cost, and improved patient experience.


In urban and rural areas, the need for transportation and the lack of skilled providers are barriers to care. In addition, there is growing recognition of the need for providers who can provide culturally competent care, and the staffing complexities required for appropriate patient matching. These underscore the need for virtually distributed capabilities. On-demand and virtual mental health care can help meet these needs and increase access to care. By combining mindfulness, meditation, wellness and behavioral health coaching with video therapy and psychiatry options when needed, these models can effectively serve up to 80% of people with mild mental health disorders. and moderate, who do not need clinical support from therapy or psychiatry.


Virtual mental health can also reduce the cost of care. While the cost of live (synchronous) care may approach that of in-person therapy, combining much less expensive asynchronous care with synchronous care can make virtual mental health care more affordable than in person – in. particularly during coaching and computerized cognitive care. behavior therapy are incorporated. These cost differentials are particularly important for patients who have to pay for mental health services entirely out of their own pockets, as around 56% of psychiatrists do not accept insurance. Recent data confirms, for example, that black Medicare beneficiaries are more likely to have cost issues in accessing care. With the significantly lower cost of digital coaching and related forms of asynchronous care, plans and providers can quickly narrow these gaps.

Improved patient experience

Virtual care has proven to be acceptable, if not preferable, for many patients. Large numbers of behavioral health patients were introduced to virtual care for the first time during the COVID-19 pandemic. This experience has been positive enough to stimulate wide acceptance for the practice, suggesting that improvements in access and costs can be achieved for some patients without sacrificing patient confidence.

Next steps and signs of progress

To advance adoption of these strategies, regulators should recognize the value of virtual mental health care and support improved access for Medicaid members and other underserved groups. As a first step, CMS proposed in July to ease long-standing restrictions on behavioral telehealth services. In addition, they should support reimbursement for preventive and on-demand mental health care services.

The time has also come to let telehealth providers deliver services across state lines. As emergency telehealth extensions began to expire, one of the most pressing policy areas became state licensing and flexibilities that temporarily allow out-of-state providers to treat patients by telehealth during the pandemic, regardless of location. A recent Kaiser Sant̩ news The article reported that as emergency orders run out, licensing becomes a major barrier to care as providers and patients now face cancellations. In Maryland, Johns Hopkins Medicine Рwhich hosted more than one million telehealth visits during the pandemic, 10% serving out-of-state patients Рhad to cancel more than 1,000 appointments with Virginians due to expiring state orders that had authorized interstate telehealth.

Addressing these licensing issues will also allow policymakers in the state to seriously tackle reimbursement. Some states have made progress during the pandemic; for example, New York State issued an executive order in March 2020 requiring New York State Medicaid to reimburse telephone assessment, monitoring, evaluation and management services in cases where visits in no one is not recommended. This emergency order and other similar emergency orders should be extended or made permanent.

Additionally, AmeriHealth Caritas District of Columbia (DC) recently announced that it is providing a free suite of on-demand mental health society virtual mental health services Ginger (I’m a member of the Ginger board) at 110,000 enrolled in the AmeriHealth Caritas DC Medicaid plan. .

But doesn’t the shift to digital mental health just serve to further widen the digital divide? The answer is no, it is not necessary. Federal policy is stepping up its commitment to broadband access. The current administration’s national infrastructure plan will ensure massive expansions of broadband access to urban and suburban communities as well as rural communities.

While more effort is needed to ensure access to devices such as smartphones, tablets and wireless personal health monitors, to pay data charges, support digital literacy, and establish virtual and physical community programs to To support adoption, a large portion of Medicaid populations have a smartphone or digital device – over 86%, according to a Deloitte poll. For the approximately 5-15% of the Medicaid population who need help with these technologies, innovative health plans are developing ways to identify them and provide help with accessing equipment, bandwidth, and to digital literacy.

Additionally, acceptance rates for telehealth are high among Medicaid patients.

Concerns about fraud and abuse have been a long-standing argument against the viability of digital health. But traditional mental health counseling, the results of which are also extremely difficult to measure, are equally vulnerable to these claims. In contrast, digital mental health programs could provide better documentation and measurable clinical assessments of patient progress.

Fear and mistrust of traditional health care institutions and practitioners among marginalized communities can be extreme. Community programs have limited resources. Qualified therapists, if they can be found, often refuse to accept Medicaid. Digital solutions are a given and perhaps the only real answer to begin to address the scale of the problem.

Our growing awareness of the mental health challenges facing so many underserved populations at this unique time is an opportunity to make lasting and meaningful change. Now is the time for health plans, providers and regulators to step up and make the necessary investments to address the mental health inequalities that have such a tragic impact on the most vulnerable among us.


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