Many of us are aware that mental illness is prevalent and undertreated, and we know we need to do a better job of improving mental health awareness and accessibility. We know that research estimates that only half of people with mental illness will receive treatment. And we’ve heard all the different vows to improve accessibility and equity in mental health care. So why are we still talking about it? There are several areas we can be working to improve mental health awareness and accessibility to services on an individual, public, and federal level.
Integration
A key component of improving mental health care is integrating behavioral health professionals in the primary care and other care settings for patients and families. The Collaborative Care Model embeds behavioral health professionals into primary care settings to make mental health services more accessible.
According to the AAFP, up to 75% of primary care visits include mental health components. A large source of frustration for primary care physicians is the lack of accessibility for mental health services, leading them to be put in compromising positions to handle a situation they aren’t fully equipped for.
There are many benefits to a Collaborative Care Model aside from the obvious benefit of making mental health care more accessible. This approach is patient-centered and leads to improved patient satisfaction. It also improves communication among healthcare providers. It is likely more financially feasible for some patients/families. It’s also far more convenient to be able to address both mental health and medical needs in one setting.
While there are a lot of benefits to an integrated approach like this, there are a lot of barriers to fully achieving it as well. Billing codes and reimbursement rates are one of those potential barriers, as it can be complicated to determine the codes that should be used based on the health care that was given. To be successful with an integrative approach, there must be join accountability and quality control on both sides – medical and mental health. Effective, full implementation of this approach requires development of clear protocols, proper training and education, patient/family engagement, regular communication and collaboration among the treatment team members, and tracking of patient outcomes.
Stigma
Improving mental health awareness and accessibility requires us to address stigma – both our own and that of others. While progress has been made to reduce the stigma surrounding mental illness, there is much work left to be done. To further complicate the matter, there are multiple different ways stigma can manifest. Many of us hear stigma and immediately think it entails other people making an outside judgement about something. That is public stigma – negative or discriminatory attitudes from the public about mental illness.
There is also self stigma – negative attitudes including shame that people have about their own mental illness – as well as structural stigma. Structural stigma is systemic, involving either the intentional or unintentional limiting of opportunities for those with mental illness, usually involving government policies. Culture can be an additional factor to consider when we think about stigma. For example, in some Asian cultures, seeking mental health care can be counterproductive of the cultural expectation of remaining strong, demonstrating emotional restraint, and avoiding shame.
Stigma needs to be addressed on both a public health level and an individual level. On an individual level, we should encourage talking openly about mental health, show compassion for those who are struggling, be conscious of the language we use when speaking on mental health, let others know when they are using stigmatizing language, and (if you are comfortable) be honest about your own mental health when appropriate.
At a public level, we should all take equal responsibility of educating ourselves and each other, and holding ourselves and each other accountable for how we speak about mental health. We should focus on raising awareness through public education. The media could have a profound positive impact on mental health stigmatization as well if they chose to avoid negative portrayal of mental illness and provide more articles on hope, wellness, and recovery.
Pay Models
Another way to improve mental health care is to look at pay models and reimbursement rates. The problem with reimbursement rates is it seems they were initially set rather arbitrarily, and have been unable to adapt going forward. The Mental Health Parity and Addiction Equity Act was passed in 2008 and it mandates insurance plans to equally cover behavioral health benefits and physical health benefits. However, this is not reality. We can begin to improve care reimbursement rates by simply enforcing the existing parity laws.
We also need to look at developing new payment models for services. The collaborative care model was quite a win – under this model, primary care practices that provide collaborative care services can bill using elevated CPT codes. As mentioned above, collaborative care involves bringing behavioral health and primary care providers together to provide the best possible care to a patient. But for direct mental health care, there is a lot of work to be done.
We need to ensure that reimbursement rates and pay models for mental health services are valued equally to other services. We need to look at reimbursement rate setting processes and focus on the disparity between in-network and out-of-network mental health providers. Poor reimbursement rates for mental health services will almost surely result in attracting less professionals than in other health care services. Until we are ready to take a hard look at how we can reset rates to be reasonable and in line with other services, we can’t expect change.
Crisis Response
There are several federal initiatives aimed at continuing to improve behavioral health crisis response systems. SAMHSA set forth national guidelines for crisis care in 2020 that states the following are essential principles and practices: addressing recovery needs, peers playing a significant role, trauma-informed care, suicide safer care, consideration of the safety/security of staff and people in crisis, and crisis response partnerships with law enforcement, dispatch and EMS. Crisis hotlines, mobile crisis units, and crisis stabilization are 3 core crisis services that should be available to anybody in a mental health crisis.
Other federal initiatives include the 988 crisis line launch in 2022, the Consolidated Appropriations Act passed in 2022, and the initiative for states to use Medicaid funding for mobile crisis services through the American Rescue Plan Act in 2021. However, there are more ways to enhance federal funding for crisis services. As of 2024, there are still 16 states that are either undecided or have no plans to implement the ARPA mobile crisis intervention services, which is available to states for 3 more years. This option is for qualifying Medicaid programs that provide community-based mobile crisis services, and ensures they will receive 85% enhanced federal matching funds for the first 3 years of implementation.
Additionally, only 8 states are planning to lean into SAMHSA’s best practice guidelines which advocate for utilizing technology to support implementation of crisis call centers or other crisis services. Best practice guidelines advocate for using a system for assessing crisis levels, wait times, matching with appropriate services, crisis bed registry, GPS mobile crisis dispatch, and performance monitoring dashboards.
There are a lot of challenges to implementing better crisis response services, including workforce shortages, geographic challenges (reaching rural areas), and sustainability of funding. Ultimately, crisis response systems are most effective when they can have smooth care coordination with other systems and health care areas. There is a huge opportunity here to leverage technology even further to help us do some of this work.
Community
A sense of community is so important when considering mental health. Community provides someone with a sense of belonging, support, and purpose. Communities that openly discuss mental health and create safe spaces to share experiences actively help break down barriers to addressing mental health. There are so many community factors that can directly impact mental health – housing, income, social status, social norms, available public services, neighborhood conditions, school systems, food availability, employment opportunity. The list goes on and on. It makes sense then, that we should also be addressing the mental health crisis at a community level.
There is strength in numbers. Communities can also rally together to support initiatives such as increasing access to certain programs and services, sustaining partnerships, implementing more/better crisis response initiatives. Special focus should be placed on intervention for young people. Communities can come together to identify struggling youth, determine what interventions or strategies best meet the needs of their youth, and determine how to best implement them. It is everyone’s responsibility to ensure that mental health resources, and especially crisis resources, are openly shared and available.
Communities can also celebrate together. Celebrate the wins – what has already been done in your community to break down barriers to mental health services, what resources are already available? And then, keep working together to address the ongoing mental health needs of the community. Continue to encourage open conversations about mental health and personal experiences. Ensure that you as a community know what direction you are heading.
Some of the key things that communities can do is promoting mental wellness and awareness in the school systems, encourage dialogue about mental health, offer support groups, encourage physical activity, teach coping strategies and resilience, collaborate with mental health professionals, and incorporate mental wellness into community events.
Align Policies and Programs
Mental health policymaking often fails to appropriately consider important factors such as neighborhood, race, gender, age, etc, which can have detrimental affects. Rural communities often have higher suicide rates than metro areas, and communities of color often experience less access to mental health services. It is common for research to be used and considered in policymaking, but less common that it’s applied in a way that responds to local needs.
There are so many policy changes/advancements that could greatly better mental health treatment. We’ve talked about better integrating mental health and primary care as well as improving crisis response. Other important initiatives are expanding telehealth services, building a more robust workforce, improving mental health insurance coverage, peer support programs, addressing social factors such as poverty and discrimination, empowering community-based services, and expanding mental health education in the school systems.
Training
Training non-specialists in mental health care is an effective way to improve knowledge, attitude, skill, and confidence levels among health workers. This would lead to improved clinical practice and patient outcomes, thus leading to improved clinician satisfaction and retainment. We need to make sure non-mental health care workers are equipped with the knowledge and tools needed to provide the best patient care possible if mental health challenges arise.
We also need to look at increasing the funding to train and develop our mental health care professionals. The strongest professionals continue to stay aware of new evidence based practices and research, and continue to evolve as the practice and needs evolve.
In honor of mental health awareness month 2024, the government has taken action to continue their efforts to make mental health services more accessible. They nearly doubled the a mount of funding available for the School Based Mental Health and the Mental Health Services Professional grant programs which help fund the training and hiring of mental health professionals in schools. The government also released additional funding to invest in improving school climate and safety in underserved schools. They are also providing more trainings and resources for youth mental health through the Departments of Education and Health and Human Services Technical Assistance Centers.
Insurance Coverage
In mental health care, many providers do not take insurance at all, because they can make much more money by being able to bill patients directly. By billing insurance, they could ultimately end up making half or less than half the amount they could make by billing the patient directly and not accepting insurance. According to Mental Health America, a psychiatrist could make $550 off an initial consultation by billing a patient directly, but could make as little as $216.44 by billing Medicare, and $177.44 by billing Medicaid. Private insurance companies also pay reimbursement rates that do not compare to what they could make by billing patients directly.
What will it take to make improvements? Many things. Better support of primary care providers is a great place to start. The federal mental health parity requirements need to be enforced. Additionally, states need to work on closing the Medicaid coverage gap. Improving access to coverage will improve access to mental health services, improves the behavioral health of lower income people, increases provider capacity, and contributes to positive mental health.
Advocacy
Getting involved is a great way to help improve mental health awareness and accessibility. There are many ways to be an advocate. You can be open about your own experiences, be open to discussion about mental health, and hold space for others to share their experiences. You can help spread awareness. The MN Mental Health Ambassador Program provides many ways to be an advocate by sharing your story, being an advocate, and providing valuable feedback and information. Ambassadors have the chance to impact policy and funding decisions through the Mental Health Minnesota’s Lived Experience Action Network. Participants have access to attend advocacy training, connect with their legislatures, and attend Mental Health Day on the Hill.
There are also many ways to volunteer your time with events, support/help lines, etc. MN Mental Health offers ways to get involved in volunteer your time. You can also attend NAMI walks, conventions, awareness events, and fundraise. Check out some of these pages to learn more about how you can get involved:
I encourage everyone to take the Pledge to Be StigmaFree 💗
