Opinion: Rethinking Mental Health Access for a New Model of Care

The current model for managing major depressive and anxiety disorders is outdated, ineffective and more focused on masking symptoms than effecting cures. That’s a massive problem when you consider, according to the National Institute of Mental Health, nearly 20% of adults or 46.6 million Americans have a mental illness, 17 million of whom suffer from depression. The solution is an emerging new model of care that is holistic and transformational, taking a multi-dimensional and personalized approach to treatment while also ensuring access to the latest groundbreaking therapies that can achieve rapid and sustained wellness.

As we progress toward this model, we must consider access in the context of more integrated care. Despite the passage of mental health and addiction parity laws in 2008, too many people cannot access the mental health care they need. It's suspected this will only worsen as we embark on much needed systematic changes. We cannot allow that to happen, so we must reconsider historic and emerging issues as we move forward.

A major problem is that many patients simply can’t find a psychiatrist who accepts insurance. Psychiatrists are less likely than other specialists to take insurance, with just 62% accepting commercial or Medicare plans, and only 35% accepting new Medicaid patients. This dates back to years prior to mental health parity when insurers wouldn’t cover mental health patients or taxed them with high premiums. It remains a significant driver of mental healthcare disparities among our most vulnerable patients.

Consider this in the context of a new, integrated care model combining cognitive behavioral talk therapy, standard-of-care medications, telepsychiatry, and novel treatments, such as recently approved esketamine, and transcranial magnetic stimulation (TMS). Many psychiatrists are disincentivized to move this way because today’s model is a cash business that patients can somewhat afford. An integrated approach simply wouldn’t be affordable for most patients, and thus they’d need to rely on insurance their provider doesn’t accept or struggle to find a new provider. Even if a psychiatrist who accepts insurance were to adopt this model, they still have to change their practice, acquire new staff, equipment, and technology and then negotiate with insurance companies to ensure a sustainable business.

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The unintended consequence is a gap between those who can and can’t afford a new model of quality mental healthcare. As we advance toward better therapies, there is a real possibility of a widening gap among people in remission, not in remission, or not treated at all.

There is an emerging access threat to novel treatments: the interim final rule recently published by the Centers for Medicare and Medicaid Services (CMS) for esketamine coding and payment makes it harder to access novel treatments within this new model. The rule proposes $70 to $75 per visit above wholesale drug cost, not considering esketamine is unlike any treatment ever approved for depression. The medication requires extensive training, adhering to a stringent risk evaluation and mitigation strategy (REMS) and post-administration monitoring for a minimum of two hours. The time required to properly administer esketamine makes psychiatrists’ adoption impossible with the proposed payment. In fact, many would lose money thus providing an incentive to not recommend esketamine or give it only to cash-paying patients. It validates a false rationale for many psychiatrists to not accept insurance. 

The wrong message is being sent. Esketamine use is an outpatient procedure. How we evaluate its reimbursement needs to be commensurate with that. Many novel treatments in the pipeline have complex administration and monitoring requirements. The CMS rule may disincentivize the innovation we so desperately need and stall a move toward more holistic and integrated care.

As we move to a new care model, there must be tradeoffs on both sides of the aisle to close the gap among those who can and can’t access quality mental health care. More psychiatrists must work with insurers to become in-network providers. Payers should be perspicacious enough to consider that successfully managing patients with depression can decrease the cost burden on them and the health care system down the line. 

All patients need improved access to mental health care. That conversation must happen now. Millions of Americans struggle to find care each year. Nearly half of them are left untreated. Even those who do get access to treatment face skyrocketing out-of-pocket costs. It’s time for all parties relevant to this equation-providers, payers, the government-to rise to this challenge with visionary leadership. It’s time to reconsider access more holistically, to close the gap between the treatment haves and have-nots and to restore mental health patients to full, socially active and productive lives.

Steve Levine is founder and chief medical officer of Actify. Levine is a board-certified psychiatrist internationally recognized for his contributions to advancements in mental healthcare.