Mental Health Access Back on the Agenda

The need for access to mental and behavioral health services has never been greater

By Joanne Sammer Sep 8, 2016
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Since the Mental Health Parity and Addiction Equity Act became law in 2008, group health plans that provide mental health or substance use disorder benefits may not impose coverage limits on those benefits that are more restrictive than limits on medical/surgical benefits. In 2010, the Affordable Care Act required coverage of mental health and substance use disorder services as one of 10 essential health benefits in nongrandfathered individual and small group plans. 

But barriers to psychological counseling and addiction services under employer-provided plans still exist and are becoming untenable, mental health advocates warn.

"Even if people have access to benefits, that is not meaningful if it does not ensure access to the services they need," said Steve Wojcik, vice president of public policy for the National Business Group on Health in Washington, D.C.

The need to provide adequate coverage for mental and behavioral health care has arguably never been greater. In 2012, federal data estimated that more than 2 million people in the U.S. were addicted to prescription opioids and 467,000 were addicted to heroin. Despite these numbers, the flow of prescription opioids continues. In 2014, health care providers wrote 259 million opioid prescriptions, according to data from the U.S. Centers of Disease Control and Prevention (CDC).

At the same time, suicide rates have risen sharply in recent years. The most recent data on suicide in the U.S. from the CDC show an overall increase of 24 percent between 1999 and 2014. However, the rate of increase, which was about 1 percent a year from 1999 to 2006, doubled to 2 percent from 2006 to 2014. A significant increase in suicide among women (45 percent) seems to driving this trend. While 4.5 times more men than women committed suicide in 1999, that figure is now 3.6.

What Needs to Be Done?

A key part of the problem is that mental health parity and the expansion of health insurance coverage under the Affordable Care Act have increased demand for mental health and addiction services at exactly the time that there is an acute shortage of mental and behavioral health care providers. And the problem is likely to get worse: Nearly 60 percent of practicing psychiatrists are age 55 or older, making it the third oldest medical specialty in the U.S., according to research by Staff Care, a physician staffing firm.

The need to address this staffing shortfall has become apparent to many, including members of Congress. At a time when it is difficult to gain bipartisan support for many things, the U.S. House of Representatives passed the Helping Families in Mental Health Crisis Act nearly unanimously this summer. Whether the bill will pass the Senate and be signed by the president remains to be seen. However, its passage indicates that there is bipartisan support for measures designed to improve the U.S. mental health system.

The bill, among other things, expands Medicare and Medicaid coverage for mental illness, requires the integration of evidence-based treatment into systems of care, and expands enforcement to ensure that insurer and employer health plans are complying with the mental health parity act. The bill also includes additional resources to train staff behavioral health personnel to help ease the staffing shortages in mental and behavioral health care facilities.

As such, this bill is "more of a framework to make sure that mental health services are available, that the individuals providing those services are plentiful and accounted for and protected, as well as shoring up some holes" in Medicare and Medicaid coverage, said Danielle Horstman Capilla, chief compliance officer with United Benefit Advisors in Chicago.

For employers and insurers, the bill calls for some long-needed guidance on how to ensure compliance with the mental health parity act. "The regulations for the mental health parity act came out in 2013, right around the time employers were focused on the Affordable Care Act," said Kaye Pestaina, a principal with Mercer in Washington, D.C. "Mental health parity compliance got moved off the agenda a bit."

She also noted that the regulations' complexity has been a challenge for employers. To address compliance challenges, the Helping Families in Mental Health Crisis Act calls for additional guidance on how to comply with the Mental Health Parity Act, including examples of compliance and noncompliance.

In addition, the 2016 Democratic Party platform makes a case to expand access to addiction services through insurance coverage, and to establish parity between coverage for mental and physical health care services—presumably beyond that required by the existing Mental Health Parity and Addiction Equity Act and along the lines of the Helping Families in Mental Health Crisis Act. Clinton called for the country to "bring mental and behavioral health care on par with physical health care.”

A Telehealth Gap

Ninety percent of large employers will make telehealth services available to employees in states where it is allowed in 2017, according to a recent survey by the National Business Group on Health in Washington, D.C. But behavioral teletherapy services are less universal, offered by 34 percent of large employers.

"Employers that have been ahead of the curve in offering telemedical services are just at the forefront of recognizing how telebehavioral health can help employees access much-needed mental health services," said Julian L. Cohen, president of Teladoc Behavioral Health, a telemedicine provider based in Lewisville, Tex. "Today, it's still considered new, but our expectation is that many more telehealth packages will include mental health in the near term."

A telemedicine platform is particularly suited to providing behavioral health services "due to the stigma long-associated with mental health or geographic barriers to care," Cohen said. "The talk therapy principally used in mental health care today is extremely well suited to phone and video-based teleplatforms."

A 2012 study in the Journal of the American Medical Association found that among patients with depression, providing cognitive behavioral therapy over the telephone for 18 weeks rather than through face-to-face sessions resulted in lower therapy drop-out rates and close to equivalent improvements in depression.

Easing the Stigma

Changes to the mental health care system are an important part of ensuring that everyone who needs mental health services has access to them. However, there is still a stigma associated with seeking help for mental health issues. Helping to remove this stigma is an important role that employers are well-positioned to play. (Earlier this year, SHRM Online reported on efforts to overcome the stigma around mental health services at Sprint, which significantly increased employees' use of the telecom firm's employee assistance program for mental health counseling.)

"Employers are increasingly focused on the emotional health and well-being of their employees," Wojcik said. "It can be beneficial for employers to provide outreach to let people know that benefits are there."

Mental Health and the Workplace

The nonprofit Disability Management Employer Coalition (DMEC), which provides education and support for absence-management professionals, has been an advocate of behavioral or “whole person” health care. 

“Stress, depression and other conditions are among the most significant causes of short and long-term absence and disability, and employers are the institutions often left to identify and assist people suffering from these condition,” said DMEC President Terri L. Rhodes. 

She offered these steps to help address employees’ mental health issues:

  • Think and act as though mental illness is just that, an illness. Treat it the same as a physical disease. Recognize that mental illness, like all illness, respects no title or position.

  • Use screening tools to recognize signs and symptoms of depression and anxiety. Assure employees that revealing mental health issues is an avenue that will help them access treatment options so they can better perform their jobs.

  • Make better use of employee assistance programs (EAPs). Most employer-provide EAP programs are woefully underused. Employers must do a better job of communicating the services they provide and continue to emphasize that they can be used confidentially with no impact on an employee’s work status—just like any other health care service.

“When employers effectively communicate about EAPs, the results are impressive,”  Rhodes said. “Studies suggest that employer-sponsored EAPs can increase necessary treatment and reduce company disability, medical, pharmacy and workers’ compensation costs.”

Joanne Sammer is a New Jersey-based business and financial writer.

Related SHRM Articles:

Overcoming Stigma Around Mental Health Services, SHRM Online Benefits, March 2016

Solving the EAP Under-Use Puzzle, SHRM Online Benefits, August 2014

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