Community Access To Mental Health Services Discussion Essay.

If health services research is a relatively new discipline, mental health services research is of even more recent vintage. In a brief ten or fifteen years the initial group of mental health services researchers have built on the early foundation of studies in health care and expanded the knowledge base, particularly regarding systems of care and the relationship of public and private services.

Health care reform comes at an opportune time, as the debate demonstrates daily the need for systematic knowledge to answer immediate questions and to develop, support, or oppose the myriad proposals and permutations under consideration.Community Access To Mental Health Services Discussion Essay. Whatever the outcome of the reform process, it is abundantly clear that services research is an essential element of the health care infrastructure.

Mental health now constitutes one of the most promising areas of opportunity in health services research. The availability of credible mental health information—unexpected by many policymakers—in the health care reform debate has enhanced the stature of the research and its practitioners. The reform debate itself has highlighted both the common and the specialized mental health issues within the health care framework.

The public sector remains the predominant source of funds for mental health services research, primarily via the National Institute of Mental Health (NIMH) and other federal agencies. On the private side, a review of annual reports of various private foundations with significant health services research interests reveals none with a specific focus on mental health.Community Access To Mental Health Services Discussion Essay. However, most of these foundations have funded several projects involving mental health in conjunction with their major areas of focus, such as substance abuse, homelessness, elderly, children, education, and primary health care. These include The Robert Wood Johnson Foundation, The Pew Charitable Trusts, The Commonwealth Fund, The Henry J. Kaiser Family Foundation, W.K. Kellogg Foundation, Milbank Memorial Fund, and The William T. Grant Foundation, The John D. and Catherine T. MacArthur Foundation health program, which does not accept unsolicited proposals, supports two endeavors to conduct and/or publish significant mental health services research: the Mental Health Policy Resource Center andHealth Affairs. In addition, MacArthur's Law and Mental Health Research Network focuses on many issues germane to mental health services research. This essay examines the development of mental health services research and the opportunities for future research that merit the attention of both public- and private-sector funders and researchers. Community Access To Mental Health Services Discussion Essay.

WHAT IS MENTAL HEALTH SERVICES RESEARCH?

Unlike other areas of health, mental health has long looked to a single federal agency—NIMH—as the major source of national funding for all types of research, services, training, and statistics. Perhaps for that reason, NIMH has defined the services research arena somewhat more broadly than does the Association for Health Services Research (AHSR), which defines services research as “a field of inquiry that examines the impact of the organization, financing and management of health care services on the delivery, quality, cost, access to and outcomes of such services.” For NIMH, the boundaries among clinical, epidemiological, treatment, and services research are not always clear. For instance, considerable attention has been devoted to distinguishing between clinical services research and service systems research, both of which have been treated as part of mental health services research.

Mental health services research began in the late 1970s and early 1980s; it grew out of NIMH's epidemiology and data collection programs and emphasized statistical information and economics. The priority of the institute during this time was the public mental health system and the primary public patient population—persons with serious and persistent mental illness—and this priority was reflected in the services research program. In its 1991 report, Caring for People with Severe Mental Disorders: A National Plan of Research to Improve Services , a chapter entitled “Clinical Services Research: Enhancing the Real-World Applications of Clinical Science” articulates the boundary with other types of research:

Major areas of concern for this research include salient characteristics of mental illness, such as demographics, risk factors, cultural influences, and family issues; assessment in terms of specific diagnoses as well as physical, social, and vocational functioning; specific treatment and rehabilitation interventions; and outcomes and effectiveness of services.

The next chapter of NIMH's 1991 report, “Service Systems Research: Improving the Organization and Financing of Care,” describes service systems research as focusing on how to provide services most efficiently, economically, and equitably. It encompasses a broad and eclectic set of questions and issues: identifying the nature and scope of local needs; matching local services to needs; structuring integrated care that reaches the consumer; allocating financial resources so that consumers and providers have proper protection and incentives to use services appropriately; legal issues such as the role of the criminal justice system, civil commitment, patient rights, and confidentiality; human resource issues; and stigma and strategies for changing attitudes.

The Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act of 1992 (P.L. 102-321) split the services and research programs of NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and transferred the three as research-only institutes to the National Institutes of Health (NIH). Services research went with the research portfolios, protected by a mandatory set-aside—12 percent of research funds in fiscal year 1993 and 15 percent in fiscal years 1994 and 1995 must be spent on services research. The new Substance Abuse and Mental Health Services Administration (SAMHSA)—including its new mental health component, the Center for Mental Health Services (CMHS)—was given evaluation authority but no specific funding in the form of a line item to support evaluation studies.

The ADAMHA Reorganization Act defined health services research as “study of the impact of the organization, financing, and management of health services on the quality, cost, access to, and outcomes of care.” This definition is essentially the same as that used by AHSR. Mental health services research may be defined most simply as a subset of this domain.

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Given the mandated set-aside, it has become particularly important to distinguish between mental health services research and other forms of research. A recent work group convened by the Foundation for Health Services Research (FHSR) suggested two key distinguishing factors: (1) the intent of the study and nature of the hypotheses, and (2) the distinction between studies of factors influencing the effectiveness of health services in “real-world settings” (health services research) and studies concerning the efficacy of specific preventive, diagnostic, or treatment services done under highly controlled conditions (not health services research). ² One NIMH services research official recently offered the following general definition:

For this essay we reviewed recent and active projects in mental health services research and consulted with selected knowledgeable persons; this provides a descriptive snapshot of the kind of work currently funded and under way. This base, together with the newer areas of priority resulting from the health care reform process, suggests many promising opportunities for the future.

CURRENT WORK

For an overview of recent grants identified as mental health projects, we turned to the Health Services Research Grants Information System, a database of ongoing and recently completed health services research projects that is being developed by FHSR and the Cecil G. Sheps Center for Health Services Research of the University of North Carolina at Chapel Hill. This database, whose creation was funded by The Pew Charitable Trusts, will allow researchers as well as policymakers to keep abreast of current research, rather than waiting until the results are published.

The Health Services Research Grants Information System will become a part of the National Library of Medicine's MEDLARS system. The information system is scheduled for completion in late 1993. Information in the database will include the name and address of the performing organization and principal investigator, amount of the award, an abstract of the project, and a description of the population studied. Initial funding agencies include the Agency for Health Care Policy and Research (AHCPR), the Health Care Financing Administration (HCFA), NIH, the Health Resources and Services Administration (HRSA), the Department of Veterans Affairs (VA), and seven private foundations (The Pew Charitable Trusts, The Robert Wood Johnson Foundation, The John A. Hartford Foundation, W.K. Kellogg Foundation, The Henry J. Kaiser Family Foundation, The Commonwealth Fund, and The William T. Grant Foundation). Additional federal agencies and private foundations will join the effort in the future.

Our database search turned up nearly 200 grants (of a total of 1,500 listed) that focused on mental health issues. All but a handful were funded by NIMH and other federal agencies. Of these, roughly one-third could be generally categorized as targeting services for persons with the most serious mental illnesses. The remaining two-thirds covered a wide spectrum of topics, including mental health issues related to aging, women, family violence, adoption, various minority groups, alcohol and/or drug abuse (which generally coincide with mental health problems), general health care, homelessness, and many more.

NIMH is by far the largest funder of projects identified specifically as mental health services research. The NIMH Services Research Branch oversees a broad program of investigator-initiated grants addressing virtually any area related to mental health services. Funding in fiscal year 1987 was $18 million. The current set-aside (12 percent of the total NIMH research budget) translates into roughly $50 million for fiscal year 1993.

More than 250 active grants (listed with NIMH as of January 1993) are concentrated in the following areas in descending order: severely mentally ill adults; mental health economics; children and adolescents; rural mental health; adult primary health care; and multiple diagnoses of alcohol, drug abuse, and mental (ADM) disorders. Significant numbers focus on mental health service systems, minority mental health, homeless mentally ill, and research scientist awards, and some are devoted to disability and rehabilitation, human immunodeficiency virus (HIV) infection, self-help services, research methods, and state research capacity building.

NIMH has established a program to develop and maintain Centers for Research in particular areas of priority: severely mentally ill adults, children and adolescents, minority mental health, rural mental health, and self-help. Exhibit 1 lists specific grant announcements that detail areas of focus and priority.

In addition to NIMH, a variety of federal agencies have services research programs that include mental health issues as a component, although not as a priority. Agencies that are funding projects included in the FHSR database are the Department of Veterans Affairs, the National Institute on Aging (NIA), NIDA, NIAAA, HCFA, the Office of Rural Health Policy, the National Center for Nursing Research, and AHCPR.

 

FUTURE OPPORTUNITIES

The heightened health care reform debate has accelerated the development of agendas in mental health services research and is likely to provide a framework for setting priorities for the next several years, both in foundations and in the various federal agencies. Even at this early date it is possible to discern several significant themes. These can provide some guidance for the development of mental health services research ideas and extended programs during the next several years.

REFORM-RELATED ISSUES WITH A SIGNIFICANT MENTAL HEALTH DIMENSION.

The issue of risk adjustment in health insurance has particular relevance to mental health. Risk adjustment has to do with the probability that any given health plan may become responsible for a larger number of persons with more serious health problems than other competing health plans-Health plans that fear this situation could develop procedures that discriminate against persons with known high-cost illnesses; the more severe mental illnesses, as well as acquired immunodeficiency syndrome (AIDS), cancer, and others, lead the list of illnesses that insurers wish to avoid. A concern will be how to protect health plans with disproportionate numbers of high-risk enrollees and how to protect high-risk persons from creative forms of exclusion.

A second issue relates to functional disability. Current measures of illness, such as diagnosis, often are not good predictors of service needs and outcomes. The problem of measuring illness is now a policy issue for long-term care in determining eligibility and assessing needs. This same issue will become a problem for acute care, as the need arises to sort out persons with significant service needs from those with less serious conditions, be they physical or mental

Third, in a health care system that relies heavily on managed care, the development of appropriate standards for such management becomes essential Practice variations are widespread, and good managed care systems are difficult to define and measure. No recognized standards now exist either for “carved-out” programs to manage mental health care or for addressing mental health issues within an overall managed care program. Furthermore, once managed care is in place, how will its performance be monitored? What are reasonable measures of undertreatment? These issues are likely to be important for various vulnerable populations, including the mentally ill

Fourth, the definition of outcomes, as well as the design of outcome measures, is a major preoccupation of the health care reform process. The new emphasis on quality-of-life measures necessarily involves mental health considerations. And the emphasis in medical outcomes on effectiveness (what works in real-world conditions) as opposed to efficacy (what has a statistically significant impact in ideal research conditions) also involves psychological and psychosocial factors.

Fifth, the interaction between physical and mental health is likely to attract increasing attention in a managed care environment. The mutual impact of physical and mental factors on health and care-seeking behavior is better recognized than it is understood. As mental health care is more explicitly integrated into general health care settings, this interrelationship will continue to stimulate research interest.

Sixth, a reformed health care system is likely to include a major role for states. Historically, states have played a more comprehensive role in mental health than in any other area of health, and much can be learned from that experience. The new configuration will provide a natural laboratory for explaining and exploring different states' approaches to their new role in both physical and mental health.

Finally, the incorporation of Medicaid (in whole, in part, or not at all) into a reformed health care system will create numerous opportunities for assessing different configurations of services that are included or excluded and their impact on various elements of the Medicaid population (particularly indigent persons with severe mental illness and welfare mothers and children).

INTERSECTION OF MENTAL HEALTH CONCERNS WITH POPULATION GROUPS OR ISSUES.

Different segments of the population have unique needs that demand research attention. The necessity of integrating health and mental health services for children with a host of other types of services (education, income support, social welfare, juvenile justice, and so forth) has been a continuing theme of the health care reform debate. Similarly, in the coming debate over welfare reform, what should be the interface between mental health and child welfare? The mental health services research sector has been a leader in developing model approaches for integrated systems of care for children. The elderly also pose unique challenges to services research. The recognition and treatment of mental disorders in elderly persons is a major issue for both the primary care and long-term care elements of the health care system. The impact of mental health conditions on the ability of aging persons to live independently and to manage their own health care has gained much attention. Finally, different patterns for various population groups in the use of general health versus mental health services raise many concerns. The interplay between minority cultural norms and majority community attitudes is of particular interest.

In addition to population-linked concerns, specific issues have a major mental health facet. Both alcohol and drug abuse disorders frequently overlap with mental disorders. The service systems are sometimes integrated but more often operate separately from each other. Agencies concerned with ADM problems recognize the need for collaboration and exchange on issues of etiology and comorbidity. Mental health and behavioral issues are also important in AIDS prevention and treatment. In fact, persons with severe mental illnesses have been found to be at especially high risk for contracting AIDS. Finally, the emergence of violence as a public health issue has led to heightened interest in researching possible relationships between violence and mental health. Is there a link between mental disorder and violent behavior, and, if so, what are its parameters? Also, what are the health care and mental health care consequences of experiencing or witnessing violence?

INTEGRATION OF HEALTH AND MENTAL HEALTH DATA SYSTEMS.

A reformed health care system will require extensive collection of uniform data. Historically, health and mental health information systems have been separate. In efforts to redesign existing national data sets, as well as to plan for new data collection systems, the issue of the separation or integration of mental health information must be addressed. Episodes of care are likely to be a significant form of measurement in a reformed health system. Appropriate and consistent definitions for both health and mental health care will need to be developed.

POTENTIAL SOURCES OF FUNDING

Foundations are identifying issues ranging from how various elements of the new system will operate, to financing strategies for services that are not fully covered in the new system, to the impact of reform on individuals and families. In general, as foundations announce their primary health care interests or priorities, they can consider developing the mental health dimension as an example or element of the foundation's particular areas of focus.

By far, the most significant funder of mental health services research remains the federal government. Numerous agencies of the Department of Health and Human Services (HHS) are discussing health care reform implementation issues (many of which include mental health); however, until legislation is passed, clear lines of responsibility cannot be established. The broad agenda described above likely will fit within the research programs of NIMH, NIAAA, and NIDA via the 12 percent set-aside for services research in fiscal year 1993 and 15 percent in fiscal years 1994 and 1995. The office of the HHS Assistant Secretary for Planning and Evaluation (ASPE)/Health may fund some research into risk adjustment, managed care, and functional disability. Under SAMHSA, the Center for Mental Health Services is likely to concentrate on system evaluation, integrated services for children and adults with severe mental illness, homelessness, prevention services (if funds are appropriated), and Medicaid. The SAMHSA Center for Substance Abuse Prevention and Center for Substance Abuse Treatment likely will fund research into comorbidities. The AHCPR, in accordance with its mandate, likely will produce mental health practice guidelines, and HRSA likely will focus on primary care, indigent populations, and rural health care.

Probably the most significant change in NIMH's services research agenda is the broadening of its focus to include more issues beyond those involving persons with severe mental illness. The implementation of national and state health care reforms will have a dramatic effect on both public and private service providers and on access to and use of mental health services by the general population (including low-income persons). The severely mentally ill population remains a high priority, and NIMH remains committed to its National Plan of Research to Improve Services. However, the infusion of new money from the set-aside and the demand for information on additional reform-related matters have combined to stimulate a broader agenda.

NIMH is now developing a new grant announcement on issues relating to health care reform; this announcement is expected in fall 1993. It is likely to encourage research on risk adjustment and to emphasize the impact of health care reform on the states. Comparisons of different states' approaches to financing and covering mental health services—from publicly managed, capitated forms of financing catastrophic and long-term mental health care to buying into private managed care systems—may be highlighted. Development and assessment of monitoring capabilities and methods of assuring quality of care also are likely to be emphasized.

NIMH also will reissue its mental health and economics announcement.This research area targets the role of economic factors in mental health services delivery, providing a near-term opportunity to develop essential baseline information before enactment and implementation of health care reform. Later, this research funding should provide an opportunity to assess the reform system in relation to mental health and to develop recommendations for change. Specific areas of interest include assessment of factors affecting supply and demand; financing of publicly supported mental health services; financing of alternative delivery systems, managed care, long-term care, and catastrophic care; the impact of reimbursement methodologies and insurance benefit design; social and economic costs of mental disorders; cost-effectiveness of services; the impact of reimbursement policies on quality of care; the impact of legislation and regulations on reimbursement; financing and reimbursement policies affecting the market for services of providers in various settings; financing of services for particular population groups (for example, minorities, children, and the elderly); and the impact of state rate-setting methods and systems on services.

 

NIMH also will continue to give priority to its National Plan for Research on Child and Adolescent Mental Disorders (1990), including services research issues. ⁴ During 1994 research is expected to focus on obtaining baseline data on who is providing what services to children and adolescents. Research probably will encompass delivery of mental health services to children and adolescents in general health care, specialty mental health, and other settings; coordination and integration of mental health services with other services such as criminal justice, education, and welfare; service needs and delivery of services to subpopulations of youths with comorbidities of various types; and evaluation of innovative service models.

CONCLUDING COMMENTS

In conducting this brief review, we were struck by the perception on the part of funding agencies and others that the limited number of mental health services researchers hampers the progress of a field that is ripe for expansion. There is a clear and explicit interest in developing new talent and attracting experienced researchers from a variety of other disciplines and areas.

Mental health will be a particularly interesting area of change and challenge in health care reform. Among the salient issues will be tensions among national, state, and private-sector roles in providing and financing mental health services; the likelihood of early coverage limitations designed to be expanded later; and how to assure nonmedical wraparound services for vulnerable groups such as children and adults with severe mental illness.

Underlying these questions is the larger issue of integrating mental and physical health services. Which services are health, which are mental health, and which are “something else?” Will (or should) there continue to be a separate mental health system? If so, for whom? Is mental health services research separate from health services research?

Mental health services research began in an era in which mental health services and policy were defined largely in terms of mental illness—indeed, in terms of the most severe mental illnesses. As the health care reform debate continues, attention increasingly is drawn to the broader issues of mental health care for the general population. The challenge for mental health services research will be to address both the traditional and the expanded agendas within a changing health care system. This may suggest expanding the field of mental health services research to encompass both the discrete specialty researcher and a wider group of health services researchers who address mental health factors as a matter of course in examining health issues.

Mental health and substance use disorders affect people of all ages and demographics and are extremely burdensome to society. At least 18.1% of American adults
experience some form of mental disorder, 8.4% have a
substance use disorder, and about 3% experience cooccurring mental health and substance use disorders
(SAMHSA, 2016). In 2013, health-related spending on
mental health disorders in the United States was about
$201 billion (Roehrig, 2016). Moreover, four of the top
five sources of disability in people 18–44 years old are
behavioral health conditions (WHO, 2001). While knowledge regarding recognition and treatment has steadily
advanced, the public health effects of that knowledge
have lagged. More effective and specific treatments
exist now than in the past, and increased numbers of
people who have these conditions can now lead productive, useful lives if they are treated properly.
Behavioral health is an essential component of overall health. People seen in primary care settings with
chronic medical conditions—such as diabetes, asthma,
and cardiovascular disorders—have a higher probability of having a substance use disorder or more common mental health disorders, such as depression and
anxiety disorders. Coexistence of mental health or substance use disorders with general medical conditions
complicates the management of both.
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DISCUSSION PAPER
People who have more severe behavioral health
conditions—such as psychotic disorders, complex bipolar disorders, treatment-resistant depression, severe obsessive–compulsive disorder, and substance
use disorders—commonly have or develop such medical problems as diabetes or heart disease and often
die early, as much as two decades earlier than the general population.
Although behavioral health and overall health are
fundamentally linked, systems of care for general
medical, mental health, and substance use disorders
are splintered. For historical, cultural, financial, and
regulatory reasons, the three care systems operate
separately from one another.
People who have co-occurring behavioral health
and general medical conditions make up a high fraction of the so-called super user group. The extra health
care costs due to the co-occurrence of medical, mental
health, and substance use disorders were estimated to
be $293 billion in 2012 for all beneficiaries in the United
States. Most of the increased cost for those who have
comorbid mental health and substance use disorders
is due to medical services, so there is a potential for
substantial savings through integration of behavioral
and medical services (Melek et al., 2014).
We have an “execution” problem and a “know-how”
problem in the fields of mental health and substance
use. Although for many conditions there is still a need
to develop better and more effective personalized
treatments, we do have effective treatments; but we
have not been successful in getting these treatments
to many of the people who can benefit from them.
We often fail to identify, engage, and effectively treat
people in primary care settings who are suffering from
behavioral health conditions. People who have severe
mental health and substance use disorders have difficulty in accessing effective primary and preventive
care for chronic medical conditions. Yet, there are welltested models for providing care for people who have
common behavioral health conditions in primary care
settings with support from behavioral health providers. And there are effective care models that provide
integrated care for people who have complex behavioral health conditions in behavioral health settings
with support from other medical care providers. In
both cases, establishing a team approach fostered by
an integrated care system and supported by effective
use of technology needs to have high priority. We are
not routinely applying accountability strategies that
offer incentives to use these models. Execution is hampered by shortages and maldistribution of psychiatrists, psychologists, social workers, counselors, and
other providers that care for these populations. The
stigma attached to these conditions, as is often perpetuated in the mass media, still presents a challenge
to getting people the care that they need. And we have
substantial knowledge gaps. Currently, available treatment approaches are not always effective, and many
patients are not able to achieve optimal response. We
need to develop more effective treatments and learn
much more about tailoring treatments to individuals.
We also need to develop better strategies for implementing effective programs across large and diverse
health systems.
Barriers to Service Delivery and Coordination
Three key barriers to improving well-being and health
outcomes for people who have behavorial health conditions and general medical conditions need to be
addressed.
A Fragmented Care System
Most Americans who have both medical and behavioral health conditions must interact with separate,
siloed systems: a medical care system, a mental health
care system, and a substance use service system. Each
system has its own culture, regulations, financial incentives, and priorities. Each focuses on delivering a specific set of services and overlooks key questions, such as,
“How can I help this person to lead a productive, satisfying life?” “What is the full array of needs that must be
addressed to make this person healthier and put him
or her on a path to well-being?” Many small front-line
agencies, offices, and organizations in primary care,
mental health, and addiction are poorly run, poorly
capitalized, and poorly staffed. They are struggling to
adopt more modern approaches to patient care.
Amplifying the fragmentation is the failure to ensure
that behavioral health is fully integrated into the mainstream of health information technology (HIT). Strong
HIT is a cornerstone of effective coordinated and integrated care; it has the potential to enable the automated provision of outcome assessments to patients
and to summarize data in practical formats to facilitate
provider decision making, quality measurement, and
improvement. However, behavioral health providers
face key barriers of cost, sustainability, concern about
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privacy and information sharing in the context of behavioral health conditions, and regulation in implementing electronic health record (EHR) systems. Notably, the 2009 Health Information Technology for
Economic and Clinical Health (HITECH) Act—which promotes the adoption of EHRs in medical settings, authorizes financial incentives for HIT uptake, and defines
minimum acceptable standards for EHR systems—
excludes behavioral health organizations and nonphysician providers from eligibility for the HIT incentive payments and thus renders EHR implementation
and sustainability prohibitively expensive for many of
these providers.
Until our nation establishes shared accountability in
culture and in practice and integrates the various elements of its care systems, good outcomes and valuebased efficient service strategies are unlikely to be
achieved.
An Undersized, Poorly Distributed, and
Underprepared Workforce
The diversity of health care workers required to deliver effective care of Americans who have behavioral
health and complex medical conditions includes professionals with a wide array of backgrounds and skills,
including physicians, psychologists, nurses, mental
health and substance use counselors, care managers and coordinators, and social workers. Our current
workforce is undersized and inadequately resourced,
and available providers often lack the specific skills and
experience to offer effective evidence-based and integrated care. Racial, ethnic, and geographic diversity of
the workforce is lacking, and there is extreme maldistribution of behavioral health professionals; people in
rural and impoverished areas have limited access.
Psychiatry is the only medical specialty other than
primary care in which the Association of American
Medical Colleges has identified a physician shortfall, a
deficit that will get progressively worse by 2025 if not
addressed (IHS, 2015). According to the federal government, in 2013, the nation needed 2,800 more psychiatrists to address the gap (IHS, 2015, p. 11). But the psychiatry deficit is growing. For example, the number of
psychiatrists per 10,000 of population decreased from
1.28 in 2008 to 1.18 in 2013 (Bishop et al., 2016). It is difficult to see how the current national infrastructure for
psychiatry training would address the gap, inasmuch
as only 1,373 medical-school graduates matched to
psychiatry in 2016 (NRMP, 2016). The number of PhD
psychologists was virtually unchanged over the same
period (Olfson, 2016). Similar trends persist for social
workers and substance use counselors. The constant
size of the mental health and substance use provider
workforce is one factor that has made it so difficult for
many people who have behavioral health needs to get
access to services. One recent study found that twothirds of primary care physicians report that they cannot obtain referrals to psychiatrists for their patients
in need (Roll et al., 2013). Workforce shortages exist
in most areas of the country, but some locales have
rather small numbers of trained professionals who are
delivering behavioral health services.
Providers in different parts of our care system are
not sufficiently incentivized to work efficiently as a coordinated team to identify, engage, and manage care
effectively for people who have both medical and behavioral health conditions. Primary care doctors need
to be effective in identifying mental health and substance use problems and in engaging patients to get
the care that they need on a continuing basis. Similarly,
behavioral health providers need to be prepared to
identify medical problems faced by patients and either manage patients or link them to required medical care.
Mental health and substance use providers often lack up-to-date training in delivery of empirically supported treatments. In addition to shortcomings in specific
clinical skills, behavioral health providers often work in solo or small independent practices, and our training system has not prepared them to work effectively in teams or collaborative settings. Nor has our payment system offered incentives to encourage providers to work in these settings. Working in isolated practice settings also limits the adoption and implementation
of integrated delivery approaches. In addition, reductions in public-sector programs, low percentage of
commercial insurance premium attributable to behavioral health, and low market rates for these services
help to keep the numbers of people entering these professions low and thereby limit access to care and the ability of providers to embrace and implement new technologies.
There are important needs and barriers regarding
care for behavioral health conditions in children and
youth—in whom these conditions typically emerge.
There are clear benefits to early intervention, but effective treatments are often not implemented. The relative shortage of child psychiatrists serves as a major barrier to developing effective integrated care models for this population. And there are profound challenges at the other end of the age spectrum as a consequence of the growing number of older Americans
and the high prevalence of chronic conditions in this
population (IOM, 2012).

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Finally, our health system has not made full use of
new communication technologies, such as telehealth and mobile health, to leverage the capacity of the existing behavioral health workforce. New technologies
are simplifying communication with patients and offering opportunities for real-time health monitoring of
patients. A major barrier has been tensions regarding
information sharing and confidentiality that are specific to clinical substance use and mental health data.
Emerging technologies have the capacity to overcome
those barriers and improve the productivity and effectiveness of the workforce, but it is crucial to integrate
new technologies with other treatment approaches so
that they do not constitute an extra burden but rather become a seamless part of practice that enhances
outcomes.
Payment Models that Reinforce Care Silos and
Fragmentation of Care
The dominant approach to medical care and behavioral health care reimbursement is to use a fee-forservice (FFS) system. Essential elements of integrated
care (outreach, provider-to-provider consultation, and
population management) are often not reimbursed.
FFS payment does not provide the flexibility to implement needed coordinated care effectively. Moreover,
the current FFS system does not sufficiently value payment for behavioral health services (which are generally cognitive and time based, as opposed to procedure
based).
In theory, bundled or capitated approaches can allow more flexibility in how resources are used by a
provider and allow a broader team of professionals to
coordinate the care of patients. However, the methods
for implementing and pricing capitated payment arrangements are less than ideal for patients who have
behavioral health conditions.
One barrier is that the wrong provider may be capitated. For example, if a physician group receives a
fixed payment for managing the nonhospital care of
patients, the effects of better treatment approaches
on hospital use will not accrue to the provider. In the
case of Medicaid, the capitated payment by a state
government to a managed care organization might be
distributed to individual providers by using FFS payment approaches; the actual provider has little flexibility to use the capitated payment to improve outcomes
and efficiency.
One other substantial challenge in using reimbursement schemes to provide incentives to make care
more effective is that the needs of patients who have
behavioral health conditions can vary from one patient
to another. Thus, capitated or bundled payments for
patients who have behavioral health conditions need
to be appropriately risk adjusted to account for differences in the expected costs of care for different
patterns of problems. McGuire shows that current
risk-adjustment approaches are not sophisticated
enough to pay providers the fair amount for high-need
patients (McGuire, 2016). That failure can lead providers and payers who use capitated payment systems to
discourage the enrollment of
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insurance plans (Bishop et al., 2014; Boccuti et al.,
2013). Of all physician specialists, psychiatrists are
least likely to accept new Medicare patients. Only 64%
of psychiatrists report that they accept new Medicare
patients in their practices, whereas 53% report taking
new patients who have private noncapitated insurance, and 44% take new Medicaid patients (Bishop et
al., 2014). Thus, a large number of psychiatrists accept
only new patients who have the capacity to pay higher
fees out of pocket (Bishop et al., 2014; Boccuti et al.,
2013).
Facilitators of Potential Improvements in Care
There are opportunities to overcome the barriers to effective care to improve the well-being of people who
are coping with mental health disorders, substance use
disorders, and medical care conditions. A new administration can take advantage of the opportunities both
to improve outcomes for people who have those problems and to reduce the financial burden of the services
that they need. Several key facilitators are described
below.
Know-How
Effective Treatments
Abundant evidence demonstrates the acceptable efficacy of several pharmacologic, psychotherapeutic, and
behavioral treatments for management of most mental health disorders. In addition, there is a substantial
evidence base supporting the efficacy of psychotherapies and pharmacotherapies for treatment for substance use disorders. Recent progress led to Food and
Drug Administration (FDA) approval of medications
for treatment for smoking, alcohol use disorders, and
opioid dependence. There are not yet FDA-approved
pharmacotherapies for treatment for cannabis use
disorder, stimulant use disorders (involving cocaine,
amphetamine, or MDMA), or hallucinogen abuse disorders (involving ketamine, PCP, LSD, or psilocybin). With
the possible exception of disulfiram (Antabuse) treatment for alcohol use disorders, which generates high
rates of abstinence among fully adherent patients (the
minority of treated patients), medications for addiction
are more successful in reducing the intensity of use of
the abused substance than in producing and sustaining abstinence. That finding has led to a growing focus
on reducing the harm associated with substance use
as a treatment objective that may complement that of
attaining total abstinence. In addition, there are various group and individual therapeutic approaches and
counseling strategies that have favorable effects on
the lives of people who use such services. The growing recognition of the link between early life trauma,
mental health, addiction, and poor health outcomes
has led to increased interest in trauma-informed care.
With the increasing evidence base, there is a need to
develop, train in, and implement these approaches.
Effective Models of Care
Substantial investment in research and demonstrations has improved our understanding of what effective care is. Examples of models of care that have been
demonstrated to be effective and scalable are collaborative-care models in primary care, integrated-care
models in mental health clinics, team-based assertive
community treatment programs for people who have
severe mental health disorders, and early-intervention
programs for first-episode psychosis.
The Current Imperative for Integration
Health care providers around the country have entered an era of business integration. Hospitals are
merging, hospitals and physician practices are merging, and traditional medical care practices are affiliating more closely with mental health, substance use,
long-term care, oral health, and social service providers. In part, the imperative for integration is driven by
market forces that seem to encourage scale and scope
in service offerings. But the integration imperative also
has been encouraged by federal policy initiatives that
have created financial incentives for providers to integrate, especially with a focus on services supported by
Medicare and Medicaid.
Changing Approaches to Paying for Care
The first and foremost principle that has to be adopted
is that payment by payers and provider agencies should
be reasonable and adequate for evidence-based practices. If that simple principle is not observed, all other
issues will remain difficult to solve.
In addition to integration, our national health system has been exploring a broad array of value-based
payment systems that reward providers for good outcomes rather than for the volume of services provided.
Experiments in changing incentives in payment systems are occurring among the three key types of payers: Medicare, Medicaid, and private insurers.

Value-based approaches and bundled-payment
models not only create better incentives to improve
outcomes but allow flexibility to support nontraditional services or nontraditional providers that are
central to integrated care. For example, Coloradobased Rocky Mountain Health Plans is testing whether
a global payment model can support the provision
of behavioral services in local primary care practices.
Under the Sustaining Healthcare Across Integrated Primary Care Efforts pilot, which was launched in 2012,
three practices in western Colorado that have already
integrated behavioral health care are receiving global
payments to pay for team-based care; three integrated practices that earn FFS payments are serving as
controls.
Insurance Expansion and Mental Health
Parity Laws
The large increase in the number of Americans now
covered by health insurance because of the Patient
Protection and Affordable Care Act (ACA) facilitates improvements in the care of people who have complex
conditions. And insurance policies offered in the ACA
marketplaces are required to cover behavioral health
services. Furthermore, recent health parity laws prevent insurers from placing greater financial requirements (such as co payments or treatment limits) on
mental health services than are placed on medical care
services in any insurance policy offered. Those laws
will substantially expand financial access to a full array
of behavioral health services. Community Access To Mental Health Services Discussion Essay.
Technology
Advances in technology have the potential to enhance
access to and quality and cost efficiency of behavioral
health and mental health care.

 

Electronic Health Records
Quality and cost efficiency of care rely on effective and
efficient communication among providers and on the smooth flow of information into and among medical
records. Community Access To Mental Health Services Discussion Essay.Similar benefits could derive from EHR use in behavioral and mental health, but their adoption has been notably slow. In fact, in comparison with the rapid rise in EHR use in general medical and primary
care settings, less than 20% of behavioral health facilities have adopted EHRs (Walker et al., 2016). Reasons
for slow adoption include concerns about information
sharing and confidentiality that are specific to clinical
substance use and mental health data and to the cost
and affordability of HIT, particularly in small and widely
disseminated practice settings, which have substantial
financial barriers to adoption. To realize the benefits of
HIT, innovative solutions are needed to address confidentiality issues and provide incentives for behavioral
health providers to purchase and use the technology
in ways that are integrated into general medical systems. Innovative solutions are also needed to make
the EHR more efficient, more informative, and easier
for providers to use. Community Access To Mental Health Services Discussion Essay.
Technology-Enabled Therapy for Behavioral and
Mental Health
Technology-based therapies that patients can access with greater ease and at lower cost than faceto-face conventional psychotherapy have been
developed, such as Mood Gym (Australia National
University, 2016), Beating the Blues (2015), and
ThisWayUp (2016) (Richards and Richardson, 2012).
Although much work remains to optimize the application of the therapies in clinical settings, evidence suggests that with proper patient selection and appropriate strategies for successful engagement, patients
who have less complicated psychiatric needs (such
as for mild to moderate depression or anxiety) can
derive clinical benefit at lower cost while overcoming
the logistical hurdles to access, including basic availability of clinicians in a locale. Such on-line resources
are rapidly expanding to cover a broad continuum
from educational and self-help materials to modular
offerings that emulate manualized evidence-based
cognitive behavioral therapies. Community Access To Mental Health Services Discussion Essay.
Virtual visits provided by clinicians over the Internet improve access and outcomes principally by enhancing patient convenience. Compelling examples
include geriatric patients who have mobility challenges and young patients who have autism and for
whom transport to a doctor’s office can be difficult
or even prohibitive. Community Access To Mental Health Services Discussion Essay.In such instances, the ability to hold a session by video conference can reduce cancellations and “no shows” and give clinicians a better
window into behavior in the actual home context.
Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders
NAM.edu/Perspectives Page 7
Summary Recommendations for Vital
Directions
To improve the lives of people who have behavioral health and medical conditions, it is essential that
public policy play important roles in changing the approach to delivering services to this population. The
following three vital directions are critical for improving outcomes by increasing access to effective services:
• New payment approaches that recognize the costs
of managing the care of patients who have complex
conditions and that encourage the use of teams
and technology to identify, engage, and manage
the care of such patients. Community Access To Mental Health Services Discussion Essay.
• Investment in strategies and programs to expand,
improve, diversify, and leverage— through technology and more efficient team-based approaches—
the clinical workforce and to develop incentives to
improve service in underserved areas.
• Development and implementation of clearly measurable standards to encourage dissemination of
tested organizational models and to establish a culture of shared accountability to integrate the delivery of services.
Implement Payment Models That Support Service
Integration
The current approach to paying for behavioral health
care and general medical care will never lead providers
to meet the needs of people for these types of care adequately. The emphasis is on payment for the volume
of service provided, and incentives to push providers
to focus on patients’ outcomes are not in place.
A first public-policy goal should be greater use of payment approaches that offer incentives to providers to
improve outcomes by paying adequately for evidencebased services. Current trends toward more integration of service capacity among health care providers
will make it more likely that the provider system will
develop care approaches that meet the varied needs
of people who are facing behavioral health challenges.
To design a payment system that works, we need
a blend of policy strategies that create incentives
for good care for the full array of patients who have
behavioral health conditions:
• Payment models should encourage quality and
value, as well as allow flexibility, so that providers
can choose management strategies that will lead to
the best possible outcomes. Through Medicare and
Medicaid, the federal government can lead the way
in the transition to value-based payment.
• People who have complex behavioral health and
medical conditions should be specifically encouraged to enroll in Medicaid programs and exchange
policies offered through the ACA. Community Access To Mental Health Services Discussion Essay.
• Payments should be risk adjusted with sophisticated methods so that providers are paid appropriately to ensure that adequate resources flow
to providers who care for the neediest in our
population.
• Regulations to complement new reimbursement
approaches should be implemented so that there
is a level playing field for providers and so that delivery of adequate care will be guaranteed.
Such strategies should have high priority in the
coming years and could lead to better outcomes and
more efficient use of our medical care investment.
Train a Workforce Skilled in Managing Behavioral
Health Conditions
The workforce needs to grow and diversify to meet the
demand to engage and serve people who have mental
health and substance use disorders more effectively.
Access to insurance is growing, but insurance is not
valuable if there are no providers to deliver needed
services. The development of innovative organizational models for managing behavioral health conditions
is laudable, but they will not be sufficiently implemented if there is not a workforce that understands and is
trained to deliver services with the new models of care
that have been tested in careful studies.
A new administration should give high policy priority to ensuring that our health-system workforce can
deliver the services required to improve outcomes for
people who have behavioral health conditions. Three
policy approaches could contribute:
• Fund well-tested programs that could encourage new
entry into the behavioral health services field. A wide
array of federal programs supports the training of
physicians and other traditional medical care providers, such as nurses and dentists. For example,
the federal Bureau of Health Workforce oversees
loan repayment programs for physicians and
dentists, and scholarship programs are aimed at increasing the numbers of primary care physicians,
dentists, and nurses. Those programs should be
expanded and should focus on increasing the numbers of professionals who care for people who have
mental health and substance use disorders.
• Provide opportunities for providers to learn principles of care coordination and of teamwork. Building an effective workforce to improve outcomes
of people who have mental health and substance
use disorders requires more than scaling up of the
workforce. Public policies should also focus on new
skills for members of the workforce. Educational
programs directed at the skills needed to work in
teams and the skills needed for effective care coordination are needed around the country. Similarly,
primary care physicians need additional training
to be comfortable in working collaboratively with
providers of care for mental health and substance use disorders because they must often manage patients who have these conditions, especially patients whose disorders are mild to moderate.
• Spread use of new technologies that leverage the workforce. New technologies that can help leverage the
skills of providers in this field are being developed
each year. Community Access To Mental Health Services Discussion Essay.For example, telehealth technologies can
link psychiatrists to primary care providers in rural
areas who require help in diagnosing problems and
developing treatment plans. Public policy should
correct the failure to provide the needed incentives
for behavioral health organizations and providers
to invest in and use tools and information systems
to “defragment” care and accelerate the development of new technologies that assist in managing
behavioral health care. Federal policies should fund
training to help the existing workforce to learn how
to use technology more effectively to leverage the
ability to treat as many patients as possible and as
effectively as possible. Community Access To Mental Health Services Discussion Essay.
Develop Incentives to Disseminate Tested
Organizational Models
A third vital direction for public policy in behavioral
health is to fund improvements in know-how for building better care models, in organizational strategies,
and in accountability to attain better outcomes.
Expand Investment to Develop, Evaluate, and Implement
Behavioral Health Quality Measures
Better care models can be identified only when there
are clear, routinely collected quality measures for
tracking the effectiveness of health care integration.
Several strategies could support development of measures at the interfaces between behavioral health care
and general medical care:
• Expanding expectations for health systems to establish structural mechanisms for integration of
mental health care, substance-abuse care, and
general health care. This could include expanding
requirements for accreditation or recognition programs, such as Patient-Centered Medical Home,
that focus on the population of people who have
mild to moderate behavioral health conditions and
are being seen in general medical settings.
• Expanding measures that focus on access to effective behavioral health care and behavioral health
outcomes for patients in general medical care
settings. Community Access To Mental Health Services Discussion Essay.
• Developing measures to assess access to preventive health services, primary care, and chronic-disease care for people in behavioral health care settings and to assess their associated outcomes.
Beyond specifically developing measurement strategies for integrated care, a lead agency should be identified that has responsibility, expertise, and resources
for stewarding the field of behavioral health quality
measurement to be held accountable for their development.Community Access To Mental Health Services Discussion Essay. In collaboration with other public and private
stakeholders among the “six Ps”—patients, providers,
practice organizations, payers, purchasers, and policy
makers—that agency should develop a coordinated
plan to implement this and the next two recommendations (Pincus et al., 2003).
Take Action to Overcome Barriers to Improve and Link
Data Sources
Effective integration of behavioral health and general
medical care must incorporate strategies to develop,
implement, use, and coordinate HIT to meet the needs
of consumers who have behavioral health conditions
and of their health care providers and systems.
Gaps in standardizing and capturing behavioral
health information must be addressed. For example,
under the HITECH Act, SNOMED-CT and LOINC are
mandated medical terminologies for the exchange
of clinical information, but if these terminologies
do not accommodate behavioral health needs, the
goals of the act cannot be achieved. A recent Institute of Medicine report recommended incorporating
Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders
NAM.edu/Perspectives Page 9
evidence-based behavioral health psychosocial intervention in classification systems, such as Current
Procedural Terminology (IOM, 2015). Policies and
regulations should include specifications for standardizing behavioral HIT among different general medical,
mental health, and substance use treatment settings
to ensure data sharing and data transportability. More
sophisticated information-exchange protocols are
needed to address behavioral health privacy and security concerns. Vendors should be expected to develop
EHRs that enable tagging of specific data elements
with different privacy levels; this would be important
for accommodating the use of consumer-driven technologies, such as mobile applications. Finally, behavioral health clinical organizations and nonphysician behavioral health providers will need funding (possibly as
part of bundled payments) to assist in deploying and
using HIT that meets specifications that the HITECH Act
provided for hospitals and physicians.
Conduct Research to Develop the Evidence Necessary to
Expand Our Treatment Armamentarium and Support a
More Robust and Comprehensive Set of Standards and
Measures
Standards and measures should be developed to
• Document the mechanisms underlying mental
health and substance use conditions better. Community Access To Mental Health Services Discussion Essay.
• Develop and test new, more effective, safer treatments.
• Determine which treatments achieve the best outcomes for different types of patients, especially in
the context of different comorbidities.
• Implement evidence-based treatments.
Collaboration among funding agencies and health care
organizations should inform the development of a research agenda that could marry the goals of intervention development and testing with the needs of quality
measurement and improvement at clinical, organizational, and policy levels.

 

Conclusions and Summary
We face substantial and enduring challenges to improve the lives of many Americans who cope with
mental health and substance use disorders. Those disorders are often chronic, and recovery can be a lifelong process, but better outcomes and the potential
for better life courses are within easy reach for our
society. There are barriers to progress, but our nation
is at a moment when there also are many facilitators
that can help us to make striking progress in improving people’s lives. We have much of the know-how that is needed, and now we need to put the know-how into action.
It will take the energy and commitment of many parts of our society to improve outcomes for people who have mental health and substance use disorders, especially in the presence of other medical problems that these people commonly face. We need supportive, and supported, families, supportive workplaces,
supportive health providers, and supportive communities. But public policy at the federal level can also play a role in leading progress in this social challenge. Community Access To Mental Health Services Discussion Essay.
Three vital directions are offered to guide efforts to improve behavioral health care across our nation:
• New payment approaches: Develop and apply
new payment approaches that provide fair payments that recognize the costs of managing the
care of patients who have interacting medical and behavioral health conditions and encourage the use
of teams and technology to implement evidence based strategies to identify, engage, and manage
the care of such people effectively.
• Workforce development: Invest in strategies and
programs to expand, improve, diversify, and leverage—through technology and more efficient teambased approaches—the clinical workforce and to
develop incentives to improve service in under served areas.
• Standards and incentives to disseminate tested organizational models: Encourage and invest
in improvements in know-how for building better care models, clinical and organizational strategies, and accountability mechanisms to attain better outcomes. Measurable standards must be created to implement incentives to diffuse tested organizational models and establish a culture of shared accountability to integrate the delivery of services.

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There are barriers that make progress difficult, but there are also clinical and policy strategies that hold potential for enabling striking progress in improving the lives of people who face these challenges. We have much of the know-how that is needed, but we need to put it into action. Community Access To Mental Health Services Discussion Essay.

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Suggested Citation
Knickman, J., K.R.R. Krishnan, H.A. Pincus, C. Blanco,
D.G. Blazer, M.J. Coye, J.H. Krystal, S.L. Rauch, G.E.
Simon, and B. Vitiello. 2016. Improving Access to Effective Care for People Who Have Mental Health and
Substance Use Disorders. Discussion Paper, Vital Directions for Health and Health Care Series. National
Academy of Medicine, Washington, DC. https://nam.
edu/wp-content/uploads/2016/09/improving-access-to-effective-care-for-people-who-have-mentalhealth-and-substance-use-disorders.pdf.
Author Information
James Knickman, PhD, is Derzon Clinical Professor,
Robert F. Wagner Graduate School of Public Service,
New York University. K. Ranga Rama Krishnan, MB,
ChB, is Henry P. Russe Dean of Rush Medical College
and is Senior Vice President for Medical Affairs, Rush
University Medical Center. Harold A. Pincus, MD, is Professor and Vice Chair, Department of Psychiatry,
College of Physicians and Surgeons, and is Co-Director, Irving Institute for Clinical and Translational Research,
Columbia University and is Director of Quality and
Outcomes Research, New York Presbyterian Hospital.
Carlos Blanco, MD, PhD, is Division Director, Division
of Epidemiology, Services, and Prevention Research,
National Institute on Drug Abuse, National Institutes
of Health. Community Access To Mental Health Services Discussion Essay.Dan. G. Blazer, MD, PhD, MPH, is J.P. Gibbons Professor of Psychiatry Emeritus, Duke University
Medical Center. Molly J. Coye, MD, MPH, is Executive in Residence, AVIA. John H. Krystal, MD, is Robert L. McNeil Jr. Professor of Translational Research,
and Chair, Department of Psychiatry, Yale University
School of Medicine. Scott L. Rauch, MD, is President,
Psychiatrist in Chief, and Chair, Partners Psychiatry and Mental Health, McLean Hospital. Gregory E.
Simon, MD, MPH, is Senior Investigator and Psychiatrist, Group Health Research Institute. Benedetto
Vitiello, MD, is Chief, Treatment and Preventive Interventions Research Branch, National Institute of Mental
Health, National Institutes of Health. Community Access To Mental Health Services Discussion Essay.