Mental health stigma dissipates, but cost and coverage barriers remain

More than half (56%) of 5,024 Americans surveyed want mental health services either for themselves or for a loved one, but about three-quarters said there are access issues, with 34% pointing to cost or poor insurance coverage, according to a survey commissioned by Cohen Veterans Network and National Council for Behavioral Health. Others pointed to social stigma, lack of direction and poor quality of care as barriers to mental healthcare.

"Access has been a major problem. It is a crisis in America," said Anthony Hassan, president and CEO of Cohen Veterans Network. "When you wonder why there are such high suicide rates among children, it's because they are not getting the care when they need it."

Sometimes cost is prohibitive and providers are overworked. Some CEOs of community health centers are operating on shoestring budgets that make it hard to hire skilled staff, employ evidence-based practices and adopt new technologies, he added.

One in four reported having to choose between getting mental health treatment and paying for daily necessities. Nearly one in five of Americans, or 17%, noted they have had to choose between getting treatment for a physical condition and a mental health condition due to their insurance coverage, or lack thereof.

If they can afford it, 38% have had to wait longer than one week for mental health treatments and nearly half (46%) had to, or know someone who had to drive more than an hour round-trip to their appointment.

Part of it is that there isn't uniform standards of care throughout the country, said Linda Rosenberg, president and CEO of National Council for Behavioral Health, citing variations in Medicaid coverage, demographics and policy.

"There is no national standard so it's not clear if what they are getting is the best evidenced-based practice," said Rosenberg, adding that reimbursement becomes much more uncertain after residential treatment.

Minimal reimbursement also limits telehealth options to treat behavioral health, Rosenberg said.

While most have heard that telehealth is an option for treating mental health issues, only 7% have reported using it. When asked if they would be open to using it, 45% of those who have not already tried telehealth services for mental health said they would be open to it.

While there has been progress, "we still have a long way to go until telemedicine is fully reimbursed by Medicaid, Medicare and commercial insurance in all instances," Rosenberg said.

More than three-quarters surveyed believe mental health is just as important as physical health. But as the stigma of dealing with mental health has diminished, it's still a hurdle.

Thirty-one percent of those surveyed said they have worried about others judging them and 21% have even lied to avoid telling people they were seeking mental health services. This stigma is particularly true for younger people, who are more likely to worry about being judged, according to the survey.

"Stigma is no longer the No. 1 barrier," Rosenberg said. "Where we get care and how do we pay for it is the big problem."

The survey also included a state-by-state breakdown that indicated states are struggling to keep up with demand due to lack of funding and facilities.

Texas, Wisconsin and Georgia ranked among the lowest because they don't have enough providers, facilities and funding to support their needs. Pennsylvania, New York and Minnesota were some of the best in meeting demand.

There is also a large disparity in access to mental healthcare based on income and location. Coverage gaps are felt acutely in rural areas and by lower-income individuals.

Philanthropy can help fill those gaps, Hassan said. Billionaire hedge fund investor Steven Cohen pledged $275 million to create a national network of free mental health clinics for military veterans and their families. The Cohen Veterans Network will use that donation to open 25 clinics by 2020.

As for a more permanent solution, Medicare has started to pay for collaborative care, where a mental health counselor or case manager can get paid to join a primary-care physician during a visit, or a psychiatrist can remotely sit in, Rosenberg said. It's also important that the Mental Health Parity and Addiction Equity Act is enforced in each state, she said.

The act requires health insurers that cover mental health or substance abuse treatment to offer coverage commensurate for medical and surgical care. But ParityTrack found that the proportion of inpatient care that was provided out-of-network was more than four times higher for behavioral care than medical/surgical. Also, medical/surgical providers received higher reimbursement rates than behavioral providers for comparable services.

While the recently passed federal opioid bill was a step in the right direction, it did not require long-term funding for mental health and substance abuse treatment, only temporary pilot programs, Rosenberg said.

"Providers need to be reimbursed based on cost, not rely on a seed grant from the state government," she said.

Certified community behavioral health clinics, which are similar to federally qualified health centers but specialize in mental health and addiction, receive cost-based reimbursement and provide evidence-based treatment, are valuable resources, Rosenberg said.

"We are seeing the beginning of solutions to meet the growing demand," she said.

The growth of peer-to-peer counseling efforts aided by technology is also promising, Hassan said.

"That could be an important part of continued care before and after treatment," he said.