This year, Congress could finally pass a wide-ranging package of reforms designed to overhaul the nation's broken mental healthcare system, increasing the volume of psychiatric beds and boosting treatment for young patients with mental health disorders.
But that pending bill — first introduced after the Sandy Hook shootings in 2012 — is just a first step in reforming a system that hasn't kept pace with a changing understanding of the brain. That was the conclusion of dozens of clinicians, researchers and policymakers who attended a day-long symposium called “Synaptic Gap: 21st Century Brain Science Meets Mental Health Policy."
The late September event, hosted by Massachusetts General Hospital as part of the HUBweek festival, took a hard look at the economics of mental health care and challenged attendees to find new ways to improve individual patient care and treatment policy. Here are the main takeaways.
1. Don't define mental health too broadly
While many other areas of medicine are segmented, behavioral health conditions tend to get lumped into one big category. But it's wrong to think about mental health in the aggregate, said Emma Stanton, associate chief medical officer for Beacon Health Options, which provides behavioral health solutions for health plans and employers.
“We need to be thinking about what population we're treating, whether substance abuse, depression or suicidality," Stanton said. “Our inability to segment the population into those meaningful groups is what has hampered our ability to get a payer system that reflects where we need to be today."
2. Know what not to do
Marriage problems and losses of loved ones can be traumatic, but they often don't bring on chronic mental health disorders. When patients experience these types of adverse life events, speakers said, they don't necessarily need to be referred to out-of-practice therapists for treatment.
In addition, speakers said, physicians should consider treatment options that can be monitored in a primary care setting. For some patients, computerized cognitive behavioral therapy can deliver as good or better outcomes as seeing a therapist face-to-face, according to a 2014 study in World Psychiatry. The electronic program improves access to mental health care by letting patients use it at their convenience for little to no charge.
3. Take a team-based approach to care
Experts at the symposium agreed that integrating mental and physical healthcare in one setting provides great benefits to both patients and their physicians. Just as physicians can't refer every patient with diabetes to an endocrinologist, they shouldn't refer every patient with mild depression to a psychiatrist, said Toyin Ajayi, M.D., chief medical officer for Commonwealth Care Alliance.
“We have a huge need to reframe the role of the medical care provider," she said. “We need to integrate care in a way that is person-centered."
Ajayi's comments are supported by a 10-year study from Intermountain Healthcare, published in the Journal of the American Medical Association, which found that delivering integrated mental and physical healthcare in team-based primary care settings resulted in more preventative measures, fewer total visits and lower costs.
The study tracked 113,452 adult patients in 113 primary care practices and found that in team practices, 48.4 percent of patients had self-care plans, compared to 8.7 percent in traditional practices. Patients in team-based practices were estimated to have seven percent fewer visits over their lifetimes.
4. Get beyond fee-for-service
Many experts agreed that mental health care will improve when practices move away from the fee-for-service model, which compensates doctors only for the assistance they provide to patients in front of them, rather than any proactive measures they take.
Massachusetts' Medicaid program, MassHealth, is moving toward accountable care, in which health care professionals are paid a set amount to treat patients — and incentivized to take steps they wouldn't be compensated for under fee-for-service, such as arranging patient rides to appointments.
“We're putting new investment dollars into behavioral health to increase the earning power of primary care providers who have to partner with behavioral health practitioners," said Massachusetts Secretary of Health and Human Services Marylou Sudders. “We're trying to raise incentives for a desegregated health care system."
Some hospitals and practices are moving toward bundled payments, in which providers assume financial risk for the cost of services for a particular treatment or condition, as well as costs connected to preventable complications. A recent survey from the consulting firm PricewaterhouseCoopers found that 31 percent of hospitals and 20 percent of employers surveyed had adopted bundles, many for chronic physical health conditions. Out of those adopters, 34 percent achieved a savings of more than 6 percent.
5. Consider non-medical approaches
Better mental health doesn't have to come from services in the healthcare system, said Amitabh Chandra, Ph.D., director of health policy research at Harvard's Kennedy School of Government. Instead, we should also consider the role people other than doctors, such as teachers and social workers, can play in promoting mental health and awareness.
“There's a tendency for all of us to confuse the thing we want, which is better health, with the thing we want to deliver, which is health care," he said. “My worry has been that, while I've always supported insurance expansion, we're privileging the kind of care that gets reimbursed by insurance."
Allison Pohle is a writer based in Boston.