Our Mental Healthcare Apparatus Is Broken, but We Can Fix It

Financial incentives in our mental healthcare system have an outsized influence on why we are failing.

Source: Ibrahim Boran/Unsplash

A mental health crisis has emerged from our year of distressing pandemic life, but society is not responding the way it should.

Forty percent of US adults are experiencing symptoms of depression and anxiety [1]. For many people living with mental health disorders, the pandemic has exacerbated their conditions. The pandemic has been a disastrous introduction to a national apparatus ill-equipped to meet the demand for mental health treatment for others with no formal psychiatric history.

People in need of help are, in many ways, unable to access it [2]. To those who do not work in mental healthcare, this may seem like another rung in the long ladder of disappointing societal responses to our pandemic. I believe, however, that the system has been broken for decades and that the pandemic is simply revealing it more egregiously to the world.

Before Covid-19, patients struggled to navigate a tiered mental health system where patients are often not treated equally. These discrepancies can be secondary to local geographic resources, but they're also present squarely because of socioeconomic disparities found in every corner of the healthcare landscape. For years now, there has been a trend of third-party payers almost ubiquitously reimbursing mental healthcare at lower rates than other medical specialties with similar levels of training [1, 3]. As a result, a market for private practice psychiatrists and therapists emerged that caters to those who can only pay for mental healthcare in cash.

Financial incentives in our mental healthcare system have an outsized influence on why we are failing.

Source: Ibrahim Boran/Unsplash

The Broken System at Work

While this phenomenon may occasionally exist in boutique primary care practice or dermatologists and plastic surgeons who perform cosmetic work not covered by insurance, psychiatry is the only area of medicine where the out-of-pocket business model is widespread and well accepted.

While some medical centers do not allow for out-of-pocket payments, many academic psychiatrists working at top university medical centers for part of their day see private patients at other hours. The same doctor might accept Medicaid at the hospital but take no insurance in their private office an hour later. The patients who are seen privately engage in treatment with their doctors and therapists outside of the insurance-based reimbursement model altogether, giving them greater flexibility in the kinds of therapies being offered.

People without the means to pay privately must find practices or clinics where insurance is accepted. Even within this apparatus, an access-related bias occurs strictly based on wealth and structural discrimination. While most major medical centers accept mental health patients with any form of insurance and provide reputable care, many psychiatrists in the community may choose to only see patients under certain commercial insurance plans that they feel adequately value their time, effort, and expertise. This approach – reasonable from the perspective of the individual practitioner – is detrimental to our society at large and may exclude patients with public plans that tend to reimburse less for certain forms of treatment, such as the traditional 50-minute psychiatric session.

I have first-hand experience in this access discrepancy because while I am able to see patients with versions of Medicare and MassHealth (i.e., Medicaid) in my academic medical center, I also have a small practice outside of my hospital position both to supplement my income and also to allow me to do integrated care where I can see patients for medication management and therapy in the same setting.

The clinic model, employed by mental healthcare centers around the country – and specifically where many patients with public insurance can access care – has for years financially incentivized providers to see more patients per hour with shorter visits. Reframed, I believe that most patients with public insurance are receiving a fundamentally different kind of care secondary to the structural systems erected years ago that govern our practice today.

The System Needs to Be Rebuilt

For decades, the system has been broken, incentivizing the development of a socio-economically based class system for mental healthcare access that by definition funnels most Americans into oversubscribed clinics and health systems where lengthy wait lists are the norm [4]. Similarly, patients with acute and severe mental disorders needing hospitalizations sit in overcrowded emergency departments awaiting placement in part because inadequate reimbursement has led to reduced inpatient psychiatry beds [5].

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What are the solutions? Increasing access for all means increasing reimbursement for all psychiatric services that truly achieve parity with other medical specialties. It also means eliminating barriers to care across state lines; no field is better suited to embrace permanent and effective use of telehealth than outpatient psychiatry. If new apps can provide remote care from well-trained and properly credentialed mental health providers, this too can be a resource that can help engage an entirely new part of the population in need.

Most importantly of all, the solutions moving forward begin with destigmatizing mental healthcare to be adequately valued within society. The demand is increasing, but the supply is frozen because the societal apparatus does not yet account for the value of mental healthcare. Let's change that.