Academic Medicine Open Forum

Another recent poll from KFF and CNN confirmed that nine out of ten Americans believe we have a mental health crisis. But what, exactly, does that mean?

For most of us, it means that we can't get the care we need for the anxiety, depression, substance use disorders, and other mental health issues we're now (at least slightly) more willing to acknowledge we/our families/our friends have. We know even those of us with insurance for our bodies seem to fight endless battles to get care for our minds.

So how do we begin to address the crisis?

My colleagues and I at the AAMC Research and Action Institute have put together a new issue brief that explores:

• The magnitude of the mental health workforce shortage;
• The false promise of parity from insurers; and
• The barriers to integrating care for our minds along with our bodies.

(well, except for our teeth and eyes-that's a whole other issue)

Above all, how can we begin to get our friends, families, and ourselves the mental health care we need? We would love to hear your thoughts on how we can access this care and how you have been bringing awareness around this topic, with Oct. 10 being World Mental Health Day.

• The ongoing impact of stigma and discrimination as well as implicit bias related to individuals with psychiatric disorders including substance use disorders (e.g., https://pubmed.ncbi.nlm.nih.gov/34932103/) 
• The ways in which these implicit biases extend into medical and residency education, in interactions with patients as well as with trainees and colleagues.  As one example, students who consider psychiatry training are still asked by other specialists or mentors why they would want to pursue a psychiatric career and "waste" their medical education.
• The phantom network issue is real but the insurance panels are particularly deceptive in implying that all listed psychiatrists have office based practices. The practice setting is not listed in the insurance listing nor is the person's subspecialty (child vs. adult vs. geriatric psychiatry). Hospital based psychiatrists typically do little or no outpatient care yet we need to be on insurance panels for hospital care to be covered.  It's no wonder that patients calling for appointments just give up. 
• Low reimbursements are one part of lack of psychiatrist participation in Medicaid and Medicare but other factors are the significant number of unfunded requirements and the potential for legal/financial risk for inadvertently being unaware of and not complying with some convoluted regulation. The need for time consuming pre-authorizations, utilization review, and denials of medically necessary care are all reasons that many psychiatrists avoid dealing with any insurers. 
• Lack of use of electronic health records also has multiple contributors.  While interoperability has positive features, not all patients with psychiatric conditions want their information to be shared and the ability to have discrete patient-specified sharing vs. protection of data is not well developed in EHRs.  The inefficiencies in EHRs that have contributed to clinician burnout in all specialties are of particular concern to psychiatrists since the low reimbursements mean that psychiatrists have limited office staff (if any). 
• The low levels of psychiatric reimbursement are made worse by the lack of reimbursement for care coordination and assessing/addressing complex needs, including social determinants of health.  This is true in the outpatient setting but also the inpatient setting where complex multi-component interventions to identify and address delirium are not paid for, despite the well documented long-term effects of delirium on morbidity and mortality.  These issues are not unique to psychiatry but are relevant to the majority of psychiatric patients, and particularly those who have Medicaid, Medicare, or both. 
• There are also significant interactions with health disparities more broadly that contribute to even greater disparities among individuals with psychiatric disorders. 

Another recent poll from KFF and CNN confirmed that nine out of ten Americans believe we have a mental health crisis. But what, exactly, does that mean?

For most of us, it means that we can't get the care we need for the anxiety, depression, substance use disorders, and other mental health issues we're now (at least slightly) more willing to acknowledge we/our families/our friends have. We know even those of us with insurance for our bodies seem to fight endless battles to get care for our minds.

So how do we begin to address the crisis?

My colleagues and I at the AAMC Research and Action Institute have put together a new issue brief that explores:

• The magnitude of the mental health workforce shortage;
• The false promise of parity from insurers; and
• The barriers to integrating care for our minds along with our bodies.

(well, except for our teeth and eyes-that's a whole other issue)

Above all, how can we begin to get our friends, families, and ourselves the mental health care we need? We would love to hear your thoughts on how we can access this care and how you have been bringing awareness around this topic, with Oct. 10 being World Mental Health Day.