Solving the nation's mental health crisis: Insights from 9 leaders

Increasingly, the nation's behavioral health crisis is straining hospital emergency departments, prompting health system leaders to pour more resources and energy into expanding access to mental health services. 

While the issue is not new, worsening emergency department boarding has put a lack of access to mental health care front and center for hospital leaders. While there is no single solution to a multi-faceted and complex problem, many experts agree a robust approach that involves higher reimbursement rates, stronger alignment between behavioral health and primary care providers, and more investments in community resources are the first steps in expanding access to mental health care.  

Here are nine healthcare leaders' thoughts on what it will take to solve the nation's mental health crisis, which have been lightly edited for clarity:  

Shawn Coughlin. CEO of the National Association for Behavioral Healthcare: 

Behavioral health has historically kind of been an afterthought, and that can't continue. I think what it requires is treating behavioral the same way we've treated med-surg, and that is by providing sustainable financing for the entire behavioral continuum of care.

The second kind of area that needs focus is parity. We need parity in benefits, that ensure individuals have benefits that address the entire behavioral health care continuum, regardless of where an individual needs to step into that continuum. 

We also need parity in payment. There are countless studies that we have as an association coordinated that have looked at payments for behavioral health providers, and they are woefully inadequate across the board. We make pennies on the dollar, even less than primary care providers make. 

It will also take recognizing that we need to integrate behavioral into the broader healthcare system electronically. And the best way I think to do that is providing those same financial incentives that hospitals and doctors received under high-tech. That would put us on a more level playing field to attract providers.

John Krystal, MD. Chief of psychiatry at Yale New Haven (Conn.) Hospital and professor of psychiatry, neuroscience and psychology at Yale School of Medicine:

What obstacles do we need to remove to make this happen? First, we need to incentivize healthcare systems to deliver mental health care through carrots and sticks. The key "carrot" would be better reimbursing the delivery of mental health treatments. Despite the passing of mental health parity legislation introduced by former Congressman [Edward] Kennedy, mental health treatments are reimbursed at rates that substantially disincentivize healthcare systems from providing comprehensive mental health care. These problems worsened as economic pressures on these healthcare systems increased during the pandemic yet demands for mental health treatment increased. 

Second, we need to systematically measure the outcomes of mental health treatment and then hold healthcare systems accountable for delivering treatments that get people better. This would ensure that the most effective treatments are offered to patients. 

Third, we need to build a workforce that is capable of meeting the need. We have a severe shortage of psychiatrists in the United States, and a minority of the patients with many mental illnesses receive treatment by a psychiatrist. This means that we need to better prepare primary care physicians, nurses, and social workers to deliver front-line, evidence-based mental health care including medications and psychotherapies. We need to ensure that there is a sufficient psychiatrist workforce to treat the large number of patients, perhaps the majority of people with mental illness, who need access to more sophisticated psychopharmacology and neurostimulation treatments. 

Further, psychiatry is going to evolve toward a precision medicine approach where "biomarkers" guide the delivery of treatments that are more likely to work for particular subgroups of patients. A similar case may be made for evidence-based psychotherapies and rehabilitative treatments. Thus, it is likely that we will need to better train psychiatrists for this future and to increase the number of psychiatrists that we train. Lastly, we need to recognize the limitations of our current treatments. For the past 50 years, psychiatry relied primarily on medication types that were discovered before 1960. In 2019, we saw the first two mechanistically novel psychiatry medications approved by the FDA in 50 years, Esketamine and brexanolone. Currently, the FDA is evaluating new medications for psychosis, PTSD, and depression.

Jennifer Lyons, MSN, RN. Director of behavioral health at Altamonte Springs, Fla.-based Advent Health:

There are five essential things that must align in order to change the direction of our nation's behavioral health crisis. Firstly, we need to adopt an empathic approach to the care of those in need of behavioral healthcare. Early identification is crucial. In healthcare, early identification can be achieved by conducting genuine and empathic screening and assessment with every encounter. It is essential to ensure timely access to evidence-based care in the right setting. We need to adopt a treat-to-target methodology that ensures successful outcomes. Finally, we need to ensure that we have enough behavioral health experts to care for this growing population.

Edward Norris, MD. Chair of the department of psychiatry and chief medical executive for the behavioral and community health service line at Allentown, Pa.-based Lehigh Valley Health Network:

There are lots of short-term solutions that many places, including ours, are employing to address [a growing number of behavioral health patients in the ED]. We're allocating many more resources to the emergency rooms to try to stabilize and divert inpatient stays, but that is a symptom. What we really need is better and more enhanced outpatient services. More mental health clinics. More providers caring for people who need it the most and are the least able to access it. That means a national and local, in how we support patients who need our care the most. 

When we look at long-term solutions, we need to consider how to integrate into primary care more effectively, really following the collaborative care model based out of the University of Washington. That involves partnering with our primary care colleagues to better support them and help give evaluations to their patients and give them treatment recommendations, so that the primary care providers are actually the ones delivering the care with support from psychiatry as a way to leverage the number of psychiatrists we have. 

Jeff Parobechek. Director of clinical operations and behavioral health at Indiana University Health in Indianapolis:

The answer to the current behavioral health crisis is one that will require a wide range of solutions implemented and supported by partnerships with many organizations within our local communities and across the country. The five major areas that we are continuing to assess and attempt to address include: awareness/de-stigmatization of mental health needs, developing partnerships for early interventions for individuals, increased training and education opportunities for behavioral health providers, easier access for patient to attain the care they need and funding to provide for those four other groups of work.   

The attention brought by the current crisis in the country is finally shining the light on the number of people who struggle. Still, we have much work to be done on the national and local community levels with various social and racial groups who still struggle with stigma of behavioral health care and concerns about behavioral health care and healthcare in general.  As a society, we need to invest in stabilizing some current mental health challenges and investing in the future. 

These efforts need to include partnerships for early intervention which includes coping skills and conflict management skills training for children, adolescents, and adults.

We also committed to invest in the training and education for advanced practice providers, doctors, nurses, therapists, social workers, and other mental health workers so we have enough qualified individuals to meet the demand. As a healthcare system, we continue to leverage technology to better increase access in both rural and urban areas, where it is difficult and cost ineffective to have enough qualified providers. Finally, despite multiple attempts at federal mental health parity laws, behavioral health insurance coverage for care and funding continues to fall short of the cost of high-quality care. 

Leo Pozuelo, MD. Chairman of psychiatry and psychology at Cleveland Clinic:

We cannot hire ourselves out of this crisis. Earlier interventions are needed on the front lines, and that involves a two-prong approach. First, we need to lift the behavioral outcome of our primary care clinicians and empower them to initiate treatment. This will require a serious commitment to training and reimbursable time to screen and treat common psychiatric disorders (depression, anxiety) as well as have access to evidence-based talk therapies, available on digital platforms.

In a studied collaborative care model, this approach allows psychiatrists to focus on more complex psychiatric disorders such as treatment resistant depression and severe mental illness. Second, we need more innovative triage and psychiatric stabilization programs (crisis units, partial hospitalization, intensive outpatient programs) for psychiatric patients in distress, that can safely bypass the emergency visit or the inpatient psychiatric hospitalization, while allowing the patients to receive the right level of care. It is imperative we tackle the behavioral health crisis from a systems' perspective, involving all stakeholders that touch these patients' lives.

Jean Scallon. Vice President of behavioral operations at Brightwell Behavioral Health in Indianapolis:

There has been a growing concern across the United States regarding the adequacy of available beds to meet the demand for mental health treatment. However, I would like to offer a different perspective on this issue. I believe the notion that there aren't enough beds may be somewhat misleading.

In my view, the challenge lies not necessarily in the availability of beds, but rather in the obstacles related to reimbursement and workforce shortages. Despite having an existing infrastructure of beds nationwide, the reimbursement rates have failed to keep pace with the rising costs of providing care. This includes the rapidly increasing demands for salaries and supplies.

The shortage of qualified staff compounds this issue. Regulatory bodies require specific staffing levels, which many hospitals struggle to meet. Additionally, the lack of mental health parity means that the process for obtaining pre-authorization for care is not standardized, adding complexity and time to an already burdensome system.

In order to truly address the challenges in mental health treatment, we need to focus on tackling the systemic issues such as reimbursement rates, workforce shortages, and regulatory burdens. Only then can we ensure that individuals in need of mental health care receive timely and effective treatment.

Ken Rogers, MD. Vice president and chief medical officer of behavioral health at WellSpan in York, Pa.:

We feel we've found a better way to care for behavioral health patients using innovative programs that meet these patients where they are and get them the care they need before they arrive at the emergency department. 

In fact, we've seen an almost 50% decrease in the number of patients in WellSpan emergency departments seeking behavioral healthcare in a statistical comparison of January 2023 versus January 2024. Of those, we saw a nearly 90% reduction in patients that require a length of stay greater than 24 hours. 

We feel strongly that the impact is being made by our innovative START program as well as mobile crisis units in our communities to get these patients the care they need in the right place at the right time. For our patients that utilize the START program, we’ve seen a 32% reduction in emergency department utilization for behavioral health reasons comparing 1-year prior and 1-year post engagement with the program. 

Joy Rosen, Vice president for enterprise clinical services at Mass General Brigham Behavioral and Mental Health in Boston:

Solving the nation's behavioral health crisis will require a host of key stakeholders across the federal government, states, payers, and healthcare systems working together on prioritizing behavioral health treatment. We view this as a multifactorial approach with specific priorities, including advocacy for equity, parity and reducing stigma in behavioral health, paired with 10 specific strategies listed below as a starting point.

1. More adequate reimbursement, both from the perspective of increased rates and more comprehensive reimbursement by commercial and public payers for varying levels of care.

2. Expansion of training slots across specialized areas including geriatric and addiction fellowships, psychology training, and social work training.

3. Incentives increasing the number of students entering the behavioral health workforce for all role groups.

4. Support for new non-traditional staff roles to extend professional staffing.

5. Deeper investment in pediatric and adolescent mental health – including more comprehensive screening – as we know most mental health concerns begin before 21.

6. More training on mental health for non-mental health folks – police, schools, clergy, after school programs, corrections, etc.

7. Increased access to integrated care in primary care settings and in other medical specialty care settings (part of the reimbursement discussions), and in school systems.

8. Funding to support and test innovative care models.

9. Accelerating the adoption of technology and providing adequate reimbursement for it.

10. Eliminate the current impediments to providing care across state lines, as there is great unevenness across our country on the availability of mental health clinicians.

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