Guns Or Roses: Solving The Mental Healthcare Crisis in America
As I noted last time, there’s no way that anyone can claim that un-diagnosed or poorly-treated mental disorders are at the root of all mass shooting incidents in our country. But whether we want to admit it or not, it’s very possible that untreated mental illness is a major component of a person’s ultimate decision to take lives in a mass shooting.
Take one major component away, and the plane is very unlikely to fly.
So, it should go without saying that we should be focusing more attention to fixing the broken mental healthcare system in this country, and less time on arguing about banning guns or quoting the Second Amendment.
It should go without saying. But I’ll say it anyway.
The Mental Healthcare Crisis in America
By now, is universally concluded that there is in fact a mental healthcare crisis in this country. Certainly the current pandemic and restrictions on our movements in the past as greatly increased the estimated numbers of people who report anxiety and depression, these are only two clusters of diagnoses among a much wider list of mental health diagnoses. I contend that the mental healthcare crisis in this country has been brewing for much longer.
Root Causes
Lack of Qualified Providers
One root cause behind the mental healthcare crisis, is the glaring lack of mental healthcare providers. Some reports note that up to one-third of Americans live in areas lacking mental healthcare coverage.
Now, we probably have 10 orthopedic surgeons for every person in America (an admittedly unscientific estimation, but probably not too far off the mark). But we have a serious lack of mental healthcare providers in this country. Why is this?
Since the average surgeon can earn hundreds of thousands of dollars per year more than the average psychiatrist, obviously part of the issue is monetary.
Lack of Money
In 2008, Congress passed the Mental Health Parity and Addiction Equity Act, which effectively forced insurers to cover mental health on an equal footing with physical health. However, since the law was enacted, many insurers have found ways around paying for mental healthcare, including imposing “medical necessity” criteria to payment for medical health services. Clearly, the money (reimbursement for services) is not there to be able to attract medical students into psychiatry as a specialty.
Lack of Governmental Will
It doesn’t seem that the will among government officials is there, either. Sure, they’ll pass a law or two, but don’t back up that law with the teeth required for enforcement, and when they do attempt enforcement, it’s usually a light-handed like a slap on the wrist instead of a severe penalty meant to carry a message.
Many government officials would prefer to turn a blind eye to the need, knowing that the money that would be needed to help fix the problem could be better spent on their district’s pet pork project.
Let’s not also forget qualified advanced practice providers (nurse practitioners and physician assistants) who would be able to step into the gap, but are limited in certain states by draconian governmental regulations and restrictions on their practice. Though thankfully not all states have such restrictions, the fact that they exist in some states to this day, reduces the desire for some APPs to enter and practice in the mental/behavioral health specialty.
The Solution
The problem is multifaceted: too many people needing mental health services, and not enough money to pay for it, not enough providers to supply it, and not enough political will to fix it.
Likewise, when it comes to mental healthcare services, the solution is multifaceted.
Play Straight or Get Out
Congress, CMS (Centers for Medicare and Medicaid Services), and state lawmakers must get teeth… no, FANGS, behind the law. Rigid compliance with the Mental Health Parity act must be enforced by strict sanctions and penalties for any insurer found skirting the mandates in the law.
If payment for mental health services finally rose to be on-par with physical medicine services such as PCPs and specialists/surgeons, more future healthcare providers (an umbrella term that includes physicians, nurse practitioners, and physician assistants) may be encouraged to specialize in mental/behavioral health, and perhaps within a generation, we may have a sufficient number of HCPs to meet the need.
Encouraging New Providers
Medical/nursing education must actively encourage psychiatry and mental/behavioral health as an option.
Speaking for my own profession, way too many nurse practitioner programs focus solely on family medicine (although with the dwindling number of family practice physicians, the need for family practice NPs is great). More schools of medicine and nursing need to make mental health an equal portion of the curriculum as they do others, and not relegate it to undesirable status with attitudes such as, “well, you can make $800,000 a year as a surgeon, or maybe $150,000 as a psychiatrist.”
The money should not be as important as the desire to treat and/or possibly cure disease. However, the money would be there if insurers “did right” by mental healthcare services in the first place.
Increase Access and Coverage Across Settings
Third, the Federal and state governments need to increase funding and support for resources that enhance mental healthcare. Obviously this includes the government holding insurers accountable for providing mental healthcare access, but it needs to push for access across all treatment settings.
Payments and access need to be available not only in traditional psychiatry or psychology practices, but better coverage and reimbursements need to be enforced for mental healthcare coverage in acute care settings (hospitals, emergency departments), and in provider offices such as PCPs and specialists.
Barriers to health information portability need to be not just broken down, they need to be destroyed. A new culture needs to be encouraged in the overall healthcare community that allows providers not in the mental health specialty to be able to communicate patient needs to mental health specialists and each other. While the HIPAA law and patient confidentiality must always be considered, patients need to be encouraged to allow HIPAA-compliant automatic access to their medical records and treatment plans to and from their PCPs and other specialists, so that any mental health concerns can be transmitted to the appropriate members of a patient’s healthcare team.
Early Screening and Treatment
The Department of Health and Human Services (HHS) oversees the Medicaid services for children under a program known as “Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)”. It’s intended to provide early and active coverage to children for not only medical, but dental and mental healthcare.
Strengthening this program could expand access to pediatric mental healthcare. It could also provide authorization and protections for non-healthcare authorities (such as teachers, school administrators, and law enforcement) to work with healthcare providers to provide appropriate data to help in identifying needs and implementing care plans to meet those needs.
The goal here is that children receive appropriate screening, prevention, and intervention services with ongoing care coordination across all settings, so that it becomes far less likely that a child in need of mental healthcare services would “fall through the cracks.”
Expand Coverage of Crisis Services Across The Payor Spectrum
Although Congress and several administrations have taken some steps to improve behavioral health crisis care, coverage and access to a full continuum of crisis services is still lacking. Congress needs to do more to cover this gap.
CMS can make existing mobile crisis teams provided in some emergency departments eligible for full reimbursements for services, and encourage states to use the Children’s Health Insurance Program (CHIP) to fund crisis-related resources for children.
For states and commercial insurers, the definitions of “crisis services” need to be defined as part of the existing definition of “essential health benefits.” This will allow regulations covering emergency services to cover mental health crisis services on an equal footing.
Making A Difference
Solving the elephant in the room, the long-standing mental healthcare crisis in this country, is a daunting task. But if we want to help reduce the incidence of mass shootings in this country, we all need to step up to the plate and solve this problem.
At the end of the day, solving this issue isn’t good only for reducing gun violence with mental disorders as a major contributing factor, it’s good for the mental and physical well-being of all Americans. It’s something that not only should we do, it’s something that we have to do.
