Picture this: You are a junior in high school. During the social isolation of the COVID-19 pandemic, your mood progressively worsened. In addition to feeling down most of the time, you found it difficult to sleep and concentrate on schoolwork. You had to push yourself to do things, and your appetite diminished. Then you thought about jumping in front of a car and killing yourself. That is when you finally told your parents, who, frantic and worried, brought you to the nearest hospital emergency room. You are told you are suffering from a major depressive episode and need to be hospitalized for a few days to receive treatment. But there are no beds in the system, and you need to stay in the ER until one is found. That takes four days. You are then discharged from the facility after 10 days, the typical length of stay, with the plan to receive outpatient care. But you cannot find an available psychiatrist or a psychologist. And most of them do not take any insurance.
This scenario is the reality right now for the majority of patients in the United States with mental illness. Would we do the same thing to a patient suffering from a heart condition? Certainly not. More than 47,000 people die from suicide each year in the United States, and yet this is all we have to offer a young person with depression and suicidal ideation.
The country faces an alarming mental health crisis — a pandemic within a pandemic. The rates of depression are roughly three times what was observed prior to the COVID-19 crisis, as evidenced by a national survey by Massachusetts General Hospital investigator Roy Perlis and colleagues, and most adults with mental illness do not receive treatment. Access to care must be dramatically expanded. Legislators, insurance companies, and regulators, including medical boards of registration, need to respond boldly and swiftly to this crisis. We need their help to:
▪ Increase the number of trained mental health clinicians to improve access to care.
▪ Expand the number of psychiatric beds to allow for greater ability to treat the acutely ill.
▪ Improve insurance reimbursements for psychiatrists and psychologists to reduce the incentive for clinicians to accept only those who pay out of pocket.
▪ Allow clinicians to provide virtual care across state lines to optimize mental health care.
During this pandemic, psychiatric emergencies have emerged as a tremendous challenge, not just in MGH’s ER but also nationwide. Mass. General’s commitment to the treatment of psychiatric disorders has allowed the psychiatry department to provide over 230,000 outpatient visits per year, grow the number of trainees over time, and, in April 2021, open a state-of-the-art, 20-bed facility in the emergency room for the management of psychiatric emergencies. Mass General Brigham has also opened 92 psychiatric beds, a 20 percent increase in overall capacity. Yet every day we face the problem of “ED boarding” — holding a patient in the emergency department while waiting for an inpatient bed.
Psychiatry patients in our ER include adolescents at risk for suicide or who have shown disruptive or violent tendencies, adults with substance use disorders, and agitated individuals of all ages in acute distress. They can spend their days on a stretcher in a brightly lit hallway of the bustling, nerve-jangling 24/7 ER. Here, too, COVID-19 has taken its toll, as psychiatric facilities grapple with a shortage of beds and staff due to the virus, and wait times are extended. But that is only part of the problem.
Even before COVID-19, the federal government predicted a shortage of 57,490 psychologists and 15,400 psychiatrists by 2025 in the United States. Mass General Brigham is investing $15 million to collaborate with entities across the state to increase the pipeline of the behavioral health workforce over the next five years, partnering with schools of higher education and the League of Community Health Centers to increase the pipeline of mental health clinicians who will work in under-resourced community-based settings and inpatient units. These initiatives will include loan repayment, scholarships, living expenses, and financial support for mentoring and supervision. These investments will help us in the future, but there is a clear urgency to help with the shortage we are experiencing now.
Key to expanding access to care is changing the insurance reimbursement model for mental health clinicians. The training of psychologists and psychiatrists is a significant expense to hospitals and academic health centers despite Medicare’s Direct Graduate Medical Education support of psychiatry residency programs. A significant proportion of the care of patients with mental illness is provided by these trainees, and yet, with the exception of some enlightened insurance companies, most insurers do not reimburse the visits provided by psychiatry and psychology trainees. This creates a strong disincentive for hospital and academic health centers to train psychologists and psychiatrists. It’s surprising that insurers do not react to the tremendous access problem by beginning finally to reimburse visits of psychology and psychiatry trainees, at least for certain types of visits.
An analysis by Milliman of all 2017 commercial insurance claims for 37 million Americans demonstrated that primary care providers and other medical providers receive in-network office reimbursement amounts that, for the country on average, are approximately 21 percent higher than the amounts received by mental health/substance use disorder providers carrying out the same type of visit. These inadequate reimbursement rates drive many psychiatrists and psychologists into private practice, where typically no insurance is accepted.
Geographic location too often determines access to care, and that needs to change. Patients face great difficulties accessing psychiatry subspecialty experts within their state. The pandemic has demonstrated the effectiveness of virtual psychiatry visits, and yet regulators and boards of registration are creating significant obstacles, such as requiring clinicians to obtain a license in their state to practice out of state, preventing patients from accessing potentially lifesaving treatments. Why can’t boards of registration allow out-of-state mental health providers access to their patients in need of care?
The stress of COVID-19 has taken a toll on the mental health of our country. The challenge of facing the tremendous increase in the rates of psychiatric illnesses cannot be met with our current system of care. We create disincentives for hospitals to expand their psychiatric services by under-reimbursing outpatient psychiatric care, and the number of patients suffering from mental health conditions and unable to access care can only increase. We need a bold approach, with joint efforts to help with this from all stakeholders, including legislators, insurance companies, and regulators.
Dr. Maurizio Fava is psychiatrist in chief at Massachusetts General Hospital.