Health care in the US has made some strides in making behavioral health treatment more accessible by pouring more money into services like telebehavioral health. So why are we still seeing significant increases in mental health conditions and drug overdose deaths? Are we putting our money in the right places?
Read a lightly edited excerpt from the interview below and download the episode for the full conversation.
Rachel Woods: So if we’re going to solve this problem, I think we need to take a deeper dive into how the behavioral health problem actually occurs—the root causes. And if I think about where our audience might be, they’re probably all at the starting point of thinking about stigma, something that’s definitely improved over the last couple of years, at least partially. But I’m guessing you’ll both tell me that addressing stigma alone won’t solve the problem of equality. What are some of the biggest fundamental challenges we need to address as an industry?
Darby Sullivan: Well, I’m glad you brought that up, Rae. And actually I would push a little bit on our assumption that the stigma has improved.
Forests: What do you mean?
Sullivan: As you were probably hinting at a bit, the stigma is not the same for this high-income yuppie who can talk about going to therapy once a week, compared to someone who lives on the streets and has unmanaged schizophrenia. Stigma is different. This happens exactly with that internal inequality we were talking about. So while we can acknowledge that maybe as a culture, we talk more about depression, we talk more about anxiety, that doesn’t mean we’ve overcome the stigma barrier by any means.
The other part of the stigma that I think a lot of people don’t talk about, but is just as important, is the stigma against the profession itself. So a lot of people who are, you know, practitioners or potential clinicians very rightly look at behavioral health as a field and say, “Hey, do I want to get into this? Because it’s low-paying, it’s work very stressful, there are so many barriers to actually getting my help to the patient, which has a lot of ripple effects.”
Forests: So we haven’t actually solved the stigma problem either, but what are some of the other root cause challenges that the industry would probably not solve, but at least advance in order to improve equity in the space of behavioral health?
Rachel Zuckerman: I want to be really clear when we talk about the root causes of behavioral health disparities. The root causes are really the same as any other health disparity. So it is structural racism, economic injustice. And then in behavioral health, there’s this additional layer that we talked about as sort of behavioral health deprecation. So those are the main historical causes, but we see them manifest today in five big ways that continue to drive these health behavior disparities.
Forests: What are those five?
Zuckerman: So we already talked about stigma, which is one. The second is the lack of strong evidence about which behavioral health treatments work in which scenarios. Third, the fact that our current system does not effectively address the social determinants of health needs that increase behavioral health challenges. Fourth, we don’t have enough behavioral health physicians, and fifth, low reimbursement rates contribute to all of these challenges.
Forests: Okay, so the five root causes are a lot, but let’s try to go through each of these in turn. As you said, we’ve already talked about stigma. Now let’s move on to the evidence. Help me understand what the problem is here.
Sullivan: So the problem with clinical trials and behavioral health is not that there’s no research or no evidence that it worked, but that we just, as a sort of scientific community, don’t fully understand why a treatment would work for our patient. particular and does not work for another.
But it’s even bigger for behavioral health conditions that simply have less research writing associated with them. So what this means is for a patient, they may have to go through multiple rounds of trying different drugs with different side effects, combining them to find the right regimen that works for them. And it just takes a lot of time. So one of the things that we’re looking at in this space is actually just a new innovation in the types of therapy that we’re using to treat these conditions, like psychedelic-assisted therapy and deep brain stimulation with the goal of a can we unlock something we haven’t found before for some of these more difficult diagnoses?
Forests: The other one you talked about is the social determinants of health. How does SDOH uniquely contribute to behavioral health needs?
Zuckerman: So in behavioral health, if you don’t have access to things like healthy food, safe housing, stable employment, we know you’re more likely to develop mental health needs, and it’s a vicious cycle. So if you need high-acuity behavioral health, it can affect your ability to get a steady job or go to the grocery store, or even go to your doctor’s appointments. So it is particularly influential in increasing behavioral health needs.
The other thing that’s really prevalent in the behavioral health space is social isolation and a kind of lack of agency. So this is another complex social determinant of health. Historically, as a health equity team, when we’ve talked about social determinants of health in the past, we know that those tend not to be core competencies or strengths of traditional health care providers, so we’re really we pay attention to partnerships where more traditional health care actors are partnered and see the value in other organizations that have expertise in addressing some of these other needs that are really critical to behavioral health care.
Forests: We’ve talked about stigma, we’ve talked about evidence, and we’ve talked about social determinants of health. Your last two root causes, I think will be the ones that our audience is most familiar with when it comes to behavioral health specifically, starting with the fact that we simply don’t have enough doctors to meet the demands of health of behavior. services. And I’m assuming you’re going to tell me that it’s something that’s gotten worse, not better, between the pandemic and everything else we’re going through.
Zuckerman: You’re definitely right, Rae, and probably many people have experienced this personally, just trying to find a therapist for themselves or a family member. It’s really hard right now. And I think the problem is much more nuanced than people realize, because when we see people talking about physician supply, they’re usually talking about raw numbers. And it is very well documented that there is a shortage of psychiatrists in the US, just to take one example of one type of provider.
But even if there is a doctor in your area, should you also consider whether they are accepting new patients? Do they take patient insurance? If they don’t, do they offer a fee the patient can afford? Do they have the right expertise for that particular condition? And you also have to think about the relationship. Is it a good match between patient and provider?
Sullivan: And the other part of that is, when we think about that second level of disparity, what are the ways in which our workforce can actually provide culturally sensitive or responsive care to every patient? Because we know our workforce is not diverse enough to represent all the communities we serve. In combination with everything else Rachel said, it makes sense why the supply challenge is far more complicated and sinister than you might first realise.
Zuckerman: And I think it’s not just that the supply is worse than we expect. It also contributes to the inequalities in access we have been talking about. Because if you’re someone who can’t afford to give up work to take the first appointment that’s available, or can’t afford to pay out of pocket, or needs higher acuity, this will do the trick. harder to find care.
Forests: The last big one is the refund or lack thereof. This is not a new problem either. What do you want health leaders listening to this podcast to know about this root cause?
Sullivan: So they’re not supposed to be as bad as they are now because of the equity regulations, which basically means that behavioral health services should be reimbursed at similar rates as physical health services, which sounds good. It’s kind of hard to calculate and figure out, well, what that number should be in real time.
And part of the reason it’s hard to calculate that is because our behavioral health data set is so bad, which means that behavioral health is simply not a profitable service line for most organizations. So when we’re on the phone with someone and they say, “We’re tipping the balance for behavioral health,” we applaud. We were very happy for them.
So that means people say, “Okay, we had to subsidize these services, or just accept this as a loss leader because we know it’s the right thing to do as an organization.” So I think the low reimbursement rates, along with the high administrative burden for providers to track that reimbursement and the high demand from patients means that providers don’t get insurance.
Many providers don’t take many types of insurance because simply, you’re jumping through hoops for a small fee, which as Rachel said, many patients have to pay for themselves.