In addition to being a social justice activist, wife, mom, and friend, I’m also a mental health professional. Though I value all of these roles, they often interact in unsettling ways. And that happens for one key reason – the American healthcare system (and mental health care system, in particular) is broken. The ways that these issues affect me (and millions around the country) are not political. They are sometimes literally a matter of life and death. And each time they touch my life, I think about how hard Congressman Joe Kennedy (for whom I volunteer) is working to fix them.
- Mental and physical healthcare costs are not reimbursed for healthcare consumers equitably.
This means that when my friends and family are looking for mental health services, one of their first questions is how much of it will be covered by insurance. It means that when some of the people closest to me in the world are frantically looking for mental health care for their sick children, I spend as much time considering costs as I do thinking about type and quality of care.
Congressman Kennedy is leading the fight for equitable reimbursement for mental and physical healthcare. In collaboration with Senator Elizabeth Warren, his latest effort is The Behavioral Health Coverage Transparency Act, which would give teeth to laws already on the books.
As noted in Kennedy and Warren’s op-ed earlier this year, although it is illegal (per the Mental Health Parity and Equity Act), widespread discrepancies exist in the extent to which insurance companies actually pay for healthcare services, with far higher rates of claim rejection in cases of mental health treatment. Kennedy’s Behavioral Health Coverage Transparency Act would require disclosure of reimbursement rates by insurance companies, routine audits of reimbursements, and creation of a user-friendly portal for consumers to access parity information and submit complaints.
- Mental health services are not compensated adequately.
Every mental health clinician I know grapples with this issue: will they accept insurance, or private pay only? These clinicians are “helpers.” They are professionals who studied for an extra 6-10 years after college for the purpose of alleviating suffering. No one becomes a mental health professional to get rich. But when faced with a choice of spending countless hours of unpaid time struggling though insurance forms to then be reimbursed by an insurance company at a rate less than professionals with far less education or clinical responsibility (e.g., hair stylist), it can be difficult to choose to accept insurance. I personally try to strike a compromise by working in both the private sector (where I do not work with insurance companies) and the public sector (where patients pay little or nothing). It assuages my guilt, but I don’t feel great about it. I want a mental health care system where I don’t ever feel like part of the problem.
Congressman Kennedy is working to increase rates of reimbursement for mental health providers. Specifically, he introduced the Medicaid Bump Act, which would increase federal Medicaid reimbursement rates for mental health treatment.
- There is not a system of mental health in the US that provides readily accessible care, or smooth transitions across levels of care (that is, across inpatient care, residential care, intensive outpatient care, and routine outpatient care).
This means that when a loved one was looking for inpatient mental health care for her child who was dangerously ill, it was a frantic search across the state. And it means that when that child was discharged, I was on-call to help because we couldn’t find an appropriate level of care for her in the week after she left the hospital (when someone is mostly likely to die by suicide). It means I act as a proxy patient advocate and case manager for loved ones and their children who hope that because I’m in the field, I can get their child into a mental health program sooner than the 6-8 week wait that they’ve been quoted. Only I can’t. And I can’t imagine what it is like for the countless families trying to navigate this “system” without a friend or family member who understands it to help them.
Congressman Kennedy is working to protect Americans healthcare, including mental health care for the 1 in 5 American adults who experience mental illness each year (according to the National Alliance on Mental Illness, NAMI). He took on the Trump Republicans trying to end the ACA (e.g., see his act of malice comments), and fought for CHIP when Trump and company let it expire (e.g., see his op-ed on the issue). Last year, his commitment to mental health reform was honored with the Science and Parity in Mental Health Award from the premiere organization for scientifically-based psychotherapies (the Association of Behavioral and Cognitive Therapies, ABCT).
I hope 2020 is a year of many victories to get Americans the healthcare they deserve.
Christopher says
I’m also starting to think that if we want to truly reduce the stigma and the unequal cultural assumptions regarding mental vs. physical health we have to get to the point that routine mental checkups are as common as routine physical checkups.
BKay says
Agreed! I believe some colleges are starting to do something similar for freshman. Not necessarily mental health check ups, but some basic info on mental health and coping as part of freshman orientation. It’s a good step in the right direction.
SomervilleTom says
I will be more enthusiastic about this when licensed mental health practitioners are as consistently competent as their physician counterparts.
At the moment, the “quack density” seems to be much higher for mental health practitioners — perhaps in part because of the disparity in compensation.
I suspect that our knowledge and understanding of mental health issues lags far behind medical science.
BKay says
Your comments highlight three issues in mental healthcare —
1) Mental health clinicians and researchers have not done a good enough job educating consumers about scientifically-based treatments (both therapy and biological interventions, such as medication). This means that the average mental healthcare consumer can’t readily identify treatments that work from those that don’t.
2) The mental health field has not done a good enough job educating consumers about the different types of clinicians in the field. Some clinicians have educations and credentials that are highly-regulated, and are in no way associated with a higher “quack density.” As just 2 examples – “clinical psychologist” is a legal term that means a person has completed college, a doctoral-level degree in clinical psychology (5+ years of education), supervised clinical training (at least 1, full-time year, in addition to hundreds of hours while getting their doctorate), and passed both a national and state exam to credential them as “licensed”. “Psychiatrist” is also a legal term that means a person has completed college, medical school, plus 4-5 years of residency, at a minimum. It also means they have passed various national board exams. There are others.
In contrast, there are terms that are used in mental health, but are meaningless. “Counselor”, “coach”, even “therapist” means nothing. Although well-credentialled professionals may describe themselves in these ways (e.g., I’m a licensed clinical psychologist with a PhD, and often refer to myself as a “therapist”), there are literally NO specific requirements needed to describe yourself in these terms. You can have absolutely NO training in mental health, no education at all, and call yourself any of those things (or a host of others). I would assume that in this group, there is a higher “quack density”, but it’s comparing apples and oranges.
3) The stigma associated with mental health clinicians and patients is alive and well. The suspicion (assumption?) that “knowledge and undertanding of mental health issues lags far behind medical science” is easy to assert. But if you actually review both areas of research and practice, the differences aren’t nearly what one assumes. Just ask any medical expert (or patient) in the medical world of fertility, autoimmune disease, cancer, diabetes, or a host of other prevalant medical conditions how little is actually known about causes and interventions. And just ask a neuroscientist or clinical scientist how much is known is about neurobiology of depression, posttraumatic stress, and other mental health conditions. When you actually get into the details, we have a long way to go across the board.
What decades of data clearly show is this: Scientifically-based mental health screening and treatment works to reduce human suffering and distress, reduce impairment in functioning, reduce suicidal behaviors, and reduce business and societal costs of lost work days, hospitalization, and incarceration. They also work to improve emotional well-being and quality of life.
SomervilleTom says
I’ve been an enthusiastic consumer of and advocate for mental health services my entire life for myself. my spouse (actually several, serially) and my children.
I suggest that the real world is not as rosy as you paint it. I’d like to address these point by point.
1. Scientifically-based treatments that work:
The science underneath psychiatry, psychology, and sociology is notoriously weak in comparison to the physical sciences. Compounding that is the far higher prevalence of research fraud in those fields. The standards for evaluating progress of non-pharmaceutical treatments are notoriously lax.
For whatever reasons, mental health professionals are very good at prescribing medications. Yet for many — even most — of those medications, there is no in-depth understanding of the “pathways” of the disorder or medication. Instead, practitioners prescribe drugs — in large part because it is a familiar business practice for all parties concerned — based on empirical observations of gross behavior. Depressed patients report feeling “better” when drugged.
I invite you to choose a selection of DSM codes and then write a summary of the “pathway” for the specified disorder — what mechanisms are working improperly and how do those malfunctions work together to result in the resulting symptoms. Then look up the medications that are generally prescribed for those DSM codes, and note how the medication interacts with the given pathway.
I think you’ll find this to be an impossible task. We don’t know nearly enough about psychiatry, psychology, and mental health to even begin to take this approach to treatment.
I submit that an important reason why practitioners do not educate consumers is that the practitioners themselves are unable to readily identify treatments that work from those that don’t. Too many of those practitioners do not even know the basic statistics involved in such a determination — the current requirements for an MSW typically do not include much if any math or statistics.
It is true that for profoundly dysfunctional individuals, many of our pharmaceutical interventions are effective at, for example, stopping the sufferer from harming themselves or others.
In the real world, that is (fortunately) beneficial to a relatively small portion of the population.
2. The mental health field has not done a good enough job educating consumers about the different types of clinicians in the field.
I understand that this is an issue, but it’s not the issue I’m talking about. I’m well aware of the difference between — just to choose one — a Reiki healer and a licensed MSW.
When I talk about the “quack density”, I’m talking about the variation AMONG licensed and credentialed providers. The average credentialed internist is much more likely to help and much less likely to harm than the average credentialed psychiatrist or psychologist. There was a time in the 19th century when medical doctors were much less reliable than they are today. We have not seen similar progress in actual hard science since the work of Sigmund Freud, Karl Jung, and their immediate disciples.
3) The stigma associated with mental health clinicians and patients is alive and well.
I agree. For the record, my wife of seventeen years is a practicing human geneticist (that’s why she came to Boston in 1990s). We met while we were each contributing to the effort to map the human genome at a major Boston biopharm company. Without revealing too much, let me just say that I am intimately familiar with the genetics of fertility, autoimmune disease, cancer, diabetes, and so on — that’s been our dinner-table conversation since the turn of the century.
I am well aware of the shortcomings of medical science across the board. Nevertheless, for all its faults, it is leaps and bounds above psychiatry, psychology, and sociology. I am similarly reasonably familiar with the research community that investigates “[the] neurobiology of depression, posttraumatic stress, and other mental health conditions” When I write the commentary I offer here, I’m paraphrasing what I hear from those investigators.
I fundamentally agree with you. At the same time, I think it is critical that we not oversell the current state of the art.
The fact remains that the key driver for why mental health services are the way they are today is a result of current health insurance model. “Talk therapy” is expensive and hard to prove effective. Drug therapy is easy, quick and cheap in comparison.
It is FAR easier to prescribe Adderall to generations of “misbehaving” boys than to actually understand what is really going on. The drug “works”, the child’s behavior changes, and the treatment is declared “successful”.
Those of us who have children with actual ADHD or who know children with ADHD know that reality is far more complex than that.
BKay says
I suspect you and I have enjoyed similar dinner conversations around various tables for many years, and I’m sure we would enjoy discussing these complex issues “live” as well!
My responses below are likely too long and involved for 99% of people reading this. The reason for that is because I think it’s very dangerous for anyone reading this to believe that mental healthcare can’t help them. So if people don’t have an interest in all of it, please just read to the end of this paragraph. There are over 40 years of clinical research looking at medications and cognitive-behavioral treatments demonstrating that they do help a huge number of people (although I recognize they don’t help everyone). Anyone suffering from mental health difficulties should not be discouraged from pursuing help. You can start by asking your primary care provider for thoughts on medication and referrals. There is also a lot of consumer information available at adaa.org (website for the Anxiety and Depression Association of America) and abct.org (website for the Association for Behavioral and Cognitive Therapies). Those websites include “find-a-therapist” resources.
Now, to get into the weeds….
I don’t know the comparative rates of research fraud across research in mental and physical health. I would readily concede that it happens (rarely) in both areas, and is appalling.
I also readily conced that there is zero chance of understanding much about the cause or maintenance of psychopathology from the DSM. It’s a horribly superficial (and largely political) publication based entirely on behaviorally-observable symptoms to maximize interrater reliability, and it sounds like you know it’s primary use is clinical charting and insurance reimbursement. I’m sure you also know that because of this, it is widely criticized within and outside the mental health field. But the DSM in no way represents the current state of knowledge about the causes of, or treatments for, psychopathology, or mechanisms of action for interventions. For example, though FAR from complete, there are over 40 years of research in cognitive and behavioral principles and their applications (across animals and humans), from J Wolpe to B F Skinner to E Foa & M Kozak to A T Beck, C Carver, T Keane, D Barlow, S Hayes, S Hofmann and countless others outlining models of psychopathology, efficacy of interventions, and mechanisms of action. If you’re interested, I would suggest perusing journals such as Journal of Consulting and Clinical Psychology, Journal of Abnormal Psychology, Psychological Bulletin, JAMA Psychiatry, Journal of Personality and Social Psychology, as well as most journals published by the American Psychological Association, Association of Behavioral and Cognitive Psychology (abct.org), and Anxiety and Depression Association of America (adaa.org), to name a few.
In addition, the fastest way to get a quick sense of mental health treatments that work is to review the book with essentially that name: https://www.amazon.com/Guide-Treatments-That-Work/dp/0199342210/ref=sr_1_8?keywords=treatments+that+work&qid=1577566176&sr=8-8
As well as a Oxford series that addresses the same: https://www.oxfordclinicalpsych.com/page/307/%20Treatments%20That%20Work
You are also correct that there is wide variation within mental health regarding which clinicians (even appropriately-credentialled ones) are well-versed in the science. Some professional degrees (e.g., MSW, PsyD) are almost entirely clinical, and as a result do not have the same focus on the science as professionals with research-oriented degrees (e.g., PhD). But that doesn’t mean that those clinicians aren’t skills in delivering good care.
Though I don’t agree that the “quack density” is higher in mental health, I do agree that it is easier to hide being a quack in mental health. Consumers don’t know much about the differences among mental health treatments or types of providers, so it’s hard for them to know what to ask a provider to evaluate quality of care. It’s also more likely for, say, a cardiologist, to quote their rates of success in a bypass surgery that for a mental health clinician to to quote their rates of recovery for depressive episodes. All of this makes researching clinicians harder as well. (Though I don’t think a primary care doc typically tells consumers the rates of recovery from infections treated with antibiotics in their practice either.) In any event, yes, it is too easy for ineffective mental health clinicians to “hide out.”
It is hard to demonstrate efficacy of psychotherapy, but decades of talented researchers (some of whom are noted above) have done so. Therapy can certainly be expensive (which, of course, relates to reimbursement rates by insurance). I also realize that it can be quicker and easier to take medication that participate in psychotherapy, and it is cheaper because of insurance. Given the generally similar efficacy of medication and cognitive-behavioral therapy for a wide range of (though not all) mental health difficulties, that gives patients choices. But yes, I would agree with what you seem to be suggesting, that there are many children who are quickly medicated and declared “better,” when that is not the only (or even best) option.
Anyway, I’ve gone on for far too long. I’ll finish by saying that I don’t see the state of psychological science or intervention as rosy. We need to continue improving treatments, to be better at disseminating effective treatments so that consumers can access them readily, and to increase the number of skilled mental health clinicians across the country. There is work to be done. But it does not justify the (often illegal) discrepancies in insurance reimbursement. And systemic problems of the American healthcare system makes the onging work harder than it needs to be.
Ann says
SomervilleTom states that “The fact remains that the key driver for why mental health services are the way they are today is a result of current health insurance model.” I couldn’t agree with this point more. Luckily, this is one area in which politicians can continue work to create positive change. The Mental Health Parity Law was a very positive start but certainly needs to be built upon. It helped to create some improvement to mental healthcare treatment and access.
However, the system itself remains broken – in fact, I like to argue that it’s not even really a system yet at this point. We need a web of services that can help support patients from the most severe crises (inpatient care, partial hospital care, group homes, etc) to less intensive care that can be provided on an outpatient basis. Unfortunately, even in the greater Boston area with our numerous hospitals, this kind of wrap around care is hard to find.
Joe Kennedy remains a strong advocate for more of this kind of care.
SomervilleTom says
Mental health services in fact are a canonical example of how bad our current health care system is. In fact, it is very close to fraudulent to even describe this as “health care” for mental health.
What we have instead is smoothly running system that does the following:
1. Collects lots of profits for health insurance providers.
2. Sells lots of high-margin psychoactive medications
3. Ensures a continuing market for schools that sell degrees in mental health services
4. Ensures a comfortable market for “in-service training”, “recertification” and similar aspects of the venerable credentials-needed-to-do-business racket. Microsoft and IBM have been doing this for decades at great profit. It’s a great way to sell Microsoft and IBM products that are not otherwise competitive.
5. Provides a reasonably comfortable ongoing income for a great number of providers without regard to how good or bad those providers are (by whatever measure you care about).
Any actual gains in mental health outcomes amount to coincidental benefits of the above, and any actual shortcomings amount to “collateral damage”.
Finally, a word to the wise for people who seek this care for themselves or for loved ones — do everything in your power to avoid ANY sort of insurance compensation for services you seek. No matter what these companies say on their websites and no matter what HIPAA and FERPA regulations say about disclosures, any use made of these services stays on the records essentially forever. For nearly everyone, employers pay the premiums and insurance providers work for who pays them. Any sort of complaints about things like depression, ADHD, mental confusion, and anything in that realm DO end up on your record and they DO often end up being disclosed to current and future employers — whether or not such admissions are allowed.
If you need mental health services and are fortunate enough to be in a position to afford it, your best bet is to get provider recommendations from people you know and trust. Once a provider is identified, pay everything out-of-pocket (self-pay, or whatever) so that the provider does not have to file any claims with any insurance company. Many providers will arrange more attractive fee schedules as a result because this arrangement is easier for them too.
It is too bad that our current system is this broken. Like so many other things, the people hurt the worst by this broken and essentially fraudulent system are those who need these services the most.