Continuum of Care

Addressing the Rise in Acuity

In 2009, the U.S. government allocated billions of dollars to incentivize hospitals and physical healthcare providers to adopt electronic health records (EHRs) as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Excluded from this legislation—and the funding that came with it—were providers of mental health and substance use services. 

This is one example of the long-standing separation of mental and physical healthcare in our society. To provide integrated care, we need the tools to communicate quickly and securely across care providers. 

“Not only do more people need help, but they are in more distress than we historically have seen,” says Harsh K. Trivedi, MD, MBA, president and CEO of Sheppard Pratt. Adults with a mental illness are more likely to have chronic physical health conditions and a shorter life expectancy compared to the general population.

And unfortunately, mental health disorders are on the rise. JAMA Psychiatry reports a 225% increase among the U.S. population since 2018. 

This statistic highlights the importance of prioritizing behavioral health and eliminating discriminatory policies and practices that prevent people from accessing care.

“If this were the COVID-19 pandemic, we would mobilize every community,” says Dr. Trivedi. “We’re not seeing the same level of engagement to find solutions to these structural problems that impact behavioral health.”

Fortunately, there are solutions.

Mental health parity

The Mental Health Parity Act of 1996 and the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 attempted to address the inequity in mental health insurance coverage.  

Further legislation, such as the Affordable Care Act in 2010 and the SUPPORT Act of 2018, extended and strengthened these protections. These laws apply to most public and private health insurance—excluding Medicare—and require coverage for mental health and substance use disorders to be no more restrictive than coverage for medical conditions. 

In theory, parity laws protect against discriminatory practices limiting insurance coverage and make it easier for people with mental health and substance use disorders to get care. In reality, adequate and equitable coverage remains elusive due to a lack of enforcement of these laws. 

Practices and policies that continue include requiring burdensome prior authorization, interfering in medical decision-making, and inappropriately denying claims. 

In the 2022 MHPAEA Report to Congress, the Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Department of the Treasury detail parity enforcement efforts and insurance plans’ compliance with MHPAEA’s requirements, finding violations affecting millions of Americans.

“The report’s findings indicate that health plans and insurance companies are falling short of providing parity in mental health and substance use disorder benefits at a time when those benefits are needed like never before,” said U.S. Secretary of Labor Marty Walsh in a 2022 press release.

Stronger federal oversight, with enforcement at the federal and state levels, is needed to ensure parity in practice. Beyond parity enforcement, more needs to be done to ensure network adequacy. “Eliminating phantom networks—where insurance companies say they have enough providers but in reality half are retired or not accepting new patients—is something that could be enforced,” Dr. Trivedi says.

190 lifetime days

Medicare is not included in MHPAEA, opening it up to even more discriminatory practices restricting patients’ access to care. An example is the 190-day limit, which limits Medicare patients to only 190 days of inpatient psychiatric hospital care in their lifetime. This arbitrary cap doesn’t exist for any other Medicare specialty inpatient hospital service.

“If you had cancer and you had a relapse, there’s nothing within Medicare that says you can only receive 190 days of care,” says Dr. Trivedi. “But if you have a mental health condition, once you use up those 190 days, Medicare will not cover an additional day for the rest of your life. That simply is not right.”

Medicare provides health insurance for more than 60 million U.S. adults, many with serious mental illnesses requiring ongoing treatment. Most Medicare beneficiaries treated in psychiatric hospitals also qualify for Medicare because of disability, not age. Younger than the typical Medicare beneficiary, they are even more likely to exceed 190 days of care. 

“There have been bills specifically removing this limit introduced in Congress year after year. This is in the hands of Congress to enact and change,” Dr. Trivedi says. 

IMD exclusion

The outdated Institutions for Mental Disease (IMD) exclusion prevents states from receiving Medicaid funding for care provided to non-geriatric adults in psychiatric hospitals with more than 16 beds. 

The exclusion—enacted in 1965—put the responsibility of paying for IMD-based care on the states and reduced the amount of psychiatric care provided in large institutions as part of the “deinstitutionalization” movement. 

At the time, most mental health services were delivered in large, state-run psychiatric institutions or asylums for long-term care. Those bear little resemblance to today’s world-class psychiatric care facilities, like Sheppard Pratt’s, where providers take care of the sickest of the sick. With modern treatment, patients receive care while living in the community. 

The IMD exclusion has played a significant role in the deinstitutionalization movement, but not always in the patients’ best interests. Almost 97% of state hospital beds have closed since the mid-1950s. Patients who require inpatient psychiatric care face long wait times and boarding in emergency departments, potentially resulting in inappropriate or no treatment. 

The IMD exclusion is a discriminatory policy restricting medically necessary care. By prohibiting federal payment for IMD-based care, Medicaid beneficiaries cannot access the same psychiatric services that others can.

“Across the nation, we have freestanding psychiatric hospitals that have capacity, and yet a major public payer doesn’t allow people to receive their care,” says Dr. Trivedi. “This is out of misguided fallacies from the 1960s that in no way represent what care is like today.”

And while the federal government recently has provided exceptions to the IMD exclusion, this would be better solved by repealing the IMD exclusion altogether. 

“We no longer have institutions where people get housed for 30 years. We have psychiatric hospitals in the same way we have pediatric or cancer care hospitals,” Dr. Trivedi says. “Removing the IMD exclusion would give so many more people access to lifesaving services.”

Funding solutions

Enforcing parity legislation, removing the 190-day limit, and repealing the IMD exclusion are necessary steps to ensure timely and equitable access to psychiatric services. Dr. Trivedi is hopeful that these solutions are within our grasp: “We have a Congress that doesn’t agree on many things, but they all agree that we have issues with mental health and substance use.” 

Beyond these necessary policy changes, Dr. Trivedi points to the need to end the historic underfunding of behavioral healthcare.

“We have the know-how to help people at a population level, but we’re lacking the infrastructure and the funding to effect a population-based solution,” says Dr. Trivedi. “One example is the pilot project for certified community behavioral health centers—we already know these work.”

By changing key legislation, removing barriers to care, and investing in much-needed behavioral health services, we can prioritize mental health now.

“When you consider the burden of disease and how many people are impacted and how many lives we lose, the biggest return on investment is making a concerted effort to address the mental health issues in our nation,” says Dr. Trivedi.

Improving Mental Healthcare Systems in the United States: Policy Questions Arising from a Case Study of Sheppard Pratt

Our nation is facing an unprecedented mental health crisis. The RAND Corporation’s recent case study on Sheppard Pratt examined our continuum of care and the ways we’re addressing challenges as mental health policymakers.

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