Treating Mental Health: Pay Now or Pay More Later

By Cynthia Miller and Maureen Hennessey

Mental Health Awareness Week commenced the first week of October, and this year, it is especially important as we wrap up the second year of the pandemic. Rates of mental illness, including depression and anxiety, rose early in the pandemic. At the same time, new innovative approaches to treatment and policy changes rose to meet the increased need. Payers and policymakers must ensure continued access for this rising vulnerable population. 

An epidemic within a pandemic, mental health conditions have skyrocketed in the past two years with a year-over-year increase in anxiety and depression of 93% and 62%, respectively, in 2020, according to Mental Health America. The Lancet’s COVID-19 Commission Mental Health Task Force notes that mental illness can affect up to ½ of the population yet only about 5% have access to treatment. The mental health epidemic, which will have healthcare and cost consequences for years to come, has sparked innovation among forward-looking leaders in the pharmaceutical and healthcare industries. There is growing recognition that innovation must be harnessed to transform mental healthcare. The Lancet noted, “The economic case for investment in mental health is strong: for every $1 invested in scaled-up treatment for depression and anxiety, there is a $4 return in better health and productivity.” In this article, we look at some of the newer innovations on the horizon as well as some of the policy changes in play that will accelerate transformation.

Mental Health and the Pandemic: Suicide, Substance Use, and Surges

According to The Lancet’s Task Force, risk factors for mental distress during the pandemic are COVID-19 infection (personal and healthcare workers), financial worry, homeschooling, and watching COVID-19–related news.  Healthcare workers tend to be at higher risk for psychological distress and may be at higher risk from stress, insomnia, and suicide moving forward based on data from previous SARS infections.  Protective factors include listening to music, reading, spending time in nature, and exercising. 

While there were concerns early on that suicide rates may increase during the pandemic, they have not been realized.  Data from the CDC show a steady rate of suicide nationally.  However, this may not be the case for select sub-populations. For example, other data show that suicide rates in racial minority groups rose in the State of Connecticut during the lockdown period, and during early March to early May 2020, deaths by suicide among Black Maryland residents increased by an alarming 94%.Also of note, the CDC reports that emergency department visits for suspected suicide attempts increased by 51% (February-March 2021, compared to February-March 2019) among 12- to 17-year-old US girls. Skyrocketing use of telehealth and concerns regarding suicide risk during the pandemic have led to additional training on best practices in caring for individuals at risk for suicide via telehealth.  

At the same time, every state has shown a spike in drug overdoses.  Based on the CDC’s Provisional Drug Overdose Counts, there has been a 40% increase in reported deaths between the 12-month period ending February 2021 and the 12-month period ending February 2019.  This rise in mental health issues can be addressed through innovative solutions, which have been developed in response to this need.  

A recent Morbidity and Mortality Weekly Report  (MMWR) noted that although the frequency of symptoms reported by American adults decreased after peaking in December 2020-January 2021, they are nevertheless comparatively higher than 2019 estimates obtained from the National Health Interview Survey conducted by the CDC.  Furthermore, they noted, “The relative increases and decreases in frequency of reported symptoms of anxiety and depression at both the national and state levels mirrored the national weekly number of new COVID-19 cases during the same period.” This suggests that we will continue to see an acceleration in the need for behavioral healthcare, fluctuating with pandemic/endemic surges. These fluctuations may be further compounded by a backlog of unmet needs secondary to reduced access to care during the pandemic. Ongoing monitoring is needed to determine the impact of COVID-19 surges and financial strains on the rates of suicidal ideation, attempts, and completed suicides among US sub-populations.

Innovations in Research and Treatment: Digital Transformation

The need for social distancing and lockdowns, and the subsequent rise in virtual care, have driven new innovations in mental health research and treatment.  For example, in psychiatric studies, researchers have developed decentralized trials—trials that utilize telemedical assessment and digital technology to gather data from participants—in response to the slowing of enrollment during the pandemic to treat conditions such as schizophrenia, bipolar disorders, and post-traumatic stress disorder.  

Analytics also offer promise for better outcomes through more proactive identification and intervention.  Seven health systems were able to improve suicide risk prediction for the 90-day period post–mental health visits through a predictive analytics model. In the pharmaceutical area, Takeda Digital Ventures and dRX Capital (Novartis’ Digital Venture Firm) have strategic partnerships with aspenRxHealth, which is a firm that matches pharmacists with patients through algorithms.  They use social and clinical criteria to offer customized interventions for medication adherence, which presents unique challenges for individuals living with behavioral health conditions. 

Expanded use of screening tools and resource directories, integrated within the electronic health record, can be used to address Social Determinants of Health (SDOH), like housing and health literacy, which often impede treatment for mental health disorders.  A 2021 PRECISIONvalue survey of payers, health systems, and Pharmacy Benefit Managers (PBMs) found that 90% of respondents thought addressing SDOH was moderately to very important to reduce admissions and readmissions, emergency department visits, and 30-day mortality rates post hospitalization.  Collaboration between health systems and payers can leverage these tools to improve and expand mental health care in their populations.

In addition, see telemedicine platforms partnering with well-being platforms, like Ginger Therapeutics did with Headspace. Ginger Therapeutics provides teletherapy and telepsychiatry to employer groups while Headspace is a mindfulness app that provides meditation and exercise programming. As we know, well-being activities like mindfulness, gratitude, and practicing kindness support better mental health.  Pharmaceutical companies are curating partnerships with digital tech startups to develop novel approaches through digital therapeutics and virtual care that would significantly change the playing field by providing greater access to underserved populations. For example, Boehringer Ingelheim and Click Therapeutics have partnered to advance a digital therapeutic, which will only be available by prescription, focused on behavior changes to treat schizophrenia.  Likewise, Otsuka has been a leader in digital-enabled technology with the use of the MIND-1 microchip-in-a-pill.  This allows patients and providers to predict and modify adherence patterns, which can be negatively affected by substance use, Major Depressive Disorder, and the presence of multiple medical comorbidities.

Payers and Mental Healthcare:  Policies and Strategies

Payers will continue to see rising mental health needs in their populations and need to be forward thinking. Policy changes, like the 2021 Appropriations and COVID-19 Stimulus Package, will pressure payers to ensure mental health parity. Payers must now demonstrate compliance on demand on non-quantitative treatment limits (NQTL) on mental health or substance abuse treatments, including drug formularies. This would involve maintaining a comparative analysis on NQTL that need to be available within 45 days from a request by state or federal regulators. With so much promise to treat mental health conditions on the horizon as well as new regulatory changes, payers need a strategic pathway forward to navigate, collaborate, and simplify access to new treatment offerings that will empower patients and enhance connectivity with their healthcare team.

These strategies include:

1. Expanding access and coverage of online psychologic and psychiatric care to increase the percentage of members with mental health conditions who are receiving treatment
2. Ensuring mental health parity access to pharmaceuticals, including LAIs, digital pharmaceuticals, opioid use treatments, and innovative drugs therapies for psychiatric conditions for which there is significant unmet need (eg, schizophrenia and treatment resistant depression) to improve adherence and prevent mental health–associated deaths
3. Forging multistakeholder collaborations to build capacity for addressing SDOH to create stability in areas like housing and food access so that members can focus on improving their mental health
4. Educating around the relationship between the pandemic, anxiety, and depression as well as resources when symptoms arise, for example suicide hotlines (eg, National Suicide Prevention Lifeline at 800-273-8255) 
5. Increasing supplemental benefits for activities that are protective, like online exercise programs and meditation apps, to promote resiliency

Conclusion

The COVID-19 pandemic has increased rates of mental illness and underscored the need for better treatment access and solutions. Payers must ensure access to known effective therapeutics, digital innovations, and community resources to increase the percentage of their population with mental health diagnoses who are receiving treatment. Investing in solutions now will save lives and preserve resources for the future.  

Cynthia Miller, MD, MPH, FACP, Vice President, Medical Director, Access Experience Team, PRECISIONvalue

Cynthia is Vice President Medical Director of PRECISIONvalue who brings over 15 years of experience in the health care field. She has extensive experience in patient care delivery in the outpatient setting, as well as experience in inpatient care, palliative care, and telemedicine. While in practice, she developed a referral program for physicians to the Diabetes Prevention Program through the YMCA for BayCare Health System, located in the Tampa Bay Area. Cynthia most recently practiced telemedicine to support COVID-19 pandemic access to care. Before joining Precision, Cynthia served as the Senior Medical Director of Pharmacy for WellCare Health Plans. In that role, she oversaw prior authorization development, utilization management, Pharmacy & Therapeutics Committee, Drug Utilization Review Committee and the Quality Committee. In addition, she oversaw utilization management of high-cost precision drugs. When Centene purchased WellCare Health Plans, Cynthia moved into the position of Vice President Medical Director. In that role, she built and managed a team of medical directors to insource operations and create synergies for the combined organization.  In addition, she worked closely with the population health team to develop diabetes and cardiovascular health strategies.

At Precision, Cynthia’s areas of expertise are strategic initiatives for access in national health plans and health systems.  Other areas of expertise include population health, healthcare disparities, and chronic disease management.  Key disease and focus areas include diabetes, obesity, pulmonary, oncology, and transplant.

MAUREEN HENNESSEY, PHD, CPCC, CPHQ, Senior Vice President, Director of Value Transformation

Dr. Hennessey is SVP, Director of Value Transformation for PRECISIONvalue. The Value Transformation Practice provides thought leadership and consultation to support value-based care innovation throughout the healthcare ecosystem. The practice has gained national attention, garnering PRECISIONvalue a 2021 Med Ad News nomination as a Vision Award Finalist for expansion of its Value Transformation Practice. Maureen has led more than 500 PRECISIONvalue strategic quality initiatives with more than 35 clients in 17 therapeutic areas.

Maureen’s experience offers more than 3 decades of expertise as a healthcare executive, clinician, academician, innovator, and coach. She has extensive experience as a clinician and healthcare executive with health/behavioral health plans, IDNs, and quality and population health management programs. She has developed innovative products and strategies for healthcare executives and access decision makers around the nation. Under her executive leadership, organizations have received recognition from eValue8, NCQA, and the National Academy of Medicine for innovative strategies that have reduced hospital readmissions, improved patient safety, and enhanced patient engagement by pioneering the use of interventions such as telehealth and addressing social determinants of health (SDOH), decades before their common adoption.

Maureen has served on national panels and committees for NCQA, the National Quality Forum, the Pharmacy Quality Alliance, NAHQ, and URAC, and participates with the NCQA Industry Council on Health Care Quality. She is a nationally recognized expert on physical and behavioral health integration and chaired the technical expert panel on physical and behavioral health integration for the National Quality Forum’s Medicaid Innovation Accelerator Project, funded by CMS. Maureen received her doctorate in clinical-community psychology and holds certifications in coaching and healthcare quality, and is a licensed psychologist in 2 states. She is a peer reviewer with Journal of Participatory Medicine and an author and speaker on quality, population health, value-based care, COVID-19, the infodemic, and SDOH.