Ron Mandersheid, Ph.D.
Executive Director, NACBHDD
On the May 1 “Access to Care” post, we asked, “If you or a family member needed care today for a mental health or substance use condition, would you be able to get it?”
Access to care can help prevent, delay, and treat mood disorders, other mental conditions, and co-occurring illnesses among the 45.6 million adults and 15.6 million children and youths who experience a mental health condition.
However, in reality:
- Fewer than 40% of adults and youths with mental health conditions—including mood disorders—ever get any mental health services
- Fewer than 7% of adults with co-occurring mental and substance use disorders get treatment for both.
Let’s explore access challenges to the prevention, diagnosis, and treatment of behavioral health conditions.
Getting in the Door
If you can’t open the door, you can’t get care.
You need a bunch of keys, too: there are impediments with health insurance coverage and cost; the nature of the provider; and physical or psychosocial distance.
1. Insurance-related challenges
The first key to open the access-to-care door for a mental or substance use problem is having health insurance, whether employer-provided, self-purchased, or made available through federal or state health plans.
But insurance is not itself sufficient to open the door because the insurance benefits may not cover, or adequately cover, behavioral health services.
Historically, health plans—including both Medicare and Medicaid—have excluded coverage for some, or all, behavioral health services, while other plans lack appropriate or sufficient coverage over the short or long term. Access to care can be limited by the amount and scope of coverage, as well as by the costs that you must pay.
- Until recently, health plans have been able to impose annual and lifetime day or dollar limits on behavioral health services.
- The kinds of care have been limited, such as the exclusion of substance use care and wrap-around services.
- Copayments—the share of a provider’s charge you must pay—can be excessive, particularly when managing a long-term illness like depression, hypertension, or heart disease.
- Deductibles—the amount that you must pay health providers before your insurance begins to share in the cost—can also be excessive, and they continue to rise annually.
- Out-of-pocket costs associated with medications also increase regularly, presenting additional financial challenges for consumers.
2. Provider-related challenges
Health providers may hold another key to access, closing the door to care when they choose not to accept payment through your particular health insurance. Why do some providers decline to participate in selected or all insurance programs?
- Low pay
- Too much recordkeeping and paperwork
- Delayed payment
- And some believe patient-borne payments are part of the treatment process itself!
Beyond payment issues, health services may not be culturally or linguistically appropriate and accessible. Without an understanding of your heritage and language, neither provider nor staff can bridge a divide that can make even the best-intended services inaccessible. Some providers may view you as a patient rather than a partner in care. Without engaging you (and, as relevant, your family) as a partner in care, access remains limited.
3. Distance-related challenges
It’s also about “getting there” for care: physical and psychological environments hold a final key to open the door to access to care for a mental health condition or substance use problem.
If you are physically unable to get to a provider’s office, access is denied. Distances need to be bridged; costs of travel need to be held down; and facilities need to be physically accessible to individuals who are dealing with both behavioral health issues and physical limitations.
Another Challenge: Stigma
Psychological access is, perhaps, even more of a challenge to care. Too often, little if any effort is made to reduce the stigma that remains attached to seeking care for mental health conditions and substance use disorders. Provider staff attitudes may be dismissive or unsupportive; their language may be insensitive; they may not be sufficiently attuned to manage effectively or even understand waiting room concerns regarding privacy and behavior.
Once In, Can You Get Quality Care?
When you’ve managed to get in the door, here’s the question: Have you opened the RIGHT door?
Will you get care that is individualized and collaborative, based on best-practices, and centered on you and your health needs, including your family when appropriate?
The door you’ve opened to care is the right door if and only if your provider:
- accurately recognizes and appropriately diagnoses the problem or problems.
- understands cultural and ethnic implications of a behavioral diagnosis and knows how to respect and work within any limits or differences they may pose for the individual, treatment, or family.
- intervenes early to help prevent, delay, or limit the effects of behavioral and/or physical problems.
- engages you (and/or your family, as individually and culturally appropriate) as active partners and collaborators in the process of care and recovery.
- uses evidence-based treatment, rehabilitation, and recovery practices.
- offers integrated/coordinated care that focuses on the whole individual, treating all of the problems presented and/or working with other providers to do so.
- helps ensure that other needed services and supports (housing, education, transportation, job training, etc.) are available to you..
What has been your experience with gaining access to behavioral health care? What do you think are the most pressing challenges, and do you have thoughts about solutions?
Share your stories and ideas by posting your comment below. Also, stay tuned throughout the week to hear examples of people who’ve experienced each of these three major challenges to accessing care.
Ron’s next Expert Perspective explores ways consumers, providers, policymakers, and administrators can work together to address and overcome access challenges. It also examines how the Patient Protection and Affordable Care Act (ACA) affects prevention, early intervention, integration, and collaboration in behavioral healthcare access, care, and services.