U.S. Mental Health System Needs Broad Changes to Improve Access and Quality

Conditions are ripe for transforming the U.S. mental health care system, with scientific advances, the growth of Medicaid and political consensus on the importance of improving mental health creating the possibility that goals once thought out of reach may be possible, according to a new RAND Corporation study.

Broad changes will be needed to improve how Americans receive mental health care, such as integrating behavioral health care into general health care settings, providing supportive housing to the homeless and promoting comprehensive mental health education.

Federal mental health parity legislation is one recent promising development that aims to put coverage for mental health treatment and general health care on equal footing, but researchers say that more effort is needed to enforce the law.

Other efforts urged by the report include increasing the use of evidence-based mental health treatments, expanding scholarships and loan repayments to stimulate growth of the mental health workforce, and improving access to digital and telehealth services for mental health.

The RAND recommendations come from an extensive project that reviewed published research about the nation’s mental health system and consulted with consumers, mental health advocates, researchers, clinicians, health system representatives, policymakers and payers.

“For decades, the nation’s mental health system has faced challenges such as the underdevelopment of community-based supports, high levels of unmet need, and inequities in both access to care and the quality of care,” said Ryan McBain, the study’s lead author and a policy researcher at RAND, a nonprofit research organization. “Our report outlines the fundamental building blocks that policymakers should consider to bring about transformative change to the U.S. mental health system.”

The RAND evaluation examined the mental health system broadly, encompassing the organization of people, institutions and resources that support delivery of mental health services, as well as adjacent sectors such as housing and education.

Researchers received stakeholder input from a broad-based advisory panel that met twice over the course of the project to discuss the conceptual model and policy options for achieving goals of health system transformation. The RAND team also conducted one-on-one interviews with more than 20 additional mental health policy experts.

Despite a wide need for services, just 45% of people in the U.S. with a mental illness received any mental health treatment during 2019. The shortcomings are even greater for members of racial and ethnic minority groups, who are about half as likely to receive mental health care as non-Hispanic White people.

Prisons and jails are now recognized as the largest institutional providers of housing for people with serious mental illness. There also are striking geographic variations in availability of mental health specialty care, with rural areas particularly underserved.

There has been a resurgence of innovation and bipartisan advocacy for people experiencing mental illness in recent years, with significant changes in how mental health care is financed and the emergence of a stronger evidence base for treatment and policy. Parity laws aim to improve access, and states have endorsed an expanded role of Medicaid in providing coverage for individuals with serious mental illness.

“There is reason to believe that the time is right for major changes to the nation’s mental health shortcomings,” McBain said. “Our recommendations are rooted in evidence and are patient-centered — mapping directly to the patient journey traversed by those affected by mental illness.”

This RAND report aims to lay out how policy changes at all levels of government — federal, state and local — can build on recent developments and effect broad transformational change to improve the lives of the 60 million Americans living with mental illness.

The report’s 15 recommendations are structured around three overarching goals for improving the nation’s mental health landscape: promoting pathways to care, improving access to mental health care and establishing an evidence-based continuum of care.

RAND researchers say that for people to get the mental health care they need, communities should be sensitized to the importance of mental health, ideally beginning in school systems where children and adolescents can be provided with consistent information about the importance of mental health.

To identify population-level mental health needs, screening and treatment models linked to primary medical care should be broadly implemented in both public and private sectors.

For those with serious mental illness, the report says that needs pertaining to social determinants of health should be addressed. This includes connections to housing for the homeless and diversion strategies for those who are incarcerated or end up in hospital emergency departments with no other recourse for medical care.

Many recommendations aim to make the process of accessing services straightforward.

The report recommends strategies to create a robust and well-educated mental health workforce, as well as bringing services closer to patients by expanding access and use of telehealth. Improving enforcement of mental health parity and providing financial incentives to better reimburse providers should prompt more health systems to make mental health services available.

Because the journey to care can be unnecessarily convoluted and bureaucratic for patients, researchers recommend that communities consider using established guidelines to define a continuum of care that is appropriate for meeting individuals’ level of need. For patients with both physical and mental health conditions, or who have diverse mental health needs, coordination among providers is essential.

While there is strong evidence demonstrating what works, the report says that a national effort is necessary to push out care coordination models at a larger scale.

The report includes a web-based tool that allows users to quickly scan the research literature that provides the basis for the report’s recommendations.

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