How providers, payers are responding to rising mental health concerns

The pandemic has done unprecedented damage to Americans' mental health, prompting providers to change how care is delivered and insurers to update coverage options. 

A mental health crisis

The pandemic and related measures to stop the spread of COVID-19 — such as social distancing, quarantines, and at-home school and work — all can play a role in mental well-being. In a CDC survey of 5,412 U.S. adults conducted June 24-30, 2020, 31 percent reported symptoms of anxiety or depression, 13 percent reported started or increased substance use, 26 percent reported stress-related symptoms, and 11 percent said they had serious thoughts of suicide in the past 30 days. Food insufficiency, financial concerns and loneliness were listed by the CDC as risk factors for reporting anxiety symptoms or suicidal ideation.

The most recent CDC data, the Household Pulse Survey taken Sept. 29 to Oct. 11, 2021, found 31.6 percent of Americans reporting symptoms of either anxiety or depressive disorder. The CDC used 2019's National Health Interview Survey as a benchmark for comparison. In 2019, 10.8 percent of adult Americans reported symptoms of anxiety disorder or depressive disorder.  

Of 505 U.S. primary care physicians surveyed in August 2021, 94 percent reported seeing more patients experiencing stress, anxiety or other mental health issues because of the pandemic, according to a Quest Diagnostics report.

Understanding the widespread long-term physical and mental effects of the pandemic is an ongoing effort, with much still unknown.  

Barriers to care

Many insurance plans lack in-network providers for mental healthcare, partly because there is a shortage of mental healthcare workers in general, according to a 2020 report from the National Alliance on Mental Illness. Even among plans that cover mental healthcare, insurers don't always pay mental health providers enough for them to be able to accept insurance.

About 37 percent of Americans lived in 5,833 mental health provider shortage areas as of March 31, according to data from nonprofit USAFacts. Two-thirds of these areas are in rural or partially rural communities.

The states with the worst shortages are Wyoming, with 96.4 percent of its population living in shortage areas, and Utah, with 83.3 percent. Comparatively, New Jersey only has 0.4 percent of its population in shortage areas and Massachusetts has 4 percent.

In order to fill this shortage, the U.S. needs an additional 6,398 providers to join the more than 559,600 members of the mental health provider workforce. The number of mental health professionals needed to fill the gaps are also dependent on location. Texas needs 638 professionals to fill the gap, while Delaware only needs 15, according to USAFacts.

Telehealth's potential to increase access

Telehealth has the potential to make mental healthcare accessible to more Americans, as virtual visits offer patients with busy schedules more flexibility and give rural patients more access to care.

However, some patients and providers are apprehensive about telehealth’s ability to transform mental healthcare, arguing the quality of care doesn’t measure up to in-person visits. For example, 75 percent of physicians said telehealth limits their ability to determine if patients are at risk for or are already misusing prescription drugs, according to a recent survey conducted by Quest Diagnostics.

Virtual mental healthcare is also dependent on state licensing requirements. When the pandemic began, most states, along with CMS, waived telehealth restrictions requiring clinicians to be licensed in the state where their patient lives. Now, some states are discontinuing those waivers, meaning many patients receiving virtual mental healthcare from a provider in another state may have to find a new care plan.

Eighteen states still had waivers in effect as of Nov. 22, according to data compiled by the Federation of Medical Boards.

During a congressional hearing in March, the American Medical Association voiced opposition to waiving multistate licensing requirements. Jack Resneck Jr., MD, then president-elect of the AMA, said no longer having a centralized regulator from a patient's home state would present challenges for rule enforcement, as there is no interstate authority to investigate incidents that occur in other states.

How payers are responding

The following health insurance leaders shared with Becker's how their organizations are navigating the influx of patients seeking mental health treatment as a result of the pandemic.

Note: Responses were lightly edited for clarity.

How have mental health coverage options changed since the beginning of the pandemic?

Eva Borden. President of Behavioral Health at Evernorth, a Cigna company: COVID-19 has pushed people to have conversations around mental health and to seek help, reducing the stigma and bringing to light the connection between one’s physical and mental health. The increased demand for mental health support has also pushed the healthcare industry to find innovative ways to help customers get the care they need.

While we’ve seen an increase in virtual care across all areas of health, behavioral health virtual care has grown in ways we couldn’t have imagined prior to the pandemic. It’s convenient and allows customers to access care when and where they need it. It provides flexibility for how customers receive care — via phone call, video chat or text messaging — and allows customers, especially those in areas without many behavioral health providers, to have care options. 

Customers now have access to condition-specific programs — such as support for depression, anxiety and burnout — and can determine if they want to work with a psychologist, psychiatrist or health coach, depending on their health needs. All of this allows customers to access the right care from the most appropriate provider, not only making access to healthcare easier but also more affordable.

Caroline Carney, MD. CMO at Magellan Health: Mental healthcare coverage options, particularly around telemedicine, have changed drastically as a result of the pandemic. Both federal and state policymakers have recognized the value telehealth can provide and the necessary changes in laws and regulations needed to ensure greater access. Many of the changes we have seen were meant to increase needed access to mental health services, and they did that through a variety of mechanisms, including allowing licensed practitioners in good standing to practice outside of their jurisdictions; the use of telephone only without video to conduct visits; prescribing controlled substances through telehealth; the delivery of medication assisted treatment for opioid use disorder; and the unsupervised use of methadone by stable patients. Because federal and state jurisdictions were not in sync across the country, this sometimes caused confusion between coverage mechanisms such as Medicare, Medicaid, Exchange and commercial populations.

Health plan policies and practices conformed to these regulations, rolling out state by state and nationally for Medicare. All saw dramatic increases in the use of telehealth services, which have abated only slightly as the forces of the pandemic lessened. Many providers, however, have not returned to offices and will continue to provide services through telemedicine. 

Services typically delivered only in person prior to the pandemic, such as those for eating disorders, are now growing rapidly in the virtual world.

Companies such as Magellan Health, which administer the mental health benefits for large insurers, follow all state and national regulations as well as the health plan’s policies. Because each state has responded differently with some states rescinding emergency authorizations tied to telehealth coverage and others adopting permanent changes to their laws, many insurers will have to make decisions around continuing some of the COVID flexibilities.

Because these policies have expanded availability of services, particularly to those unable to get into provider offices, and because the pandemic brought mental health into the public light and reduced stigma, we've seen an increased use of outpatient services across the country. I expect going forward we will see a mix of telehealth and in-person services, favoring telehealth. 

Rebecca Schechter. CEO at Optum Behavioral Health: The pandemic demonstrated the continued importance of expanding behavioral healthcare access. Virtual care may have been the most visible element of those efforts, but they also required more providers and better technology to deliver integrated care. 

How are health insurers trying to make patient access to mental healthcare providers easier?

Ms. Borden: Cigna and Evernorth are committed to growing our behavioral health networks so that customers can access care quickly as well as have choice and flexibility when accessing that care. Every single person has different needs and different preferences, so building our networks to include diverse providers or alternative ways to engage, such as text messaging, creates more opportunity for customers to get the care they need and are most comfortable with.

For many of our virtual providers, customers can access support and resources on-demand, reducing, if not eliminating, wait time for help.

The need for behavioral healthcare isn't going to change, so it is important that insurers and providers continue to find new ways to meet customers where they are and provide best-in-class care to support their health needs.

Dr. Carney: In addition to covering the variety of telemedicine options, insurers are also providing support services, largely through application-based methods. These apps focus on cognitive-behavioral informed services as well as mindfulness activities. Others include services specifically directed at eating disorders, addictions, anxiety and pain. 

Magellan has collaborated with NeuroFlow and Gallup to bring forth screening for well-being as well as mental health symptoms. This front-door screening approach will help guide our members to the service they most need, whether formal treatment by a behavioral health provider that can be easily scheduled online, or wellness coaching for a variety of needs such as weight management or tobacco cessation. Individuals have their own journey, and our services will reflect that. Our team believes strongly that many of the application-based supports provide important adjuncts to treatment, and, in cases of mild symptoms, may provide low-cost, 24/7 accessible services. 

Ms. Schechter: We've added 35,000 providers to Optum Behavioral Health's network in 2021 to help ensure timely access and quality care. With more than 300,000 providers, we have among the largest networks in the country and have supported more than 15 million virtual visits this year.


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