Transforming Mental Healthcare in the United States
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The U.S. mental health system has reached a moment when a historic transformation to address persistent problems appears realistic. These problems include high levels of unmet need for care, underdevelopment of community-based supports that can help avoid unnecessary emergency care or police engagement, and disparities in access and quality of services.
In recent years, encouraging trends highlight the growing possibility of addressing these challenges:
- Expanded access to coverage
- Medicaid expansion in 39 states has extended affordable coverage to millions of Americans. Medicaid is now the leading payer for U.S. mental health care among adults with serious mental illness.
- Equitable mental health coverage
- Mental health parity, the once-controversial idea that mental health benefits should equal other medical benefits, is now the law of the land.
- New evidence-based treatments
- Recent research has substantially strengthened the evidence base supporting the effectiveness of new treatments for depression, anxiety, and psychosis, as well as for new models for delivering care.
- Political consensus
- Reforming the U.S. mental health system has received strong bipartisan support at both the federal and state levels.
Against this background, a RAND research team sought to identify goals for transforming the U.S. mental health care system and to pinpoint opportunities to drive systemic improvements. To develop these recommendations, the team interviewed mental health experts throughout the country—including government officials, public administrators, health system executives, and academicians. In parallel, the team conducted a comprehensive review of the scientific literature to identify best practices and recent innovations in mental health care.
The overarching goals of these recommendations appear below.
Goals for a Mental Health System Centered on the Patient Journey
1. Finding a doorway to care: promote pathways to care
Too often, people with mental health needs do not even make contact with mental health providers. This is partly attributable to a system in which individuals are unaware of available resources, fear the repercussions and stigma associated with mental illness, and fail to receive screenings and diagnoses. High-need populations, such as those with a pattern of homelessness or criminal justice involvement, may also require shepherding to services that best meet their needs.
2. Getting through the door: improve access to care
Once a patient is identified as needing care, several barriers may obstruct actual receipt of services. These include the cost to the consumer (affordability), the capacity of the system to provide adequate care in a timely manner (availability), the location of services (accessibility), and the suitability of services from the consumer's perspective (appropriateness). All four barriers must be removed for patients to use services.
3. Once you're inside: establish an evidence-based continuum of care
Once patients are inside the system, uncertainty remains. Will the care be evidence-based? Will it correspond to the patient's level of need? Will it be provided in a timely and consistent manner? There is no guarantee that mental health systems can answer "yes" to these questions and, ultimately, improve patient outcomes. For this to happen, the internal mechanics of systems need to be recalibrated, and rewards need to be established to align services with patient needs.
With these three goals as a framework, the team recommends 15 strategies for transforming mental health care in the United States into a patient-centered system.
Goal 1:Promote Pathways to Care
We need to ensure that people come into contact with care, and their needs are identified through screening and diagnosis by appropriately trained professionals.
- Promote systematic mental health education. Mental health education should be considered a key part of a comprehensive health education curriculum. Schools have the potential to destigmatize mental health and improve attitudes, enhance the knowledge and skills needed for prevention, and promote increased help-seeking.
- Integrate mental health expertise into general health care settings. Mental health conditions are often unrecognized in general health care settings. Integrated, whole-person care approaches are effective in connecting people to care but are underutilized.
- Link homeless individuals with mental illness to supportive housing. Supportive housing programs help homeless people with mental health needs begin recovery by starting from a foundation of stable housing. Stable housing not only improves individuals' quality of life and chances for recovery; it can also save the health care system money by reducing the need for recurring care. Administrators at all levels of government should expand supportive housing programs, particularly for individuals with serious mental illness.
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Develop a mental health diversion strategy centered on community mental health.
Correctional facilities are one of the largest providers of mental health care in the United States.
Yet, in this setting, many with mental health conditions might not receive the care they need.
An evidence-based program that diverts people away from the criminal justice system and into community-based mental health services would benefit this population.
Goal 2:Improve Access to Care
Making sure that people have access to care means more than overcoming geographic barriers. It means ensuring that care is affordable, available, accessible, and appropriate.
- Strengthen mental health parity regulation and enforcement. Although mandated by law, mental health parity has still not been fully achieved. Governments can institute laws and regulations that set clear standards for assessing parity compliance, require mental health coverage from a broader range of insurance plans, and strengthen enforcement of existing state and federal parity laws.
- Reimburse evidence-based mental health treatments at their true cost. Establishing Medicaid reimbursement rates that are commensurate with the costs of providing care should encourage providers to offer evidence-based treatments that now are often unavailable. Improving access within Medicaid would particularly benefit Americans with low incomes and those with serious mental illnesses.
- Establish an evidence-based mental health crisis response system. Many communities lack an adequate mental health crisis response system. Poor crisis care results in missed opportunities to direct individuals into treatment and sometimes ends in suicide that might have been prevented. Building an evidence-based response system that swiftly identifies individual mental health needs and efficiently triages individuals into appropriate care should reduce unnecessary suffering.
- Establish a national strategy to finance and disseminate evidence-based early interventions for serious mental illness. Growing evidence points to the effectiveness of programs that deliver coordinated clinical and supportive services early in the course of schizophrenia and related disorders. These programs, as well as emerging early interventions for serious mental illnesses, fall outside the Medicaid-based public mental health system and require a national strategy to fund and disseminate them widely.
- Expand scholarships and loan repayment programs to stimulate workforce growth. Expanding the recruitment pipeline for mental health specialty workers, such as psychiatrists and psychologists, will help meet the needs of underserved areas. Policies for doing this include expanding scholarship, fellowship, and loan forgiveness programs that attract more individuals, support more-diverse students, and require a commitment to practicing in high-need settings.
- Improve the availability and quality of peer-support services. Peer-support specialists are people who have experienced mental health or substance use problems and have been trained to join teams caring for those struggling with mental health conditions, psychological trauma, or substance use disorders. These specialists have been proven highly effective in improving patient outcomes. Expanding access to training, credentialing, and reimbursement for peer support has the potential to improve access to high-quality peer-support care.
- Expand access to digital and telehealth services for mental health. Digital and telehealth services can extend access to mental health care throughout the United States, particularly in rural communities that face shortages of providers. Stimulated by the COVID-19 pandemic, state and federal policymakers should codify expansion of these services by ensuring that insurers cover them, that clinicians are adequately reimbursed, and that consumers know how to use the technologies.
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Include patient-important outcomes in treatment planning and assessments of care quality.
The current system is seldom organized to deliver patient-centered care or to provide access to the full range of community supportive services.
As a result, provider-based goals often misalign with patient-based goals.
Including patient outcomes, such as social functioning and occupational goals, in care planning can improve this alignment and enhance the patient-centeredness of mental health care.
Goal 3:Establish a Continuum of Evidence-Based Care
Once patients are in care, it is the responsibility of the health system to make sure that patients are receiving care that meets their level of need and that all providers are on the same page.
- Define and institutionalize a continuum of care in states and communities. Individuals with mental health needs often fall through the cracks because of a lack of clarity regarding who should provide care, at what level of intensity, and in what settings over time. Available clinical guidelines provide an explicit framework for resolving these questions about level of care and can help optimize mental health spending within communities. State Medicaid systems should mandate their use.
- Launch a national care-coordination initiative. Care coordination involves integrating mental health providers, care managers, and other providers into coordinated teams, often in primary care settings. The effectiveness of coordination has been demonstrated in various evidence-based models, but few practices are using it. A national initiative led by the Centers for Medicare & Medicaid Services that provides technical assistance, implementation tools, and learning support for implementing practices would help transition practices to evidence-based models.
- Form a learning collaborative for Medicaid mental health financing. Collaborations between Medicaid officials, advocates, and state policymakers can help ensure that emerging evidence on innovative financing and service delivery models drive improvement in mental health care systems, especially for Americans with low incomes or serious mental illness.
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Conclusions
Leaders in government, the private sector, and health care can chart a transformative new course in improving mental health in the United States. RAND's 15 evidence-based recommendations can guide decisionmakers to feasible and effective strategies that support consumers in finding, accessing, and receiving high-quality, appropriate, and timely mental health care. These changes should receive bipartisan political support and catalyze substantial improvements in access, use, and quality of mental health care that in turn would improve the lives and health of tens of millions of Americans.
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