How payers can help fix broken mental healthcare system

The mental healthcare system in the U.S. is floundering as the mental health of its citizens gets worse, according to the Centers for Disease Control and Prevention.

That was true even before COVID-19, but the pandemic really brought the systemic problems to the fore.

Eric Reinhart, M.D., a political anthropologist of law, psychiatry and public health, said he thinks society can provide mental healthcare to the people who need it and do so in such a way that saves money in the long run.

In a country with not enough psychiatrists and psychologists to go around, Reinhart thinks that it might be time to de-professionalize how to go about providing mental healthcare, allowing laypeople to help plug the holes. However, to make this work, those people need to be paid for their efforts. 

The Centers for Medicare & Medicaid Services (CMS) has experimented with allowing community mental health workers to get paid, Reinhart said. However, it did so by tethering that support to traditional medical visits—in other words, an individual can’t go to the lay mental health provider directly, and instead they need to get a doctor’s note.

“What that does is it uses the public health model of a community health worker, but it traps it within the medical model,” Reinhart told Fierce Healthcare. “And that really short-circuits what you can do.”

Commercial health plans could potentially do a better job of making community-based healthcare that relies on laypeople a reality, he said. “Private insurers would be more incentivized because they’re not as vulnerable to lobbying by the healthcare industry," he said.

Eric Reinhart, M.D.
Eric Reinhart, M.D. (Eric Reinhart)

Also, Reinhart said that a lot of what such laypeople would do would fall under preventive health, which numerous studies conclude saves the system billions of dollars when done correctly.

“If you’re a private payer, and you’re trying to reduce the healthcare costs of the people that you’re covering, this is an ideal thing to do,” Reinhart said. “You should be moving ahead far faster than CMS.”

He said he envisions community-based mental health centers staffed for the most part by people who live in those regions. These community health workers, he said, would need two weeks to one month of training rather than years in medical school.

“A lot of the everyday care services that people need, and they’re not getting, don’t require two years of graduate school in social work,” Reinhart said. “They don’t require a psychiatry degree. They don’t require a Ph.D. in psychology. What they require is very basic training that takes weeks to a month. You live on the block; you know what grandma in the corner needs.”

Communities would benefit not just from the care that’s delivered but also by who’s delivering that care, as it can provide jobs. Reinhart also said that these types of community-based programs aren’t that unusual when it comes to delivering physical care.

“Perversely, not as much for mental health,” Reinhart said. “It’s imagined that you need professional mental health services—psychologists, licensed clinical social workers, psychiatrists.”

Reinhart cited the work of Shreya Kangovi, M.D., of the University of Pennsylvania, who designed the IMPaCT Community Health Workers model—IMPaCT standing for Individualized Management for Patient-Centered Targets. “It’s connected somewhat to the medical world, unfortunately, but she’s shown that community-based models work," he said.

Under IMPaCT, an individual who’s been hospitalized is paired with a community health worker who then follows up with them in the community. “And they’re provided minimal training, and it’s not at all expensive to incorporate,” Reinhart said. “What she shows is that over just a year, there’s a major reduction in hospital stays and a major reduction in cost. But she said that she’s had a lot of difficulty getting health systems to buy into this model because they don’t have the financial incentives to do so.”

That’s where payers come in, according to Reinhart.

“I’m not only hopeful that the private insurers will follow CMS, but actually that they might lead CMS into recognizing the importance of reimbursing for these preventative services, and really embracing a public health model of prevention rather than a medical model of prevention.”

Reinhart further outlined his ideas in an opinion piece published by Stat earlier this week.