As the nation begins to piece itself back together in an effort to return to a new “normal” post COVID-19, it’s important for the healthcare system to pay particularly close attention to what the pandemic will mean for the future of the mental health community. While there are many challenges in this space, three of the most significant are: access, coordinated care, and medical innovation. On the first issue, many mental healthcare and substance-use providers are outside of insurance networks. This lack of in-network providers is a big problem for patients and can increase out-of-pocket costs. An overall provider shortage also creates challenges for those seeking care. Secondly, our current system pays a high price tag for mental health services through fee-for-service. Lastly, despite the innovation that we have seen in the biopharma pipeline in recent years, we have seen a stagnation in the advancement of mental health drugs.
“This is a really fractured system,” says Dana Macher, managing director at Avalere Health, a leading healthcare consulting firm. “Going forward, it will take partnerships and thoughtful, data-driven strategies from all healthcare stakeholders to meaningfully change the current situation.”
While COVID-19 has accelerated the adoption of telehealth amongst providers and patients, and may help address provider access and shortage issues, weak points remain in our healthcare system. “We have an access issue,” she notes. “We have a system where a lot of mental healthcare is done out of network, which leads to a high cost-burden on patients. Many mental health professionals have gone out of network because negotiated in-network rates for their services are viewed as too low.”
Another assumption is that people who have health insurance can at least get the medications they need, but data reveals the reality. “Avalere recently did an analysis looking at mental health drugs,” Macher says, “and found that the out-of-pocket costs for mental health drugs was twice that for non-mental health drugs.”
There is a critical need for payment approaches that consider and incentivize coordinated care. Better coordination of treatment has been shown to improve outcomes; in first episode psychosis, coordinated specialty care has been shown to decrease hospitalizations and improve educational and employment rates, and patient-centered coordinated care is also effective in improving prescription adherence rates. But coordinated care between primary care providers, psychiatry, and social work is lacking for those with severe mental illness. “Patient-journey roadmaps are being created in oncology,” says Macher, “but not in mental illness — caregivers carry an enormous burden because there are not many wraparound support systems in place. We really want to change this situation because it is an extremely difficult thing for families and caregivers — the support systems just aren’t there.”
Macher notes that innovation in treatments for mental illness has not kept pace with other therapeutic areas in recent years. “In terms of drug development, the past couple of decades have been a little bit barren,” she says. “Scientists sequenced the genome and a lot of therapeutic areas, such as oncology and gene therapy, took off. It was much slower in mental health. In schizophrenia, for example, many patients are still on 30- and 40-year-old drugs that have significant side effects that really prevent patients from adhering to their medications.”
However, Macher also sees signs of hope: The FDA is utilizing the Fast Track Designation and Break-Through Designation to speed up development of mental health drugs, and the pharmaceutical industry is increasingly interested in psychiatric therapeutics. “We’re starting to see some novel mechanisms emerge,” she says.
Macher and her colleagues are looking towards the power of partnerships — and the data that such partnerships can generate and analyze — as the path towards improving the way mental health is delivered. “There are multiple stakeholders in this equation,” she notes. “You’ve got the pharmaceutical industry, you’ve got payers, employers, regulators, and advocacy organizations. There is a great opportunity in terms of partnerships and the sharing of data. For example, the National Institute of Mental Health (NIMH), academia, nonprofits, and the pharmaceutical industry are really starting to move the ball forward and develop much-needed therapies.”
Data is also essential to shaping policy changes, as anecdotal evidence isn’t very persuasive with policy makers. “A lot of people are trying to move the needle around network access, for example,” Macher says. “Recent research has shown that mental health claims are five times more likely to be out of network than physical health claims.”
Data can also prove the case that fixing these problems is in everyone’s interests — including companies worried about the bottom line.
“Usually it comes down to value, ‛Where can you improve outcomes and save dollars?’” Macher says. “Data shows you can put some of these wraparound programs in place, for example, and decrease ER visits and hospitalizations. You can look at medication adherence to help manufacturers go to the payers and demonstrate with data that putting adherence programs in place could be a win-win for them both. If you can show improvements in outcomes, or decreases in total cost of care, then why wouldn’t you do it?”
Avalere recently launched its Mental Health and Substance Use Initiative to leverage its data assets to address this complex issue for payer, provider, and life sciences clients. The answers involve partnerships and sharing data. “We realize the magnitude of the issues in mental health,” Macher says, “and we are focused on ways that we can partner on thoughtful solutions to support all stakeholders in this space.”