To: Howard A. Zucker, M.D., J.D., Commissioner of New York State Department of Health

From: Sierra Teegarden

Date: 10 July 2021

Re: Untreated and Undertreatment of Mental Health Disorders

Statement of Issue: The CDC has estimated that 40% of U.S. adults are struggling with mental health or substance use and 11% of adults seriously considered suicide as of June 2020 (Czeisler et al., 2020). Suicide is the 10th leading cause of death in the U.S. and 2nd leading cause in people aged 10-34 (The National Institute of Public Health, 2021). People with severe mental health disorders have a life expectancy 10-25 years shorter than others, which has been attributed other treatable medical conditions (World Health Organization, n.d.). Inadequate treatment has also been linked to increased incarceration and recidivism rates. According to the Bureau of Justice Statistics, 37% of prisoners and 44% of jail inmates had received a mental health diagnosis prior to incarceration but 66% of those prisoners reported not receiving mental health treatment while incarcerated (James & Glaze, 2006). Lack of proper screenings, early interventions & treatment, and community resources have contributed to the nation’s mental health crisis.

• Mental Health is underdiagnosed. According to WHO, more than 50% of patients who met diagnostic criteria for mental health disorders were not identified by their providers.

• Barriers to treatment exist due to finite availability and cost of mental health services. Geographic placement of services, private clinics that do not accept insurance reimbursement, and new patient wait lists are examples of such barriers.

• Low socioeconomic status is a risk factor for mental health (American Psychiatric Association) creating the need for increased community resources such as housing, employment, and food assistance.

Policy Options:

• A local mandate requiring a comprehensive universal mental health screening to be offered as a part of all new patient visits and annual physical exams for all medical specialties. The screening would expand upon the existing Patient Health Questionnaire for depression (PHQ-9) to include screenings for other common psychiatric disorders and alert providers to reported symptoms that warrant further investigation.
  • Advantages: Requiring healthcare settings to provide a universal screening would limit the amount of unreported mental health symptoms and complaints leading to increased recognition and subsequent diagnosis. By mandating for all specialties, patients without primary care or psychiatric services will be included in the screening efforts. In addition, this will increase the interval frequency of screening for patients being seen by multiple providers – increasing the reporting of seasonal or episodic symptoms.
  • Disadvantages: The diagnosis and treatment of mental health disorders is not within the scope of practice of all medical specialties and a universal screening mandate could lead to false positives. This scenario could place an undue burden on the patient by prompting unnecessary referrals and is not best use of healthcare resources.  Furthermore, the mandate does not address how to increase access to care for a positive screen.

• Fiscal policy to increase Medicaid reimbursement for Federally Qualified Healthcare Centers that offer Mental Health services. FQHC’s save the Medicaid program $6 billion annually and an average of $2,371/year per Medicaid patient compared to other providers but Medicaid revenue only covers 80% of the costs associating with caring for that population leading to an uncompensated gap (National Association of Community Health Centers, 2018). A policy to increase the reimbursement rate to 100% for centers offering mental health services would expand the resources of existing centers and promote the creation of new community centers while lessening the burden on government spending by reinvesting in facilities that are federally subsidized by the Health Resources & Services Administration.
  • Advantages: Increasing access to care by removing financial barriers achieved through the promotion of psychiatric services that take public and private insurance, as well as an income-based sliding scale fee for the uninsured population. Increasing geographical access to care by placing services directly in vulnerable communities. Decreasing new patient wait list times by the direct expansion of resources and attracting providers through financial incentives.
  • Disadvantages: Indirectly limiting the psychiatric provider network for Medicaid recipients by not addressing the need for increased reimbursement rates for private clinics, increasing the gap of providers that do not accept public insurances or opt out of insurance completely.

• Policy that provides a grant from the Department of Health’s budget to NYC Human Resources Administration’s Supportive Housing Program to increase the number of housing units available for applications who are homeless with a documented psychiatric disorder.
  • Advantages: Housing insecurity is linked with an increased risk of acquiring a mental health disorder and poorer treatment outcomes. Expanding the number of supportive housing units and existing resources available such as the program’s medication management and counseling would decrease the homeless population and assist in medical care leading to improved mental health outcomes for this population.
  • Disadvantages: This policy does not address the prevention of psychiatric disorders for people that will acquire a future mental health disorder from increased environmental stressors like housing insecurity. The policy also fails to improve the quality and access to care for people with a mental health disorder that currently have secured housing.

Policy Recommendation:

While mental health disorders disproportionately affect certain groups of people, the incidence rate remains high for the entire U.S. population. To achieve maximum benefit, a policy that reaches the largest breadth of people facing barriers to mental health services should be implemented. Fiscal policy to expand Federally Qualified Healthcare Centers with Mental Health Services through increased Medicaid reimbursement should be enacted. Such policy will directly increase access to care for Medicaid recipients, uninsured population, and private insurance recipients. It will, additionally, indirectly increase access to care for private insurance recipients by increasing the number of psychiatric services accepting insurance reimbursements, thus driving up competition in a market that remains largely unopposed as of today. Current geographic limitations will also be improved by increasing services in community centers that are mandated to be placed within high-risk, vulnerable communities that have disproportionate access to care.

References:

Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1external icon.

The National Institute of Mental Health. (2021, May). Suicide. U.S. Department of Health and Human Services. https://www.nimh.nih.gov/health/statistics/suicide.

World Health Organization. (n.d.). Premature death among people with severe mental disorders. World Health Organization. https://www.who.int/mental_health/management/info_sheet.pdf

James, D. J., & Glaze, L. E. (2006, September). Mental Health Problems of Prison and Jail Inmates. Bureau of Justice Statistics Special Report. https://bjs.ojp.gov/content/pub/pdf/mhppji.pdf.

World Health Organization. (n.d.). Gender and women’s mental health. World Health Organization. https://www.who.int/teams/mental-health-and-substance-use/gender-and-women-s-mental-health.

Lisinski A, Hieronymus F, Eriksson E, Wallerstedt SM. Low SSRI dosing in clinical practice-a register-based longitudinal study. Acta Psychiatr Scand. 2021 May;143(5):434-443. doi: 10.1111/acps.13275. Epub 2021 Jan 22. PMID: 33404081.

National Association of Community Health Centers. (2018, May). Health Centers and Medicaid Fact Sheet. National Association of Community Health Centers. https://www.nachc.org/wp-content/uploads/2018/05/Medicaid_FS_5.15.18.pdf

NYC Health. (n.d.). Housing Services (Supportive Housing). NYC.gov https://www1.nyc.gov/site/doh/health/health-topics/housing-services-supportive-housing.page