A Population-Based Approach to Curb the Mental Health Crisis

The unrelenting stress of 2020 extending now into 2021 caused by a pandemic that continues to disrupt the economic and social health of individuals and communities is taking its toll. Mental health issues are on the rise.¹ Latest statistics from the Morbidity and Mortality Report published February 5, 2021 show that the overall prevalence of depression in US adults was 29% during the months of April and May 2020, with suicidal thoughts/ideation at 8%, and initiating or increasing substance use at 18%.² Now nearly a year later, the stress underlying the uptick in mental health problems remains ongoing as large parts of the population still await relief through vaccination and the return to work and school. 

What COVID-19 persists in showing us are the vulnerabilities within the health care system that may have long existed prior to the pandemic but have become critical. One great vulnerability is the lack of sufficient and effective attention to mental health care, despite the well-documented and recognized evidence on the association between mental and physical health. Also better understood is the impact of environmental stressors and social determinants of health—poverty, geography, proximity to high-crime rate areas, abuse, toxic stress, among others—which place populations at increased risk of developing mental illness.^3,4 It is well-documented, for example, the role of toxic stress and trauma on a child’s mental health that can have a lifelong impact on their mental and physical health.⁵

Implementing a population-based approach to mental health is advocated by many experts as a way to prevent, identify early, and better treat mental health issues to improve the quality of life, as well as reduce the substantial burden on the health care system and society as a whole.^4,6-8 In 2013, mental health disorders incurred the highest health care spending in the United States at $201 billion or $164 billion, if excluding dementia.⁹ Additionally, mental disorders often co-occur with other chronic illnesses making them more difficult and costly to treat. 

“There has been evidence for a long time that individuals with mental health problems use health services for physical conditions more than those without mental health problems, when these problems are not recognized and attended to,” said Rebecca Fuhrer, PhD, professor in the department of epidemiology, biostatistics, and occupational Health at McGill University, who described the need for population-based mental health approaches in an editorial published in the American Journal of Public Health.¹⁰ 

A population-based approach to mental health, she said, takes a longer-term view than focusing on treating psychiatric disorders once they emerge as is now typically done. It includes strategies for early detection and intervention, as well as ways to reduce recurrence and relapse of established illness. 

If sufficiently resourced, Dr Fuhrer said the health care sector can play an important role in achieving these aims while reducing their cumulative high cost.

As with other population-based strategies for chronic illness, like diabetes and heart disease, using this approach to target populations at high-risk of mental health issues to prevent and reduce their development and severity could lead to better outcomes and reduce their high cost. Given that mental health issues often co-occur with many other health conditions, the benefits of prevention and better management could extend to improving the quality of care and cost reduction in many other conditions as well.  

Identifying At-Risk Populations

When considering how to implement a population-based strategy for mental health into their programs, managed care providers and decision makers need access to reliable data. A spokesperson from the Substance Abuse and Mental Health Services Administration (SAMHSA) underscored the importance of using data to look at outcome variability for similar diagnoses or combinations of diagnoses.

“A common example would be looking at diabetes management in those with and in those without mental illness and depression,” said the SAMHSA spokesperson. “If persons who have diabetes with depression or other mental illness have worse and more costly outcomes, then a target might be improving the abilities to identify, diagnose, and treat depression or other mental illnesses in persons with diabetes.”

Further data can be found in databases sponsored by the Centers for Disease Control and Prevention (CDC) that track population-level self-reported estimates of health indicators of mental health, such as the Behavioral Risk Factor Surveillance System, the PLACES Project (which reports county-, place-, census tract-, and ZCTA-level data and uses small area estimation methods to obtain 27 chronic disease measures for the entire United States), and Youth Risk Behavior Survey. 

“These estimates can impact how mental health care delivery is delivered by identifying populations at greater risk, especially racial and ethnic minorities, and the types of services that are needed and in what communities the services are most needed, such as rural or urban settings,” said Lela McKnight-Eily, PhD, of the CDC’s COVID-19 Social and Behavioral Health Team.

In an article that explored populations to target based on the economic evidence, McDaid and colleagues highlight a number of populations for which the data show cost-effectiveness for protecting mental health. Among these populations are maternal and infant mental health, children and adolescents, and older adults.⁴ 

Implementing Population-Based Approach in the Clinic

“I would love to see primary care as the platform for making this happen,” said Alison N Huffstetler, MD, assistant professor, department of family medicine and population health, Virginia Commonwealth University, and assistant professor, department of family medicine, Georgetown University School of Medicine. “If you put primary care first and provide the tools to help address mental health, I think you would see a lot of downstream effects of both chronic disease and mental health problems reduced.”

One way of giving primary care the tools they need to address mental health issues in the clinic is to integrate behavioral health professionals within the primary care setting, whether that is a social worker, care coordinator, psychologist, or psychiatrist. Dr Huffstetler said that the person could act both as a mental health resource for the patient as well as a resource for the provider to educate him/her on mental health issues and care. In addition, integration of a behavioral health professional would also strengthen the mission of primary care through providing comprehensive care as well as increasing capacity and continuity of care.

Other strategies discussed by Purtle and colleagues, while not specific to primary care providers, highlight other ways health care systems can implement population-based strategies to improve mental health (see table).⁶ 

Thorny Challenge of Reimbursement

Among the challenges of implementing a population-based approach to mental health, as is true of other population-based approaches to chronic disease management, is reimbursement. As discussed by McDaid and colleagues, financial disincentives and fragmented funding are among the key barriers that need to be overcome to implement population-based strategies for mental health. One way to address this is to establish dedicated streams of revenue for prevention across sectors and for promotional activities. Another way is to highlight the cost-benefits of investing in mental health prevention.⁴

Dr Huffstetler explained that primary care plans that are capitated will need to ensure, for example, that the cost of hiring a behavioral health professional is covered if that is the strategy they employ. 

“This is costly, especially in a managed care setting,” Dr Huffstetler said. “There is a need to identify how managed care can view population-based approaches as being relevant and aligned with their mandate.”

She suggests that one way to cover the cost is to adequately increase capitation fees by including a community-based mental health factor in the risk-assessment payment model. 

“When you look at community models that support a multiple pronged approach to primary care, they use community needs assessments based on several different algorithms to look at things like the poverty index and availability of transportation and this allows the clinic to provide services that the patient actually needs,” she said. “If you include mental health as a risk factor, which is highly correlated with so many disease states, you would be able to pay for a mental health professional to support primary care.”

A number of hospitals are already doing this. A 2015 study evaluating community health needs assessments used by nonprofit hospitals for implementing strategies found that 71% of randomly selected hospitals identified mental health as a priority and 49% identified mental health activities in their implementation plans.¹¹ 

In an article she wrote on payment structures to support social care integration with clinical care, Dr Huffstetler describes a Medicaid demonstration project at Hennepin Health in Minneapolis in which behavioral health, along with medical and dental services, are reimbursed per a monthly capitation payment by a licensed health plan. Hennepin Health reimburses medical providers through traditional fee-for-service payments.¹² 

“Early signs suggest that the venture has been successful, as medical expenditures have fallen 11% annually since its inception seven years ago, acute care has decreased by 9%, and outpatient care has increased by 3.3%,” Dr Huffstetler stated in an article.^12-14 

Although identification of patients at high-risk of mental health issues and using a payment structure that adequately reimburses providers and health care systems to cover these patients through a population-based approach are necessary for successful implementation of a population-based approach to mental health into clinical care, other challenges remain. 

Dr Huffstetler, who as a primary care physician sees anxiety and depression most commonly in her patients, understands the time restraints on primary care providers to attend to mental health issues that are typically more time intensive than checking, for example, blood pressure or monitoring medications.

And she acknowledges the effort it takes to change a health care delivery system that basically is built to address the end problem (ie, heart disease, diabetes, clinical depression, anxiety disorder) vs identifying the problem earlier or preventing it altogether.

But pilot programs, such as Hennepin Health, are showing that this can be done. And the current pandemic’s pervasive affect on the mental health of populations is adding urgency to tackling mental health in better and more effective ways.

“In order to respond rapidly and effectively, we need population-based strategies,” said Dr Fuhrer. “We do not have the human resources to address these sudden increases at an individual level and must think creatively to harness the assets and the experience in the health and social services sectors.” 

References:

1. Mental Health America. COVID-19 and mental health: a growing crisis. 2021. Accessed March 10, 2021. https://mhanational.orghttps://s3.amazonaws.com/HMP/hmp_ln/imported/Spotlight%202021%20-%20COVID-19%20and%20Mental%20Health.pdf 
2. McKnight-Eily LR, Okoro CA, Strine TW, et al. Racial and ethnic disparities in the prevalence of stress and worry, mental health conditions, and increased substance use among adults during the COVID-19 pandemic—United States, April and May 2020. MMWR Morb Mortal Wkly Rep. 2021;70(5):162-166.
3. Schmidt CW. Environmental connections: a deeper look into mental illness. Environ Health Perspect. 2007;115(8):A404-A410. 
4. McDaid D, Park AL, Wahlbeck K. The economic case for the prevention of mental illness. Annul Rev Public Health. 2019;40:373-89. 
5. Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-246. 
6. Purtle J, Nelson KL, Counts NZ, Yudell M. Population-based approaches to mental health: history, strategies, and evidence. Ann Rev Public Health. 2020;41:201-221. 
7. Alegria M, Frank RG, Hansen HB, et al. Transforming mental health and addiction services. Health Affairs. 2021;40(2):226-234.
8. Evans AC, Bufka LF. The critical need for a population health approach: addressing the nation’s behavioral health during the COVID-19 pandemic and beyond. Prev Chronic Dis. 2020;17:200261. doi:https://dx.doi.org/10.5888/pcd17.200261
9. Roehrig C. Mental disorders top the list of the most costly conditions in the united states: $201 billion. Health Affairs. 2016;35(6):1130-1135. doi:10.1377/hlthaff.2015.1659 
10. Fuhrer R, Keyes KM. Population mental health in the 21st Century: time to act. Am J Public Health. 2019;109(suppl 3):S152-S153
11. Donahue S. Report from the first round of CHNs and implementation strategies. Health Progress. January-February 2016. Accessed March 10, 2021. https://www.chausa.org/docs/default-source/health-progress/community-benefit-mental-health-report-from-the-first-round-of-chnas-and-implementation-strategies.pdf?sfvrsn=0 
12. Huffstetler AN, Phillips RL. Payment structures that support social care integration with clinical care: social deprivation indices and novel payment models. Am J Prev Med. 2019;57(6S1):S82-S88. doi:10.1016/j.amepre.2019.07.011
13. Commonwealth fund. Hennepin Health. A care delivery paradigm for new medicaid beneficiaries. October 7, 2016. Accessed March 10, 2021. https://www.commonwealthfund.org/publications/case-study/2016/oct/hennepin-health-care-delivery-paradigm-new-medicaid-beneficiaries 
14. Takach M, Yalowich R. Transforming the workforce to provide better chronic care: the role of a behavioral health nurse care coordinator in Minnesota. AARP Public Policy Institute. Accessed March 10, 2021. https://www.aarp.org/content/dam/aarp/ppi/2015/role-of-behavioral-health-nurse-care-coordinator-mn-AARP-ppi-health.pdf