It has always been easier to have empathy for people with visible injuries as opposed to those with invisible pain. Those with a jumbled mind are less well understood, by and large, than those with a missing limb. While we may care about all victims, we have more emotion for those with pain whom we can immediately understand. This bias has helped fashion the underdog status for people with emotional disorders. Is there any reason to believe this will change?
There may be natural differences in how we understand and empathize with visible vs. invisible sources of suffering, but healthcare policy is another important variable in this story. We have had both institutional and cultural discrimination against mental health and substance use disorders ever since the 1983 implementation of Medicare’s diagnostic related groups (DRGs).
This legislation was not malevolent in its intention, but rather was based on the belief that we could not understand the basis, course or treatment for mental health and substance use disorders as we could for the larger universe of physical health disorders. Psychiatry, psychology and social work were not being actively disrespected, but just quietly moved to the side.
Reimbursement for behavioral health—mental health and substance use disorders—would go through a wild ride of fraud, abuse and then finally managed care in the 1990s. But it was always on the periphery of general medical care.
Behavioral health is in the news now more than ever. We see articles every day that range from the devastation of the opioid epidemic to mass murderers with suspected mental illness. Could we be reaching a tipping point where emotional health is valued as much as physical health and where our society is prepared to pay for each component of health equally? Obviously that was not a serious question. No, we are not all that close to understanding and funding the impact of emotional health disorders in our lives.
We need a new strategy.
The behavioral healthcare moment
Deaths from chemical dependency and mental illness are escalating. It is not a time to wait for the larger healthcare industry to provide their sympathy or vague recognition of the importance of behavioral healthcare.
It may be our moment to offer some good solutions, especially since few solutions are being put into place despite the growing death toll. However, when your moment arrives, are you waiting for validation, or are you are assertively promoting the value that you and your colleagues offer? Sadly, I would offer that we are still mostly waiting for validation, and we are more in a moment of confusion than resolve.
Let us be clear about this: We have excellent treatments for mental health and substance use disorders, ranging from buprenorphine to cognitive behavioral therapy to intensive care management to wraparound treatment services. They are being implemented sporadically and inconsistently, and we are letting down millions of people who could use the help we could offer. Treatments are being funded poorly, from all funding sources, both public and private. We allow the myth to persist in the media that we don’t know what to do. This is a tragedy that the entire industry must address immediately.
We know what we should be doing, even though we are not doing it for political and economic reasons. If we know we face an enormous opioid epidemic, for example, why are we not funding medication assisted treatment on a much larger scale?
Goodbye to behavioral healthcare cost calculators
We have very strong arguments about how behavioral health disorders such as depression and addiction are resulting in death, disability and excessive costs, especially when those conditions are exacerbating comorbid chronic illnesses. This argument is not making an impact on decision makers.
We are moving to the end of an era for cost calculators that estimate the direct and indirect costs of behavioral healthcare disorders. The calculators were excellent, but the audience was not moved. We need a different story, and again we need to be sure that our scientific and financial leaders in behavioral healthcare are working together.
Let’s abandon our silo and become a powerful total health player
What do everyday citizens and CEOs have in common regarding healthcare priorities? They want to see an improvement in overall health status, not just some improvement in behavioral health status. And they want to see a reduction in total healthcare costs, not just a reduction in behavioral healthcare costs.
The fundamental issue here is that we must abandon our silo of behavioral healthcare, and instead we should argue with enthusiasm that we can be an important part of the equation for improving total health status and reducing total healthcare costs. Once we are grounded in the right goals, we can produce research that validates the importance of behavioral health. Shouting about its importance from the sidelines is not productive.
The strange thing about this strategy for the behavioral healthcare field is that it is a recognition that we are a second-tier healthcare discipline in terms of funding, despite our patients being more disabled than many in the first-tier.
What must change is that we need to be evaluating how overall health status is impacted by the interventions of behavioral healthcare providers and systems. We need to be evaluating how all-cause healthcare costs are impacted by behavioral health care providers and systems. This is not complicated from an assessment perspective. We just need leaders to agree that this is the right path for evaluating clinical and economic outcomes.
This does not emphasize one segment of the U.S. healthcare system over the other. The payment sources and structures for behavioral health for insured people may differ, and yet people with healthcare problems are just people with healthcare problems. Effective solutions are generally not different for each population, but we all understand the desire for two things: 1) better health status; 2) lower healthcare costs.
People have an easier time understanding and empathizing with physical injuries. The behavioral healthcare industry needs to accept this and move on. Let’s focus on how the invisible exacerbates the visible. Let’s present the full picture of health.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.