What will mental health treatment look like from the consumer perspective in the years ahead? That was the question I addressed at the Cohen Veterans Care Summit yesterday in my session, The Future Mental Health Care Landscape & Its Likely Effect On Veterans & Families. I always find it a bit daunting to make predictions. But as a subscriber to the John Naisbitt philosophy of trend analysis—”The most reliable way to forecast the future is to understand the present”—I think the present does provide some clues to what we are likely to see ahead.
So, what do current trends tell us about the likely future of consumer treatment of mental health disorders? I think consumer services will continue to change in four important ways:
- An individual consumer’s access to treatment and the treatment system will be determined by the health care coverage, their health plan choice, and their personal income. A consumer’s health insurance status; their type of coverage (Medicaid, Medicare, other government insurance, or commercial insurance); and which state they live in will be the determining factors in their access to treatment. The current uninsured rate among working-age adults ages 19 to 64 is 15.5%, an increase of 12.7% since June 2017 (see 2018 Adult Uninsured Rate Is 15.5%, Up From 12.7% In 2017)—with a high of 26.4% in Texas and a low of 5.4% in Massachusetts (see Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2017). If a consumer has Medicaid for coverage, what state they live in will be a big variable (for more on variations in Medicaid coverage, see Behavioral Health Coverage For The Medicaid SMI Population: A State-By-State Analysis and Physical Health Coverage For the Medicaid SMI Population: A State-By-State Analysis). And, personal income will be a growing factor in treatment access. Consumer cost sharing is significant and growing, along with the income gap. About 50% of Americans make less than $30,000. About 30% of Americans make less than $15,000. These are demographic factors that shape access (see Social Security Online: Wage Statistics for 2017).
- Mental health treatment will happen within integrated systems of care. Payers (whether Medicare, Medicaid, or employers) are encouraging integration and coordination. New integrated delivery systems, like accountable care organizations, medical homes, health homes, and other new models of financing, are reducing the use of specialists outside the system of care. This leaves mental health treatment integrated with primary care as part of a new coordinated care system (see The 2018 OPEN MINDS Medicaid ACO Trend Update and U.S. Medicaid Health Home Market: The 2017 OPEN MINDS Update).
- Consumers will have more limited choices of treatment—of provider organizations, professionals, and treatment models. The move to value-based reimbursement and integrated systems of care is driving the emergence of “curated networks”, making it increasingly “inconvenient” for consumers to access treatment outside the networks (see The Future Has Arrived For VBR). In addition, as we see more risk at the provider organization level, we’ll see more use of decision support to assist professionals and consumers in selecting the “best” treatment choices. While consumers will have full choice of professionals and treatment models on paper, these changes will effectively limit treatment choices.
- Tech-enabled treatment will be the rule, rather than the exception. While we have imperfect data about the comparative effectiveness of tech-enabled treatment (telehealth, text, store-and-forward, wearables, virtual automated therapies, etc.) to traditional face-to-face services, tech-enabled treatment will continue to gain traction and market share. It’s convenient, it solves part of the access issue, and it is less expensive—all drivers of use even without “perfect” information.
As I remarked to the audience at the Cohen Veterans Care Summit, you may or may not like this forecast of the future of treatment. After all, I’m not saying this is an optimal future for treatment—just a likely future scenario. What could or would change this trajectory? I think there are four possible intervening variables:
Coverage and its rules—The single most important decisions about access to mental health treatment will be made in Washington D.C. over the next year. What are the coverage rules? Will we have coverage for all Americans or not? Will the rules assure coverage of pre-existing condition limitations? Will we keep the rules with no annual and lifetime limits to coverage? Will medical loss ratio remain the same (see With The Future Of The PPACA, The Past May Be Prologue and CMS Medicaid Managed Care Rate Rules – With Limitations On Pass-Through Payments – Go Live July 1, 2017)? And, will coverage include parity for treatment of mental health and addictive disorders?
The slow progress on parity enforcement—Enforcement of mental health parity has been weak and progress has been slow (For more, check out the new report by ParityTrack released last week, marking the 10-year anniversary of The Mental Health Parity and Addiction Equity Act—see The Mental Health Parity and Addiction Equity Act 10th Anniversary.) And we’re seeing further erosion of parity with the dismantling of pre-existing condition coverage guarantees and the removal of the essential health benefit requirements from short-term insurance plans (see The Beginning Of The End Of Parity and The Thousand Right Things). This trend likely won’t be reversed any time soon, as just last week the Senate Democrats missed on an attempt to overturn the expansion of short-term, limited-duration health plans that do not require parity and allow exclusion of pre-existing conditions (see Senate Dems Fail To Block Trump’s Policy On Short-Term Health Insurance).
Addressing the science-to-service lag—The delay between the validation of new treatment practices and getting them to most consumers is somewhere between 15 and 20 years. How to address this? Our political leaders and policymakers can try to make decisions based on data and ignore parochial stakeholder interests that are not in the best interests of consumers. Organizations promoting new treatment models or technology can invest in more formal proof of concept demonstration pilots. Provider organizations can adopt “best practice” models using implementation of science to speed adoption of innovation. One note: assuming you can avoid the “bleeding edge” of losses by being early to market, there is a “first mover” advantage by being the organization to bring new science to scale (see Add ‘Speed’ To Your Treatment Tech Planning List and The Digital Decision Crossroads).
The operational definition of value in mental health—Across the health care field, we don’t have an operational definition of the value of mental health (and addiction) treatment services. I was struck by the recent session at our 2018 OPEN MINDS Management Best Practices Institute, where the discussion turned to why it is so difficult to measure the “success” of addiction treatment across systems of care. And, my recent discussion with health plan executives was a case in point—they are looking for the professional associations to unify around standard definitions and outcome measures. As we move to a health system focused on value-based reimbursement, the organizations defining “value” will shape the treatment system.
Data-informed decisionmaking by all stakeholders—Last but not least, we need more data, but not just any data. We need more digested and actionable data designed to enable stakeholder decisionmaking. And while we need more data-informed decision making in politics and policymaking, I will leave that for another day. What needs to be addressed in the short term, for both health care professionals and consumers, is the provision of better decision support platforms. We already have the data to drive treatment planning on an individual level (see Preparing For Your ‘Augmented’ Workforce and Consumer Satisfaction, Consumer Engagement & Shared Decisionmaking). We’re just not using it.
For more on planning for the future, check out these resources from the OPEN MINDS Industry Library:
- Technology & The Future Behavioral Health Service Delivery Landscape
- Innovation Success In Three Steps
- How To Create A Telebehavioral Health Strategy
- Preparing For The Very Glacial VBR Rollout In Some Markets
- Getting Your Replacement Ready To Go
- Solve The Problem, Gain A Partner
- Building The Management Pipeline: Identifying & Growing Future Leaders
- Next Generation Models For Health Plan Behavioral Health Service
- How To Adapt Your Organization To The Future: A Guide To Managing Data For A Performance-Driven Environment
- The Future Of Peer Support Services: A Review Of Successful Models In A Value-Based Market
For even more on what the future hold, join me on October 23 at The 2018 OPEN MINDS Technology & Informatics Institute for the session, Advancements In Telemedicine & The Future Of Service Delivery: Innovation Health’s Plan For Technology Integration, by Sunil Budhrani, M.D., MPH, MBA, Chief Medical Officer & Chief Medical Informatics Officer, Innovation Health.