Why Can't We Fix Mental Health Care?

 This week, I read this WSJ article about suicide rates during and after the pandemic: https://www.wsj.com/health/healthcare/americans-suicide-highest-level-2022-02eb10ea?mod=healthcare_more_article_pos44 

This blog post is a long one, so bear with me. At the end of this article, you'll see why mental health care is so hard to access and how medical systems seeking to reduce their costs should counterintuitively hire more psychologists, not less, even though psychologists don't generate enough revenue to cover their  salaries and benefits. 

Image from PlanStreet

The article discusses ongoing populations at risk of suicide (older, white men), and how suicide rates are finally declining for younger people. Importantly though, the article points out that mental health care - which was hard to access before COVID - is now even harder to find. This begs the question, how can it be with all the increased attention on mental health and increased need for mental health care, that mental health services are still so hard to find and to access?

I decided to explore this question from a financial perspective using myself as an example. I am a licensed clinical psychologist practicing in a large academic medical center. I primarily serve hospitalized patients, so I used hospital-related inputs in my analysis. 

My analysis included looking at the reimbursement rates for psychologists from insurance payers and comparing this to the real value that psychologists provide. For those who are unacquainted with the economics of mental health, psychologists and psychiatrists provide two very different services. Psychiatrists primarily provide medication management; they prescribe drugs to treat mental health symptoms. Psychiatrists are physicians who spend time at the end of their education specializing in mental health and psychopharmacology. Psychologists have PhDs or PsyDs, meaning their entire education is focused on mental health diagnosis and treatment. Psychologists also spend much more of their training learning and practicing psychotherapy. Psychologists in general do not prescribe medications (though they can, in some states) but rather treat mental health conditions using scientifically-supported treatments like Cognitive Behavioral Therapy. There are some conditions that require medications (like schizophrenia), and others that don't respond to medication well at all (like PTSD). Many fall in between. Evidence suggests that medications provide immediate relief for mental health symptoms, but psychotherapy provides the long-term "cure". The best treatment, therefore, is often a combination of both medication and therapy.

This brings me to me - I provide psychological services in a hospital to patients admitted with new disabilities, like strokes, spinal cord injuries, and limb loss. My service is to the patient in the form of therapy, but also to teams and the hospital by managing patients with behavioral issues, fears of discharging from the hospital, or who are verbally or physically abusing nurses and physicians. 

Psychologists, unlike psychiatrists, cannot bill for any time they spend doing anything other than directly treating the patient. Psychiatrists and other physicians can bill for the time they spend treating the patient but also for the time they spend charting, managing the patient's healthcare puzzle, and submitting notes and reports. Psychologists have been disallowed from billing for any of these administrative parts of the work, but they are still legally and ethically required to do so - psychologists have to chart and bill like any other provider.

So, when I bill for my services, I'm often billing for only a fraction of the actual time it took me to provide the service. And, when I bill, I'm only allowed to bill using certain codes. The codes I'm allowed to bill as a psychologist are worth a fraction of what the codes that psychiatrists use are worth. For instance, when I bill for 45 minutes of psychotherapy, Medicare pays about $100 for that service. However, that service may take me over an hour after I account for reviewing the chart, writing the note, communicating with the team, and generating referrals for the patient. 

On top of that, in my department, our bills are usually denied. We only make about 30 cents on every dollar, because insurance denies most claims, despite there being a clear indication and medical necessity for the service. This is a pretty typical denial rate in the mental health field. 

So, overall, to have psychologists available to patients in a hospital, the psychologists cannot possibly bill enough to cover all their costs like salary and benefits. In fact on my team, we consistently run at a deficit of about $300,000 per year. We are a small cost center, but a cost center nonetheless.

So, now we can clearly see why hospitals employ so few psychologists, and even why psychologists or any type of therapist are hard to come by in general. On the other hand, psychiatrists are a bit easier to find, because their bills cover so much more of their time, and therefore generate more revenue. 

But, what's the real value of the services I provide? Clearly, it's not in the revenue I generate. Rather, we know from lots of literature that psychologists improve patient outcomes. For instance, when they are medically ready to leave the hospital, patients seen by psychologists are more likely to be ready to live alone and discharge back to their own community, rather than needing to live in a nursing home. By helping hospital units with aggressive patients, psychologists also reduce risk of injury to staff and reduce staff turnover in hospitals. There's a lot of research on these topics, and it's pretty clear that psychologists produce cost savings for hospitals and for society in general. We also recoup part of our costs incurred through our bills. 

Below is a table I created this week using the financial evaluation process we learned about. I compared the cost of having psychologists to the savings psychologists generate for hospitals. I conservatively estimated that the entire team of psychologists together prevent one physician and one nurse from quitting each year. In all likelihood, the impact of psychologists on turnover is stronger than that. I also included that psychologists help patients get ready for discharge, avoiding the unreimbursed costs for one uninsured day per month. Again, in all likelihood, these are conservative estimates, and these don't even begin to consider the impact psychologists have on patient satisfaction, which itself is associated with higher hospital profit margins. This also doesn't include things like reduced readmissions, shorter lengths of stays, etc. 

In total, despite appearing to be a cost center, my analysis shows psychologists conservatively generate savings that far outweigh their costs to the institution. In fact, the real savings might be much higher than what is shown below. It's very difficult to measure these things accurately, but if we make inferences based on the available scientific literature, psychologists may produce tremendous cost savings. 

The above can be interpreted to indicate that signing an agreement today to have psychologists for five years is valued at $107,552.2, with the potential for more upside if turnover is reduced even further. 

In conclusion, it's clear to me why it's hard to access adequate mental health care. And, when mental health care is available, it's often just medication management, which is insufficient to fully treat the mental health diagnosis. My analysis above shows that healthcare systems believe they are avoiding costs by not hiring enough mental health staff to meet patient needs, but in fact, they are leaving savings on the table. This analysis suggests hospitals should hire more psychologists to cut costs. 

References

"Hospital Adjusted Inpatient Costs Per Day" (2022). KFF.com. https://www.kff.org/health-costs/state-        indicator/expenses-per-inpatient-day/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

Gamble, M. (2023, Apr 11). The Cost of Nurse Turnover in 24 Numbers. Becker's Hospital Review. https://www.beckershospitalreview.com/workforce/the-cost-of-nurse-turnover-in-24-numbers-2023.html 

Johnson, H. & Bixler, S. (N.D.). What Will it Cost To Recruit a Physician? Healthrecruitlink.com. https://healthrecruitlink.com/blog/what-will-it-cost-to-recruit-a-physician#:~:text=Many%20healthcare%20organizations%20are%20going,to%20sign%20your%20top%20choice.