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Blog Post

The root causes of behavioral health inequity—and how they manifest today

By Sophia Duke-MosierDarby Sullivan

August 3, 2022

    Behavioral health needs are increasing. There was a 28.5% increase in drug overdose deaths during the 12-month period ending in April 2021 compared to the previous year. And there was an almost four times increase in the share of adults reporting symptoms of anxiety and depression between June 2019 and January 2021.

    The pandemic and its ripple effects only exacerbated an existing crisis in the U.S. This in part is why Advisory Board's health equity research team selected behavioral health as our primary focus area for this year. Here's what we've learned so far.

    The root causes of behavioral health inequity

    The behavioral health care sector struggles with a unique "meta" inequity that makes progress intractable. This multi-level dynamic stems from two root causes: the longstanding devaluation and siloing of behavioral health care from the rest of medical care and structural inequities, like racism.

    • Inter-sector inequities: Regardless of demographic group, patients with behavioral health conditions experience unique inequities in access and outcomes compared to patients with only physical health conditions. For example, Americans with depression, bipolar disorder, or other serious mental illnesses die 15-30 years younger than those without mental illness.
    • Intra-sector inequities: Within the behavioral health sector, certain demographic groups experience worse outcomes than others—often patients of color, those with low incomes and insufficient insurance coverage, and/or those with serious mental illness diagnoses. For example, 90% of Black and African American people over the age of 12 with a substance use disorder did not receive treatment.

    5 primary pain points in behavioral health

    This meta-inequity manifests in five ways for patients with behavioral health conditions, leading to worse downstream outcomes.

    1. Our culture stigmatizes behavioral health conditions.

    U.S. culture has long stigmatized people with behavioral health conditions, which has led to discrimination (in and outside of the health care industry) and shame about discussing these needs. While stigma impacts how and whether patients seek treatment, experiencing stigma is not a personal failing.

    Behavioral health stigma has improved over time—but only for certain groups. A patient's experience of stigma depends on their socioeconomic status, racial and cultural background, and the acuity of their conditions. For example, studies indicate that the experience of behavioral health stigma is highest for non-white patients.

    Stigma also impacts the field of behavioral health itself. While behavioral health professionals themselves don't necessarily face stigma, the sector itself is often viewed as an undesirable area to work. 

    2. There is an insufficient supply of the "right" behavioral health practitioners to meet patient needs.

    Even before the Covid-19 pandemic dramatically increased behavioral health needs, the Department of Health and Human Services estimated that by 2025, the supply of psychiatrists would fall short of demand by 25%. And the behavioral health workforce shortage includes a wide variety of professionals across the care continuum.

    For example, in July 2022, Virginia stopped admissions to five of its eight state behavioral health hospitals due a staff shortage of 30%, largely driven by front-line workers leaving.

    Theses shortages stem from the challenges of providing behavioral health care, including the emotional labor required to treat complex patient needs, barriers to coordinating care with the rest of the health care system, a high documentation and administrative burden, and limited reimbursement and potential earnings.

    But the sheer number of practitioners isn’t the only facet of the behavioral health workforce shortage. Patients also struggle to find practitioners who:

    • Match patients’ geographic location: Though telehealth can help support patients in shortage areas, many patients do not have the necessary tools and skills to access virtual care—and not all conditions can be treated exclusively via telehealth
    • Have capacity to accept new patients
    • Have the right level of expertise required to treat patients’ specific behavioral health conditions
    • Have training to provide care with cultural humility: Research suggests that patients have better experiences and outcomes when they engage with practitioners of similar backgrounds. However, the behavioral health field struggles with diversity, making cultural humility (ongoing learning, self-reflection, and skill-building around understanding a patient's cultural context through that patient's own lens) even more important 
    • Offer affordable rates and accept patients’ insurance

    3. Treatment for behavioral health conditions is (often prohibitively) expensive for patients.

    According to a survey by National Alliance on Mental Illness, "eight in ten respondents had out-of-pocket costs of over $200 for psychiatric hospital or residential mental health care compared to fewer than six in ten for general hospital care." And "there were no significant differences in out-of-pocket costs between private insurance and Medicaid."

    In outpatient care, only 56% of psychiatrists accept commercial insurance compared to 90% of non-behavioral health physicians. This has left patients five times more likely to seek behavioral health care from an out-of-network provider compared to physical care. Because there are limited provider options for patients of all insurance statuses, patients are often charged for treatment out-of-pocket.

    This dynamic largely holds in the digital health sector, which dramatically increased investments in behavioral health services—especially for therapy and wellness tools. In the first half of 2020, digital behavioral health startups raised $588 million, almost equal to annual funding in previous years.

    While these solutions are promising, they still come at a cost to patients or via employer sponsored plans. This excludes patients who are low-income, don't have these benefits funded by their employer, don't have access to broadband Internet, and don't have safe, private, and quiet areas to attend therapy. But even if all patients could access these tools, open questions remain about their data privacy, quality, and efficacy.

    4. Limited investment in building the clinical evidence base for behavioral health interventions results in treatment that is less precise and less accessible.

    There is robust evidence for many different types of behavioral health interventions. However, the industry still grapples with open questions about treatment, especially for high-acuity patients and those with medication-resistant conditions. These questions persist in part because there is:

    • A relative lack of investment in measuring behavioral health interventions compared to physical health  
    • Insufficient representation of historically marginalized groups in trials and studies, limiting providers' understanding of which treatments work best for patients from different backgrounds

    These factors impact patients' experience accessing both medication and non-medication behavioral health treatment. When it comes to medication treatments, identifying the right regimen for each patient can be an imprecise process.

    Patients often go through a lengthy trial-and-error process to determine which combinations of medications work best for them, but medications can take months to work and may have serious side effects.

    The challenge is different for non-medication treatments. Payers typically lean on clinical studies like double-blind, placebo, and randomized controlled trials to make decisions on reimbursement, but the ROI of non-medication behavioral health interventions can be harder to quantify. They are often measured by patient reported outcomes, rather than clear clinical indicators.

    Non-traditional metrics like quality of life, employment status, and relationship health are important to measure for patients, but payers are unsure how to translate these outcomes into coverage decisions. That means that even when academics and behavioral health professionals know what treatment works, there is still limited coverage and reimbursement.

    5. Adverse social determinants of health lead to—and exacerbate—behavioral health conditions.

    Social determinants of health (SDOHs) impact up to 50% of health outcomes and include six major categories: finances, environment, food, education, technology, and social context. The social context category, which includes social isolation and discrimination, particularly impacts behavioral health needs as these experiences can lead to feelings of loneliness, alienation, and hopelessness.

    SDOHs impact people of all ages, starting in childhood, when the experience of adverse SDOHs can expose patients to adverse childhood experiences (ACEs), which have lifelong ripple effects. ACEs are measured in 10 factors of trauma across three categories: abuse, neglect, and household dysfunction. Patients with an ACE score over four are four times more likely to develop depression and 14 times at greater risk of attempting suicide.

    At any age, patients struggling with adverse SDOHs face elevated stress and worsened behavioral health needs. Unfortunately, it's a vicious cycle—unmet behavioral health needs can make it more difficult to function, which further exacerbates non-clinical needs.

    For example, as demonstrated throughout this piece, seeking behavioral health care can be a stressful and expensive process—exacerbating the financial needs which may have been the primary stressor at the start. Addressing these non-clinical needs are essential for recovery but they are not traditionally part of an organization’s behavioral health care strategy.

    Orienting toward solutions

    The root causes of behavioral health inequity and their manifestations in our industry are complex. But it's essential to understand the intricacies of the problem to identify solutions that will make a difference.

    Advisory Board's health equity team is actively researching action steps for key industry stakeholders to address the root causes of behavioral health inequity. If you have a solution to share, please reach out to Darby Sullivan at SullivaDa@advisory.com.

    Cheat sheet: Inequities in behavioral health

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    Download this cheat sheet to get insights on how inequities in behavioral health impact patients and health care stakeholders.

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