Alegría, Margarita

Nakash, Ora

NeMoyer, Amanda

English

Smith College: Smith ScholarWorks

Smith ScholarWorks School for Social Work: Faculty Publications School for Social Work 2-1-2018 Increasing Equity in Access to Mental Health Care: a Critical First Step in Improving Service Quality Margarita Alegría Massachusetts General Hospital Ora Nakash Massachusetts General Hospital, onakash@smith.edu Amanda NeMoyer Massachusetts General Hospital Follow this and additional works at: https://scholarworks.smith.edu/ssw_facpubs  Part of the Social Work Commons Recommended Citation Alegría, Margarita; Nakash, Ora; and NeMoyer, Amanda, "Increasing Equity in Access to Mental Health Care: a Critical First Step in Improving Service Quality" (2018). School for Social Work: Faculty Publications, Smith College, Northampton, MA. https://scholarworks.smith.edu/ssw_facpubs/43 This Article has been accepted for inclusion in School for Social Work: Faculty Publications by an authorized administrator of Smith ScholarWorks. For more information, please contact scholarworks@smith.edu Increasing equity in access to mental health care: a critical first stepin improving service qualityAs Kilbourne et al1 describe, measur-ing quality of mental health care serves asan important step towards reducing ser-vice inequities. However, quality mea-surement that predominantly focuseson treatment outcomes overlooks indi-viduals with mental health needs whocannot access value-based treatments.Untreated mental health and substanceuse disorders are associated with pre-mature mortality, productivity loss, highrates of disability, and increased risk forchronic disease. Thus, ensuring equita-ble access within a value-based frame-work is needed to not only close existingtreatment gaps but also to improve pa-tient outcomes.The degree of inequity in access tomental health care varies among coun-tries with different models of health caresystem and welfare regimes. Findings froma study of seventeen low-, middle- andhigh-income countries revealed low men-tal health care utilization despite docu-mented high need: in each country, atleast two-thirds of individuals with com-mon mental disorders went untreated2.Twelve-month service utilization rates al-so tended to be lower in less developedcountries and to align with the percent-age of gross domestic product spent onhealth care3. Furthermore, members ofsocially disadvantaged groups such as eth-nic/racial minorities and low-income pa-tients have lower mental health serviceutilization compared with members ofadvantaged groups4.Inequities in access to mental healthcare can arise due to myriad reasons, in-cluding: eligibility criteria to enter pro-grams (e.g., receiving a specific requireddiagnosis); lack of linguistic capacity; pol-icies that discriminate based on legal sta-tus (e.g., refugees, immigrants, racial/eth-nic minorities); lack of information re-garding where and how to obtain care;and logistical, psychological and econo-mic barriers (e.g., transportation, child-care, beliefs about self-sufficiency, stig-ma-related concerns, concerns about pri-vacy, long waiting times for services,high costs, or inflexible work schedules).To adequately document mental healthcare inequities, measures and proceduresto evaluate access must be consistentlyand globally implemented across mentalhealth care systems. But you cannot eval-uate what you have not measured, andunmet need is typically absent from con-ventional administrative or service data.Methods of measuring access mightfocus on one’s potential ability to accesscare, including the package of benefitsincluded under mental health coverageand the availability of appropriate andeffective service providers within reason-able geographic proximity. Additionally,access measures should incorporate ob-stacles that arise once someone has decid-ed to enter care, such as insufficient choiceof providers, low doses of services, and in-effective or low-quality services. In a value-based framework, both horizontal equity(understood as the provision of equalcare for equal needs) and vertical equity(understood as different treatments forpeople with different needs or preferen-ces) must be considered when striving forequitable access.Conducting national surveys of house-hold and institutionalized individuals ev-ery five to ten years might offer a bench-mark of those who need care and wherethey are located. Results of such investi-gations can also inform testable hypothe-ses about why some individuals do notreceive services, including explanationsrelated to specific preferences for care.Additionally, quick assessments obtainedthrough computerized adaptive testingmight simplify diagnostic evaluation andassure linguistic diversity, as well as af-ford more attention to differential itemfunctioning (i.e., the extent to which anitem measures different abilities for mem-bers of different groups), so that providerscan adequately operate across cultures,diverse populations, and languages5. Mea-suring both barriers and facilitators tomental health and substance use treat-ment access through geographic map-ping can also provide a more compre-hensive picture of specific areas in needof immediate intervention. Finally, over-lapping measures of need with adminis-trative service use data can facilitate allo-cation of resources, adjustments of riskfor inclusion of underserved populations,and payment incentives for providers toreach those with unmet behavioral healthneeds.But, before these methods can be wide-ly adopted, a shift in the purpose of medi-cal records (i.e., from being used mostlyfor billing to being used predominantly tomonitor access, quality, and patient’s ser-vice preferences) must come into vogue.Stratification by need level (e.g., thosewith comorbid conditions), age, race/ethnicity, income, sexual orientation, gen-der, urbanicity, or linguistic subgroupscan assist in isolating where there areinequities and who or what is responsiblefor them. However, it will likely be moredifficult to make the health care systemaccountable for collecting these data, giv-en the inadequate budgets and resourcesgranted by ministries of health for mentalhealth care6.Despite having several potential meth-ods to measure access to mental healthand substance use care, systems may notutilize these methods in a meaningfulway if they are not incentivized to do so.Although reporting requirements tied toprovider accreditation or funding vary a-cross oversight agencies, states and coun-tries, they typically focus on service out-comes of those in care rather than out-comes of those eligible for services. Rec-ommended performance metrics that in-clude access to care have been proposedby several relevant organizations but, with-out some form of mandated accountabil-ity, health care administrators do not re-liably collect or report this information7.More research should focus on strate-gies to make service administrators andpolicy makers responsive to reducing ac-cess inequities and incentivized to developWorld Psychiatry 17:1 - February 2018 43leadership, implementation plans, and re-sources to ensure prompt action. As thefield stands now, recommended pathsseem to converge on care that maximizesvalue for patients rather than volumeand profitability of services8. Transition-ing to value-based care delivery shouldforce health care systems to focus more onpotential and existing patients, as well asthose patients’ preferences and needs.Many creative solutions have beenoffered to increase access, including in-tegrating behavioral health services intoprimary or community-based care, aug-menting the workforce through task-shifting (e.g., utilizing community healthworkers or peer navigators to provide someservices), imparting training and super-vision to novel providers via the Inter-net, or delivering services to people wherethey live (e.g., via minute clinics, medicalvans, or telemental health services) ratherthan expecting people to travel long dis-tances to access services9,10.But it is surprising that, given all weknow about how to expand access, re-en-gineering service delivery seems sluggish.Why is access not a priority given exist-ing rates of untreated mental health andsubstance use disorders? Have we notmade a compelling case to policy makers,the general population, or health care sys-tem leaders? Do we need more evidencethan the opioid epidemic, the massive in-carceration of people with mental healthconditions, or the suicide pandemic?Now, more than ever, maximizing pa-tient outcomes will require reaching outto patients earlier in their illness trajectory,helping them recognize mental healthneeds, and making them co-leaders intheir care. It might necessitate psycho-education dissemination campaigns,home visits, and continuous communi-cation to understand what patients pre-fer as high-value health care delivery. Itwill also entail measuring mental healthoutcomes that matter to the patient ratherthan mental health outcomes related tosymptoms, even when those patients donot always come to care.We have an ethical obligation to makeour communities healthier, with a uni-versal approach to treatment rather thantreatment for the very few. Like MartinLuther King Jr. said, “of all forms of in-equity, injustice in health care is themost shocking and inhumane”.Margarita Alegrıa1,2, Ora Nakash1,3,Amanda NeMoyer1,41Disparities Research Unit, Department of Medicine,Massachusetts General Hospital, Boston, MA, USA;2Departments of Medicine and Psychiatry, HarvardMedical School, Boston, MA, USA; 3Baruch IvcherSchool of Psychology, Interdisciplinary Center Herzliya,Herzliya, Israel; 4Department of Health Care Policy,Harvard Medical School, Boston, MA, USAThe authors are supported by the US National In-stitute on Aging (grant no. R01AG046149), the USNational Institute on Minority Health and HealthDisparities (grant no. R01MD009719) and the USNational Institute of Mental Health (award no.T32MH019733). The content of this paper is solelythe responsibility of the authors and does not neces-sarily represent the official views of any fundinginstitutions.1. Kilbourne AM, Beck K, Spaeth-Rublee B et al.World Psychiatry 2018;17:30-8.2. Wang PS, Aguilar-Gaxiola S, Alonso J et al.Lancet 2007;370:841-50.3. Kakuma R, Minas H, van Ginneken N et al.Lancet 2011;378:1654-63.4. Jimenez DE, Cook B, Bartels SJ et al. J Am GeriatrSoc 2013;61:18-25.5. Gibbons RD, Weiss DJ, Kupfer DJ et al. PsychiatrServ 2008;59:361-8.6. World Health Organization. Mental health atlas2011. Geneva: World Health Organization, 2011.7. Essock SM, Olfson M, Hogan MF. Int Rev Psy-chiatry 2015;27:296-305.8. Porter ME, Lee TH. Harvard Bus Rev 2013;91:1-19.9. Fairburn CG, Patel V. Am J Psychiatry 2014;171:495-8.10. Lund C, Tomlinson M, Patel V. Br J Psychiatry2016;208(Suppl. 56):s1-3.DOI:10.1002/wps.20486Mental health quality improvement goes globalThe field of quality assessment inhealth care traces its origins back morethan 50 years to A. Donabedian’s seminalarticle outlining a framework for under-standing quality of care from a health sys-tems perspective1.Quality improvement in mental healthis a younger enterprise. A 2006 reportfrom the US Institute of Medicine out-lined the challenges in assessing and im-proving quality of care for mental disor-ders, including lack of standardized ap-proaches for diagnosing mental healthand substance use disorders; limited evi-dence base supporting current qualitymeasures, and fragmentation and lack ofinformation technology infrastructure tomeasure quality. Nonetheless, the reportargued that quality improvement princi-ples could, and should, be applied to ef-forts to improve mental health care2.Since the publication of that reportover a decade ago, innovations in healthtechnology, the growth of large integratedhealth systems, and movement of mentalhealth into the mainstream of health carehave helped spur a rapid growth of men-tal health quality improvement in theUS3.Kilbourne et al’s important paper4 pro-vides an update on the state of mentalhealth care quality improvement world-wide. The authors describe initiatives tomeasure and improve care within the USand other developed countries, and makerecommendations to better incorporatethem into routine practice. The paperprovides a valuable framework for under-standing quality improvement from aninternational perspective.There are tensions inherent in mentalhealth care quality improvement that be-come particularly evident in efforts toconsider this process from a global per-spective. Historically, performance mea-surement systems in the US and otherdeveloped countries have been built onexisting administrative datasets5. The ele-ments of these datasets vary across coun-tries and health systems – for instance,fee-for-service systems typically aggre-gate billable claims, whereas countrieswhose systems focus on inpatient careprimarily collect data from these settings.Differences in structure and financingof mental health systems may shape theavailability of data and constrain the col-44 World Psychiatry 17:1 - February 2018

Increasing Equity in Access to Mental Health Care: a Critical First Step in Improving Service Quality

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Increasing Equity in Access to Mental Health Care: a Critical First Step in Improving Service Quality

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