COVID-19 contributed to a crisis in behavioral health equity… Here are four domains where health care stakeholders can mitigate this emergency

By Ralph Judah, managing director, and David Rabinowitz, senior manager, Deloitte Consulting LLP

The COVID-19 pandemic—combined with an economic recession, high unemployment, and a growing acknowledgement of systemic racism within society at large (the health care system in particular)—further exposed some of the gaps and inequities that have long plagued behavioral health. These issues are having a disproportionate effect on Black, Indigenous, and People of Color (BIPOC).

While COVID-19 inspired innovations in care delivery, the pandemic continues to highlight many challenges related to equity. For example, virtual health expanded significantly over the past year. Many of our clients, who are responsible for large employee groups, say they are being inundated with pitches for behavioral health technology solutions. These trends are helping to improve care access for many, but the digital-access gap has made care even less available to some lower-income individuals. The future of behavioral health we envision, where access to quality and affordable behavioral health care is equitable and widespread, may be unattainable if such challenges are not addressed.

Direct-to-consumer behavioral health services, widespread adoption of virtual health, and changes to the reimbursement landscape could give organizations new avenues for responding to consumers.^1,2 However, these changes likely won’t be effective unless organizations have access to interoperable data, early identification and prevention capabilities, and scientifically validated approaches that empower consumers to take ownership of their behavioral health needs (including through the use of resources such as the World Economic Forum’s Global Governance Toolkit for Digital Mental Health).

COVID’s effect on mental and behavioral health is significant, disproportionate

Deloitte’s prior studies of the pandemic’s acceleration of behavioral health trends in the US and the racial etiology and implications of this public health crisis are compounded by the behavioral health crisis we face today. Overall, about 40% of US adults have reported symptoms of anxiety or depression since the pandemic began. That’s up significantly from just 10% in 2019.³ Mental and behavioral health issues appear to be disproportionately affecting vulnerable populations such as lower-income communities and Black Americans.⁴ Economic challenges have forced some families to forgo behavioral health services in order to pay for the basics, often resulting in higher medical costs down the road.^5,6,7  

The existing landscape of behavioral health has been further exacerbated by challenges across social, economic, and health care systems that should be addressed. These challenges include:

• Fragmented, uncoordinated, inadequate, or underfunded health care and social service systems that make it difficult to fully address physical and behavioral health.
• Reimbursement challenges as the landscape shifts to accommodate surging demand for virtual care and a growing need to show efficacy, quality, and value to regulators.
• Limited number of behavioral health professionals, which constrains capacity to meet increasing demand.
• Racial and cultural disparities in education, access, utilization, and cultural confidence in behavioral health care.^{8, 9}
• Pervasive stigmas that keep behavioral health and related treatments from being normalized and universally encouraged.^{10, 11}
• Failure to consistently and effectively prioritize the drivers of health (e.g., healthy food, safe housing, good-paying jobs) to devise integrated approaches to behavioral health.
• A digital divide that makes it difficult for low-income populations to access technology (e.g., internet and connected devices).
• Regulatory barriers that keep clinicians from providing care across state lines.¹²

Organizations should try to leverage the existing momentum around virtual health (inclusive of telemedicine/teletherapy, wearables, apps, etc.) to break through these issues and improve equity in behavioral health.

Four domains where behavioral health can be made more equitable

Building upon Deloitte’s work to help health care organizations improve health equity, we have identified the following four domains that health care stakeholders (health systems, clinicians, health plans, employers, and government organizations) should consider: 

1.   In the organization

• Push for change in benefits: Evaluate existing mental and behavioral health providers and network capabilities to help ensure that all employees have access to affordable and effective care. The Center for Workplace Mental Health’s The Path Forward Initiative, for example, includes a rubric for evaluating the rigor of care. Key measures include access to in-network mental and behavioral health providers, expanded implementation of the collaborative care model, expanded screening and monitoring for mental health with measurement-based care, and expanded access to tele-behavioral health services.
• Provide better support for the entire workforce: Recognize the importance of behavioral health for the workforce (full- and part-time employees, and contractors), and determine what is needed for optimal workforce management. Leaders should remain cognizant of productivity, culture, and the organizational impacts of absenteeism due to unmet behavioral health needs.
• Take a holistic view of health: Integrate behavioral, physical, and the drivers of health across all systems to understand the relationship between well-being and social factors (e.g., physical health, social isolation, job satisfaction, financial hardship, food insecurity). Consider involving non-traditional community workers—such as certified peer specialists and mental health crisis counselors—in care planning for individuals who have behavioral health needs. 

2. In offerings for the market

• Give consumers control over their treatment decisions: Consumers should have access to creative and customizable treatment options that help them take a proactive role in their mental well-being (e.g., text-therapy, virtual assistants, self-guided treatment). Access to educational resources can help them learn about the importance of managing their behavioral health.
• Know the consumer: Leverage innovations to uncover new, data-driven insights into the behavioral health of consumers. Implement more proactive identification and intervention strategies to address behavioral health needs.
• Use technology to increase access: Artificial intelligence and virtual health can help improve access to behavioral health care and make the services more efficient (e.g., consumer-facing apps enhanced with AI capabilities to streamline diagnosis and treatment processes). Ensure that the digitally disadvantaged have access to technology and the training needed to use it.
• Integrate equity into value: Consider both value-based and equity-based arrangements for reimbursement policies. Consider the outcomes of equity across subgroups.
• Prioritize prevention and early intervention: Help ensure that all offerings emphasize the critical importance of proactive behavioral health management.

3.  In the community

• Expand local infrastructure: Invest in virtual-health capabilities for local communities, including supplying internet access and devices to historically under-funded neighborhoods.
• Employ a collaborative community approach: Consider initiatives, such as holding a summit with local organizations and government representatives, to respond to social determinants/drivers of health at the community level.
• Invest in and/or partner with BIPOC-led organizations: Send funds directly to BIPOC-led and -centered behavioral-health organizations to meet the needs of BIPOC consumers more effectively.
• Invest in and/or partner with professional training programs: This can help lay the groundwork to expand the pipeline of BIPOC behavioral health clinicians.

4. In the broader ecosystem

• Remove regulatory barriers: Lobby for regulatory changes that streamline and improve access to mental and behavioral health care.
• Remove administrative barriers for clinicians: Regulatory paperwork and billing, managing EHRs, and navigating reimbursement can limit clinicians’ bandwidth for meaningful time with their patients.
• Address underfunding of behavioral health services: Improvements to the reimbursement landscape could more accurately account for expenses incurred by behavioral health providers. 

The COVID-19 pandemic and the country’s economic and sociopolitical crises have accelerated our trajectory toward the future of behavioral health. They have also exposed the inadequacies of a system that often fails to meet the needs of its most vulnerable people. Our hope is that stakeholders will consider some of these actions and use them to lean into the future and innovate without neglecting accessibility and equity.

Acknowledgements: Preethi Kannan, Charlotte Grimm

Endnotes

^{1.        Telemedicine takes center stage in the era of COVID-19, Science, November 6, 2020}

^{2.        Digital health reimbursement: The transforming landscape, MedCity News, October 5, 2020}

^{3.        The implications of COVID-19 for mental health and substance use, Kaiser Family Foundation, February 10, 2021}

^{4.        Mental health disparities among Black Americans during the COVID-19 pandemic, Psychiatric Times, October 11, 2020}

^{5.        It could take 4 years to recover the 22 million jobs lost during the COVID-19 pandemic, Forbes, November 30, 2020}

^{6.        The impact of Coronavirus on food insecurity, feeding America, October 30, 2020}

^{7.        Why people are still avoiding the doctor (it’s not the virus), The New York Times, June 16, 2020}

^{8.        Understanding the role of past healthcare discrimination in help-seeking and shared decision-making for depression treatment preferences, Qualitative Health Research, July 25, 2020}

^{9.        Trends in racial-ethnic disparities in access to mental health care 2004-2012, Psychiatric Services, August 1, 2016}

^{10.     The impact of mental illness stigma on psychiatric emergencies, Frontiers in Psychiatry, June 19, 2020}

^{11.     Stigma still a major hurdle in getting people the mental healthcare they need, Healthline, October 20, 2018}

^{12.     APA to states, insurers: Provide access to mental health care during COVID-19 public health crisis, American Psychological Association, March 24, 2020} 

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