Twenty-nine percent of Medicaid enrollees are living with mental illness and over 50% say their mental illness has a catastrophic impact on their lives. It’s particularly difficult for these individuals to get care because Medicaid’s notoriously low mental health reimbursement rates  (on average 20% lower than Medicare, with some states far below that) lead to a shortage of providers participating in the program. The result: untreated mental health issues worsen,  individuals use the emergency department (ED) for mental health needs, and the total cost of care balloons.  

At Brightside Health, we’ve always been committed to treating underserved populations and individuals with more severe mental health needs, which is why we recently expanded our coverage to include Medicaid (and Medicare) beneficiaries. We saw a need to address a major gap in our healthcare system and are proud to be able to ensure millions of beneficiaries receive the timely and high-quality mental healthcare they need through our services. But our  work doesn’t stop there. It’s time to fix this broken system. Medicaid beneficiaries deserve better, and we can actually save tax dollars by emphasizing more cost-effective care delivery.  While this is a complex problem with variability across states and populations, here are three ways to make meaningful progress. 

1. Providers demonstrate the return on investment (ROI) of targeted mental health services

Mental healthcare has historically been considered more art than science, lacking predictable structure, transparency, and accountability. Because payers (including Medicaid) have been unable to track patient-level outcomes and see evidence of clinical impact amidst substantial demand for care, they have kept reimbursement rates low and focused their resources and efforts on other care areas.  

What would payers need to see to be willing to pay higher rates? Rigorous care that’s aligned with proven approaches, supported by measured outcomes at the patient level. Payers are motivated to act when the subgroup of patients that drive a disproportionate share of cost and risk – including those with serious mental illness; who utilize the ED; who may require hospitalization; or who have an elevated risk of suicide – receive this type of care.  

Of course treating the hardest patients with the most rigorous care is not easy; but, thanks to new technology and tools, we have additional avenues to enable this kind of quality care at the scale needed to address the problem. By ensuring that great providers are supported via remote patient monitoring tools, measurement-based care, clinical decision support, collaborative care management, and more, we can help turn mental healthcare from art to  science.  

People may wonder, “Can technology-driven and virtual care approaches work in a Medicaid population?” To find out, Brightside Health took a data-driven approach, starting with peer reviewed research in Frontiers in Psychiatry. Over 16 weeks of treatment, individuals reporting incomes under $30k/year achieved clinically significant reductions in depression and anxiety symptoms consistent with improvements seen among higher income participants. With this  research and the success of Brightside Health’s care model – 86% of our members get better within 12 weeks – we felt confident in our offering for Medicaid. 

2. Collaborate more proactively on care management

Historically, payers and providers have been continually dueling in a zero-sum game over reimbursement rates and patient flow. In order to break the mental health gridlock, each party must change their tone and recognize the role they have to play.  

Payers already have care management teams who ensure that high-cost members get timely, targeted care. Many are also using sophisticated predictive analytics to understand which  members are at risk of costly events. There’s an opportunity and need to better apply these services to identify, engage, and treat individuals at risk of high-cost behavioral events like ED  visits, inpatient hospitalizations, and suicide attempts. 

At the same time, payers often feel like they are flying blind once these patients are sent to a provider for care. To understand a patient’s progress, they have to rely on claims data that is a delayed abstraction of the care provided. But providers have granular and meaningful clinical data that can be shared with payers in real time, allowing these care management teams to better track patient progress and support care coordination. 

Data is the currency of collaboration, and it’s time that payers and providers come together for shared clinical and financial benefit.  

3. Align incentives through payment structures

To support this deeper collaboration, payment structures should evolve to support incentive alignment. Here are two key ways we can achieve this in the near term:

1. Providers should receive performance incentives for achieving metrics consistent with best practices and payer priorities. These metrics can include time to care (e.g., first appointment within 48 hours of referral, discharged patients having an appointment within 7 days); treatment outcomes (e.g. achieving remission); and reduction in costly events (e.g. ED readmissions). These performance incentives can sit on top of a fee for service base, making them relatively easy to administer in the current paradigm.
2. Payment can be structured as a case rate, where a provider is paid a single payment for an entire course of care and must manage care delivery and costs within that constraint. This ensures that a payer has a predictable cost for each individual and introduces efficiency incentives for a provider.

Better aligned financial incentives can further support payer-provider collaboration and raise the bar on care quality.

What’s next for Medicaid and mental health treatment  

None of these tactics will be quick or easy, but Medicaid beneficiaries need better mental health care and the time to act is now. Low rates, red tape, unwillingness to collaborate, and poor care quality can no longer be excuses for failing to provide timely, high-quality mental health care to  Medicaid populations. I expect to see a meaningful and long overdue shift in the next few years. In the meantime, we at Brightside Health will continue finding ways to bring our services to  those who need it most.  

‍About the author:  

Brad Kittredge is the CEO and co-founder of Brightside Health, which delivers life-saving mental health care to people with mild to severe clinical depression, anxiety, and other mood disorders, including those with elevated suicidal risk. He has spent over a decade pioneering evidence based and consumer-driven health care solutions at innovative health tech companies like  23andMe and Lantern, where he was VP of Product, and Jawbone, where he was Director of  Product. Inspired by the challenges of a close family member with lifelong clinical depression,  Brad started Brightside Health to ensure that everyone has access to mental health care with measurably better outcomes. He holds MPH, MBA, and Psychology degrees from the University  of California, Berkeley.