For all the progress made in helping people with mental health struggles, for all the years spent improving our understanding — May is Mental Health Awareness Month, after all — one of the persistent challenges is that people’s perceptions of mental health treatment haven’t evolved enough from the days of sanitariums and straitjackets.
“There’s tremendous stigma,” said Dr. Mark H. Rapaport, CEO of the Huntsman Mental Health Institute. “There’s a belief that, somehow, brain diseases are diseases of one’s character, or personality weakness — when they’re biological diseases, as real as heart disease or lung disease or anything else.”
Proof of this is the differing ways our health care system handles mental health issues compared with other ailments.
If someone is feeling physically sick, they will likely make an appointment to their doctor, or visit the urgent care clinic that’s aligned with their insurance plan’s network — or, in a worst-case scenario, go to the emergency room. They will get treated for the problem, be admitted to the hospital if it’s serious enough, and then be referred to a specialist.
An insurance provider — if the patient has one — will then pay all or some of the bill, depending on how well they’re covered through their employer or Medicaid or other means. It’s not a perfect system, but it’s the one we have.
When someone has a mental health emergency — from anxiety or depression, for example — the chain of events isn’t quite the same, experts say.
“We’ve come a long way in the past few years …, particularly in the area of crisis services,” said Rep. Steve Eliason, R-Sandy, whose day job is as a senior finance director for The University of Utah Hospitals and Clinics. One positive development in Utah, he said, is the SafeUT app, which students and parents can put on their phones to have ready access to licensed counselors ready to listen any time at no cost.
Once the emergency has passed, things get tough — and are vastly different based on where people get their insurance.
Those with insurance accepted at the University of Utah’s health facilities, if they live in Salt Lake City, will likely go to the emergency department at University of Utah Hospital, Eliason said. Once done there, if they’re being treated for a mental health crisis, they will likely be sent to the U.-affiliated Huntsman Mental Health Institute for inpatient treatment. But if they’re in another insurance system, Eliason added, they will start at a hospital that’s in-network and, if needed, go to a smaller psychiatric ward that’s also at an in-network hospital.
“There are some insurers that refuse to have a relationship with us now,” Rapaport said. Some companies, he said, “work very hard to keep their customers within their own health system.” (Rapaport wouldn’t name names — he is hopeful he can build bridges with those providers.)
Getting a referral for a psychiatrist can be a battle, Eliason said. If one looks for a psychiatrist in their network, they often find those doctors aren’t taking new patients. And if someone has to go out-of-network, the costs escalate sharply.
Some of the difficulty in finding psychiatrists, Rapaport said, is that insurers reimburse them at lower rates than doctors who specialize in other fields. “It’s just phenomenal, the disparities when it comes to the reimbursement rates made for those services versus even other medical specialties,” he said.
Eliason said some psychiatrists and therapists, in Utah and nationally, have become so fed up with the red tape and insurers denying payment that they’ve gone into cash-only private practice.
The COVID-19 pandemic exacerbated problems in mental health treatment in different ways, Eliason said. As the pandemic began, hospitals turned psychiatric wards into emergency COVID wards, or closed beds due to staffing issues. Now that the pandemic emergency has been declared over, “a lot of those beds have not been returned to the original purpose for psychiatric patients [needing in-patient mental health treatment],” Eliason said. “And those beds were scarce before the pandemic.”
Meanwhile, the pandemic also raised people’s anxiety levels. “There probably is not one American that didn’t experience some sort of mental health issue going through the pandemic,” Eliason said, “whether it was just a short burst of anxiety waiting for a COVID test to come back, or being locked down, or fear of losing their job.”
The statistics around mental health in America are alarming.
The results of a Gallup poll released this month found depression in the United States has reached new highs. Roughly 29% of Americans reported being told by a doctor or nurse that they have depression at some time in their lives, and 17.8% said they currently had or were being treated for depression — both are the highest rates the poll had found since Gallup started asking the questions in 2015.
Utah doesn’t fare well on national rankings for mental health care. Out of the 50 states and the District of Columbia, Utah ranks 46th — sixth from the bottom — in the numbers of adults that have a higher prevalence of mental illness and lower rates of access to care, according to the nonprofit group Mental Health America. (The states that border Utah — Arizona, Colorado, Idaho, Nevada and Wyoming — all rank in the bottom 10.)
In a similar ranking by Mental Health America covering children, Utah does better: 30th in the nation.
In 2021, according to the U.S. Centers for Disease Control, 643 Utahns died by suicide — a rate of 20.1 for every 100,000 people in the state, putting Utah at 14th nationally. The CDC placed suicide as the ninth-leading cause of death in Utah that year.
Comparing Utah to other states doesn’t mean much, Rapaport said, in terms of the costs of treating mental health problems.
“There isn’t any good place when it comes to parity for mental health treatment in this country, as long as we have a fee-for-service model,” Rapaport said, “as long as we have a model where people get paid less to care for individuals who have brain diseases than they do for heart disease, or diabetes, or high blood pressure.”
Eliason cited a study from the Kem C. Gardner Policy Institute at the University of Utah that showed how much harder it has become to get comprehensive health coverage. Just one data point in the study: In 2007, just 3% of the health plans sold in Utah were “high-deductible,” meaning the patient paid more up front and out of pocket for their care; in 2020, 38% of the health plans sold here were “high-deductible.”
Insurance companies also can be, as the saying goes, penny wise and pound foolish.
“We’re creating a crisis-care center so that we can have a dignified and appropriate place for people with psychiatric disorders to get care,” Rapaport said. “But we’re having to go and engage and argue with the insurance companies, saying… the reasonable rate for crisis-care services is less than it costs when you send that same patient to the general hospital emergency room.”
Inadequate mental health treatment costs in other ways. Rapaport said that anxiety disorders, nationwide, cost the country more than $4 billion a year in lost work and wages.
“We lose a week out of every month in productivity,” he said.
Eliason said transparency in health care pricing would go a long way toward pointing out — and maybe even resolving — the disparities in insurance payouts. He said he’s working on a bill to address that, and he may be ready to introduce it during the 2024 Utah Legislature.
“The transparency of ‘Am I going to get what I pay for?’, in terms of access, is really important,” Eliason said. “[Patients] need to be provided with that information, so they can make the best choice out there.”
Transparency could also prompt providers to cut costs — like a gas station owner who sees the gas station across the street lower their price a penny, so they have to drop their price a penny, too. When it comes to health care, those pennies add up.
There’s much more that should be done. Hospitals should dedicate more beds and resources. Insurance companies should put mental health providers on an equal footing with other specialists. And both groups need to find ways to make seeking care less costly and confusing.
Mental health underlies so many other challenges — with homelessness, substance abuse, education, prisons, care for the elderly, treatment of veterans, and more. Solve the challenges in our mental health care, and Utah will go a long way toward finding solutions to those problems.
Note to readers: Paul Huntsman, chairman of The Salt Lake Tribune’s board, is a member of the Huntsman family, which donated $150 million in 2019 to launch the Huntsman Mental Health Institute.
