The COVID-19 pandemic led to an increase in depression and anxiety, along with an increase in opioid use and overdose. At the same time, emergency needs for COVID-19 vaccination and treatment captured the health community’s attention, and the focus on substance abuse treatment faltered. As a result of the worsening mental health issues and decreased attention to substance use, the United States saw an increase in alcohol and opioid use, resulting in additional comorbidities and deaths.

A shortage of behavioral health (mental health and substance abuse) providers, coupled with historically poor access to opioid treatment, has led to a worsening public health crisis that requires a call to action. Payers and health systems may see increased expenditures as a result. Pharmaceutical companies can assist other areas of the healthcare system by facilitating increased provider training and access to treatment, as well as supporting policy changes.

Behavioral Health Declines in 2020

In March of 2022, JAMA Psychiatry reported alarming facts about alcohol and opioid use mortality. Mortality from alcohol and opioids rose during the pandemic: up 38% from 2019 to 2020. Specifically, alcohol-related deaths rose by 25% between 2019 and 2020, with the highest increase in those aged 25 to 44 years. In a state-by-state fact sheet released in May 2022, the Kaiser Family Foundation reported that deaths from overdose increased by 30% in 2020, mostly from synthetic opioid use.

As of 2019, suicide has increased in nearly every state, but is widely variable, with an alarming rate of 29.6 per 100,000 in Wyoming versus 6.1 per 100,000 in the Washington, DC, area. Recent statistics that suggest a decline in suicide since the pandemic’s onset should be viewed with caution. Experts in psychiatry and public health have expressed concern about possible misclassifications of deaths by suicide as unintentional overdose deaths and warned that “consistent with early reports from individual states, national suicide death rates reveal substantial increases among several racial and ethnic minority groups.”

Mortality from alcohol and opioids rose for Black individuals and is now higher than for White individuals. The highest observed rate of 2020 overdose mortality was observed among American Indian or Alaska Native individuals. Access to therapies is of particular concern, as a recent cross-sectional study suggests a flattening of dispensing of buprenorphine and extended-release naltrexone after the pandemic’s onset. Further, across payer types, members of racial and ethnic minority groups have experienced larger losses in access to buprenorphine during the pandemic.

The study states, “These disparities are associated with multiple structural inequities, including inadequate community supply and geographic maldistribution of clinicians prescribing [medications for opioid use disorder] in minority populations with greater overdose rates; financial barriers, such as out-of-pocket cost burdens; prior authorization requirements that may have disproportionate impacts; and missed opportunities to initiate treatment at touch points, such as overdose treatment episodes.” Unfortunately, scarcity of mental health professionals will compound poor medication treatment access.

Crisis of Support

The mental health professional shortage is not a new one. The National Council for Mental Wellbeing released a report in 2018 about the “silent shortage” of psychiatrists. In June, the Health Resources & Services Administration released its quarterly summary reporting that by geographic area only 31.94% of mental health needs were met, and highlighted a need for 3,986 more providers. Some healthcare stakeholders have sounded the alarm.

The 2022 National Conference on Health Policy and Government Health Programs meeting by America’s Health Insurance Plans highlighted the need for increased mental health services, both in the number of providers and methods of delivery, including telehealth. Furthermore, President Biden asked for more focus on mental health and substance use disorder parity at his first State of the Union Address. In Medicaid managed care states, insufficient access to primary care providers (PCPs) prescribing buprenorphine presents a significant barrier to opioid agonist treatment. Clearly, PCPs need training and support to expand treatment capacity.

Despite these concerning trends, surveys fielded by PRECISIONvalue reported that health plans and health systems prioritize opioid use conditions lower than before the pandemic, while mental health conditions are rising in priority. Further, payers and health systems report that addressing social determinants of health (SDOH) related to mental health conditions has increased in focus, while addressing SDOH associated with opioid use has decreased in priority since before the onset of COVID-19. While this disconnect is concerning, policymakers have legislation drafted to open access to behavioral health providers.

Policy on the Horizon

The Senate Finance Committee released draft legislation in May to expand telehealth services for mental health and substance use disorders. The changes include removing the Medicare requirement for an initial in-person visit, allowing for audio-only visits, and ensuring awareness of telehealth services and copays. Expanding telehealth services, including audio only, will increase access for patients in areas without broadband and video access. In addition, since providers and patients do not need to be physically co-located, this will increase the workforce capacity for mental health services.

At the same time, the United States still has a shortage of beds and providers. The American Hospital Association sent a letter to the Senate Finance Committee in February 2022 requesting a lift on residency position caps, financial support to encourage more providers in children’s mental health, increased support for workforce development programs, and enforced mental health parity laws. A specific parity concern cited in their letter was using a protocol whereby “some plans limit coverage for medicines prescribed to treat behavioral health conditions by requiring patients to try less expensive drugs first before ‘stepping up’ to the more costly drug actually ordered by the provider. This approach is called step therapy protocol, and its use can delay needed treatment with often catastrophic consequences for patients.”

Payers may need to consider how conventional strategies to contain costs affect more vulnerable and historically disadvantaged populations. Ensuring mental health parity access to opioid use disorder (OUD) treatments and innovative therapies for psychiatric conditions with significant unmet need may improve adherence and prevent deaths.

How Can Pharmaceutical Companies Expand Access to Behavioral Health Treatment?

Pharmaceutical companies can partner with health systems, providers, and payers to drive access and reduce the stigma of mental health and substance abuse treatments in the following ways:

  1. Collaborate with health systems and community practitioners to support provider education, including initial training to obtain a Drug Enforcement Agency waiver to prescribe buprenorphine, and ongoing mentoring to normalize OUD treatment in the primary care setting and expand access.
  2. Support legislative efforts to expand telehealth and mental health training to develop the workforce and increase access to treatments for depression, anxiety, and substance use disorders.
  3. Partner with payers and providers to increase identification of persons with substance abuse and initiate early treatment through education on new practice guidelines and supporting evidence-based treatment.
  4. Work with community groups and payers to address SDOH that create barriers and contribute to disparities in access to medication-assisted treatment and care of mental health conditions.

The COVID-19 pandemic drew attention away from substance use disorders while simultaneously increasing their prevalence. The rise in behavioral health disorders demands a response, and pharmaceutical companies can collaborate with other stakeholders to address the needs of this vulnerable population.

  • Cynthia Miller, MD, MPH, FACP

    Cynthia Miller, MD, MPH, FACP is Vice President, Medical Director, Access Experience Team at PRECISIONvalue. Cynthia is a trained internist with over 10 years of patient care experience. In addition, she has over four years of experience in the payer space at both WellCare Health Plans and Centene. At PRECISIONvalue, Cynthia’s focuses on market access for national health plans and health systems.

  • Maureen Hennessey, PhD, CPCC, CPHQ

    Maureen Hennessey, PhD, CPCC, CPHQ is Senior Vice President, Director of Value Transformation at PRECISIONvalue. Maureen’s expertise includes social determinants of health, quality and population health, telehealth, and value-based care, with C-level experience in the payer, IDN, and behavioral health (mental health and substance abuse) fields. She has led more than 500 strategic quality and population health engagements with PRECISIONvalue clients.

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