How Benefit Plans Need To Adjust

“Hello, how are you?” If some form of this greeting is not the most common in our society, then I would like to know what is.

And for most people over many generations, the typical response is some form of “I’m fine.” And yet, we can’t ignore the fact that many people are not fine! The COVID-19 pandemic disrupted the flow of societal interactions enough to make many leaders in government, business, education, and healthcare think more broadly about how people are being impacted in daily living by a variety of forces of change. In the last decade, we have seen change at an increasing rate driven by political polarization, new workplace norms, volatile financial markets, gun violence, disease and opioid epidemics, and powerful social media.

In my recent book, Not Just In Sickness But Also in Health (ForbesBooks, 2021), total well-being is expressed as a combination of physical health, mental health, social health, financial health, and purpose. This holistic view is important in understanding if a person can say, “I’m fine” with a level of conviction that stands up to the secondary question that is usually asked by a caring person: “How are you really doing?”

Mental health has taken center stage recently for a variety of reasons and here are three of them:

• Within the healthcare industry, behavioral health claims are occurring at a rate more than 15% greater than pre-pandemic levels and prescription volumes for anti-anxiety and anti-depressant medications surpassed opioids, becoming the second-most prescribed category of drugs during this same time period.
• Media outlets and politicians have increasingly called out mental health as the reason underlying troubling acts of violence, mass violence and hate crimes that seem to jump to the top of the news feeds.
• The rate of combined deaths by alcohol, drugs and suicide has been increasing, growing over 20% from 2019 to 2020 and showing an uptick in substance-related deaths in 2021.

Benefit designs fall short for mental health

Nearly all people in the United States are insured under one of five benefit program categories. At the federal government level, Medicare benefits are generally available to citizens over age 65, and those who currently or formerly served in the military may access benefits through TriCare. Lower income individuals and those with special needs generally gain access to health benefits through Medicaid, which is operated by each state with federal support. Employees, small business owners and individuals with reasonably high incomes generally access commercial insurance through private insurers (e.g., United Health Group, Aetna, Cigna, Blue Cross and Blue Shield).

And for those individuals with incomes too high to qualify for Medicaid and yet challenged with the affordability of private insurance, Affordable Care Act plans offer subsidies for individuals and families to access private insurance plans that are like those accessed by employees under commercial insurance plans.

As you would expect, each of these benefit program types supports access to hospitals, doctors, diagnostic testing (e.g., labs and imaging), pharmacies, and medical supplies. Each of these benefits varies across a variety of dimensions based on the specific plan in which you are enrolled. Almost everything that falls under the rubric of health insurance is based upon a system of coding, called ICD (International Classification of Diseases). And as you might expect, the codes get updated as medical knowledge progresses, and the current version is called ICD-10.

Only certain types of medical providers are allowed to be reimbursed for certain procedures. For example, an orthopedic surgeon is qualified to perform a knee replacement, but a medical oncologist would be qualified to prescribe a regimen of chemotherapy for cancer. But what of the mind and human behavior? It is well established that the two major types of mental health professionals are psychiatrists and psychologists. Psychiatrists attend medical school and can prescribe medications while psychologists are not. Under certain circumstances, nurse practitioners with the proper training can prescribe medications under the supervision of a psychiatrist. Psychologists generally practice talk therapy to help patients.

Sounds straightforward … but is it? Just like medical coding, there is a set of codes for mental health disorders that is compiled in the DSM manual, otherwise known as the Diagnostic and Statistical Manual of Mental Health Disorders. And just like the coding for medical diseases, this manual is updated as new discoveries and treatments progress, with the current version being DSM-5. And yes, there is a connection between DSM-5 and ICD-10 to ensure proper billing and reimbursement. So at least all the different types of healthcare practitioners have a way to bill and get paid. Goody for them!

But how are you, as a human being without training on mental health diagnoses, supposed to navigate your way to good mental health? And do you think it just might be possible that physicians who are internists, ER docs, and gynecologists might not be experts either?

An understandable mental health “table of contents” for consumers is required

I am not a mental health expert or clinician, and that is a major point of this article. I am, however, a 35-year veteran of how the healthcare industry designs benefit plans and makes them available (or not available) to insured individuals. Improving the healthcare industry always comes down to developing a systematic approach to connect the appropriate resources that can improve an individual’s health to that individual in a low-friction and timely way, aided by their benefit plan. Fortunately, a great many intelligent and well-intended clinicians, entrepreneurs and capital sources have been forging solutions that, thanks to technological innovations in digital and virtual care, can help people achieve better mental health.

The entities resulting from these innovative efforts have successfully sold their solutions into private and public insurers, employers, and health systems. The problem is that even the people arranging the mental health solutions have a hard time classifying them, never mind the individual consumer that needs access to the resources.

My challenge to those that provide health benefits is to drive out a standard classification system or “table of contents” so that the average human being can quickly know how to access resources that can assess and offer treatments or re-navigate as necessary if the self-diagnosis is incorrect.

This table of contents might look something like this:

• Suicidal thoughts
• Drug addiction – needles
• Drug addiction – pills
• Alcohol addiction
• Eating disorders
• Anger and violence problems
• Depression
• Anxiety
• Autism
• Memory problems
• Feeling unstable
• Stress management
• Resilience building

This example list is certainly not correct or complete. However, I doubt there are many people who cannot comprehend the list. If the average person could quickly find a path to click or call specific resources that are available within their benefit plan, rather than just seeing something generic on the website that says mental health benefits or employee assistance program, then the health plan can provide low-friction convenience.

Assembling a network of full-spectrum, easily accessible mental health solutions should be an imperative in every benefit plan. With the innovation that is occurring to provide these solutions at scale, combined with an ability to connect people to local professionals when required, the healthcare industry would find itself in a better place, and so would the many people suffering from mental health disorders!