In recognition of Mental Health Awareness Month, on May 25 HC3 and Third Horizon Strategies co-hosted a special Transformation Series event exploring behavioral health. The one-hour panel discussion featured a conversation with local experts and advocates that are focused on increasing access to a comprehensive system of quality behavioral health care services and advocating for regulatory and legislative reform in Chicago and Illinois.
Mindy Klowden, Senior Director, Third Horizon Strategies
Jud DeLoss, CEO, Illinois Association for Behavioral Health
David Applegate, Director of State Policy, The Kennedy Forum Illinois
Heather O’Donnell, Senior Vice President of Policy and Advocacy, Thresholds
Wanda Parker, Vice President of Clinical and Therapeutic Services, Aunt Martha’s Health & Wellness
Watch the Recap | Link to YouTube
Opening remarks, Mindy Klowden
As we emerge from the pandemic, we are seeing tremendous stressors on the behavioral health delivery system. Individuals and families have been experiencing the psychological fallout of the pandemic and resulting economic recession. Four in 10 adults have had symptoms of depression or anxiety and people with existing mental illness diagnoses have been experiencing heightened symptoms.
What are the needs of our communities and how do we address them?
Heather: The state of Illinois and the country have been dealing with a mental health crisis for decades, we have only recently started to fight against it. There is currently not enough access to treatment, regardless of insurance coverage. Furthermore, the pandemic and social justice issues have only underscored what we already knew. The Cook County sheriff made a statement that the county jail has a large number of behavioral health needs; however, jail is not a treatment facility, and it can inevitably cause more harm and trauma. Black Illinoisans are nine times more likely to be incarcerated then white Illinoisans and Black and Latinx children and adults have less access to treatment. The upside is that most policy circles are focusing on these issues, including access to treatment, social determinants of health (SDOH), and access to housing.
David: We are facing two crises, the COVID-19 pandemic and the ongoing mental health and substance abuse disorder (SUD) crisis, of which has only been exacerbated by the pandemic. COVID-19 has uncovered the prevalence of mental health and addiction, and how these challenges have gotten worse in the past year. The silver lining during this time has been the elevated dialogue, not only to reduce stigma, but also to increase access to care and target this issue.
Dr. Wanda: Equity and inclusion is the third crisis. Service line gaps have been exacerbated in the pandemic – and it is important to level the playing field so that everyone can access services they need. Frontline workers are dealing with a tremendous amount of stress and the “moral trauma” of feeling like they need to be helping others.
Jud: Underfunding the safety net hospitals has always been an issue. Hospitals haven’t been able to treat as many people as efficiently amid COVID-19, making the problem only worse. Some progress has been made through telehealth, but the question remains: what is state policy’s role in addressing barriers (access, funding, etc.) especially as it relates to the behavioral health delivery system?
David: Consumers always cite access and cost as barriers to care. And there continues to be a lack of parity in how legislators treat health care. Despite the clear need and demand for behavioral health care, data shows we are currently only investing around 3.4 percent in behavioral health. This highlights the fact that behavioral health providers are reimbursed at lower rates, which in turn drives a workforce shortage. Adults and children are likely to go out of network for behavioral health care, so it ends up more expensive than other types of care and therefore more difficult to access.
Heather: We are really seeing a crisis in the workforce; there are not enough social workers, therapists, psychiatrists, and so forth. For a provider like Thresholds that helps people manage medical conditions as well, there is a lot of burn out for frontline workers that have been working night and day through telehealth and face-to-face. We already had a workforce shortage and are now seeing that staff really need a break. To that point that, as we look at service reductions, there are discussions at the state level about how to help providers attract and maintain staff. And there absolutely needs to be an advocacy role for payment reform to be able to pay staff members adequate salaries, provide additional student loan reimbursement, and reform antiquated rules.
What are some solutions you are seeking to support the workforce and delivery system?
Jud: At IABH (Illinois Association of Behavioral Health), we are working with partners to help alleviate some of the immediate issues. Governor Pritzker’s budget reflects a need for increased funding for behavioral health care and SUD, and there’s a bill for a pilot program for CCBHCs – the model that has been used throughout the country that has been successful. There has been some push back on this, but we would like to see this transformation because it reflects the opportunity to integrate primary care issues and behavioral health issues in one place. We are also working with the division of mental health to utilize block funding from SAMHSA to transform the system with sustainable models.
Dr. Wanda: We need talented individuals to innovate and cultivate integrated models. There has to be a commitment to addressing payment rates so we can attract that talent. Payers and providers feel the onus is on the patient to file a complaint when there is a violation of parity. But patients don’t always know the rules. How do we educate folks about what their rights are in mental health and SUD care?
David: A recent report shows that health plans are still skirting health care parity laws, a decade after they were passed. Illinois has done a good job recently. The department of insurance announced last summer that insurance companies were fined over $2 million for compliance violations. Parity audits on the medicaid side should be done and government must actively enforce the law so that consumers don’t have to make sure their plan is compliant and individual in crisis can focus on their care and health.
What needs to change in crisis care? How does creation of 988 impact the system?
Heather: The 988 line is an enormous opportunity for Illinois, but we don’t have the infrastructure in place. There’s already been a partnership in place with the Chicago Police Department for a long time. Illinois is in the infancy of developing a crisis system to respond to children and adults, regardless of insurance. We have pockets of crisis services but nowhere near what we need. We want to work with the state to make this happen because a crisis line isn’t enough, and there has to be a follow up system. We need a variety of models and options: co-responder models, mental health teams to be out in the field, with a police backup plan in place, but not the default.
Jud: There is a rush to fill the needs of the 988 system and the planning process, as well as the development of the framework needs be done.
Dr. Wanda: There is plenty of data to show that we need a new system, so we are currently in a good place to be starting to work towards those goals. Telehealth services need to continue and can be part of crisis intervention. Our system should allow people to fight for health and wellness without having to fight the system.
What needs to happen in Chicago? What is the solution to address the most vulnerable communities & mental health?
Dr. Wanda: SDOH must be part of this conversation and addressed as well. It is about access to care, but we have to broaden that net. We know that telehealth works, and it is not always feasible to go into the office. People need resources to be able to access telehealth and have the same level of access to it as those with more resources. Innovative technology has been reserved for those who have the resources to access it, but everyone should be given the same access.
Continued monitoring can be done by patients that will go to the provider (e.g., PHQ9 scores). The other portion is addressing health and wellness, which again means we need to address other SDOH (e.g., people living in food deserts, those experiencing housing instability, children who may not be able to focus on school may have experienced trauma, they may not have ADHD, etc.). At Aunt Martha’s everyone is trained through a trauma-informed model, and we have to think about the resources that the people we serve have, and understand the role providers can play aside from providing medical care.
Heather: One of the things we have seen in pandemic related to SDOH is that in certain areas of the city, you could go outside for a face-to-face visit, but on the south and west side there aren’t always safe places to do this, and people in those communities received fewer face-to-face visits. Both the city and state need to work together on the complexities of these issues. Street outreach is important for people that aren’t ready for traditional treatment. Thresholds is developing a young adult team to reach out to other young adults who are at the first stages of mental illness.
Jud: Medicaid’s design of pharmacy access limits many people, but this is changing thanks to the advocacy efforts happening across the state. Medicaid is the primary funder and the way they structure reimbursement is critical for providers meeting the most vulnerable populations. Medicaid managed care organizations (MCOs) made record profits last year and the Illinois Department of Healthcare and Family Services is going to allow MCOs to retain those profits until an audit occurs. Currently, there are hundreds of millions that should be in the hands of providers for the utilization of services provided.
Will there be a balance or blend of telehealth services moving forward? Specifically, how can telehealth benefit behavioral health?
Jud: Telehealth is well suited to behavioral health, and most of the telehealth usage this past year was in the behavioral health space. There are efforts for parity around reimbursement for in-person vs. telehealth care.
David: We do need strong public policies that make telehealth a viable option for consumers and must have parity in how plans cover telehealth care and in-person care. Care and coverage can’t be conditioned by location of the patient or provider. The digital divide is real and is a problem that needs to be addressed, and we need to increase broadband access in Illinois.
Dr. Wanda: It is possible that MCOs made money because some people had better access to services. It would be great if the money made could be reinvested into infrastructure for those in need and to provide wraparound services which everyone is entitled to whether they have resources or not.
Heather: Prior to the pandemic, SUD services could only be provided on site and not via telehealth. Telehealth has radically changed access to medication and assisted treatments. Now people can be connected immediately to medication-assisted treatment whereas before it required an appointment. One caveat: it is not just the digital divide, but the tech divide, because many clients are homeless and live in poverty, and they have a government issued phone with limited minutes and no video capacity. While telehealth was the only way to connect to some people, for people with severe problems the telehealth option didn’t provide enough. Telehealth should always be an option but face to face is sometimes crucial as well.
How do we build resiliency and prevent mental health issues?
David: We have to get in front of it early and often by Investing in a treatment system to make sure care is community-based and meet people early on where they are. The stigma and culture need to change. We are making progress in this regard with more public dialogue normalizing and letting people know it’s okay to get treatment. Solving that problem will require strong public policy and investment in behavioral health delivery.
Heather: The Early Mental Health and Addiction Treatment Act was recently passed to help young people with early signs of a significant mental health issues. Right now, you can’t get treatment unless you have a diagnosed mental illness – but kids experience so many things where they don’t have a diagnosed condition but need support for what they are going through – Illinois is in the process of putting this in place through Medicaid program. Behavioral health teams need to be redesigned to catch young people in the early stages of mental health and addiction issues, rather than only serving people already severe in their condition.
Jud: Prevention is critical right now and as we come out of the pandemic people might be in early stages of mental health or addiction issues brought on by the trauma of the past year.