Fact Sheet: Federal Investment in Behavioral Health Infrastructure Needed to Address Mounting Crisis

The Issue

Behavioral health needs have long gone under-addressed in the U.S., and the COVID-19 pandemic has and will continue to exacerbate this issue. While some have been able to access care via telehealth during the pandemic, hospitals will struggle to sustain and expand offerings that meet the large scale and severity of America’s behavioral health care needs. Children and adolescents in particular face critical care shortages, especially because of the specialized nature of their treatment.

To address behavioral health issues, hospitals need support to provide safe facilities with appropriate equipment and tailored services — which are widely under-reimbursed, and thus challenging to maintain. This will include procuring adequate end-user audio-video equipment, building remote clinics, and installing interoperable electronic health records (EHRs) to improve information sharing.

It is essential that hospitals and health systems are able to serve patients experiencing mental illness and/or substance use disorders both in-person and remotely and that capacity to respond to the unique behavioral health needs of children and adolescents is expanded. Inpatient psychiatric facilities, as well as general acute care hospitals that offer inpatient and outpatient behavioral health programs like partial hospitalization and opioid treatment programs, face unique infrastructure challenges that are critical to address now before the surge of behavioral health needs stemming from the pandemic becomes insurmountable.

AHA Take

The AHA urges Congress and the Biden Administration to prioritize funding for the infrastructure that supports the behavioral health needs of the country. These investments will not only help to stymie the wave of unmet demand for behavioral health services that has been growing for decades, but also provide the basis for better overall physical health for Americans.

Why?

• Behavioral health conditions — including mental illness and substance use disorders — are highly prevalent, but more often than not go untreated; the COVID-19 pandemic has contributed to increases in acute behavioral health episodes. One in five American adults has a behavioral health condition; before the pandemic, nearly 60% of adults with behavioral health disorders reported not receiving services for their conditions. The stresses of the COVID-19 pandemic have compounded these concerns: One in three adults reported symptoms of an anxiety disorder in 2020, compared with one in 12 in 2019. The Centers for Disease Control and Prevention (CDC) reported that overdose deaths spiked after the start of the pandemic, driven by synthetic opioids like fentanyl. Clearly, the demand for behavioral health services is high.
• The nation is in dire need of more access points for care, especially clinicians and inpatient psychiatric beds. The availability of inpatient psychiatric and 24-hour residential treatment beds has declined significantly over the past five decades; while some facilities and units have closed in an attempt to shift care to community-based and outpatient programs, most have ceased operations due to flagging financials. As a result, over 100 million Americans live in areas that have a shortage of mental health professionals. Surging COVID-19 cases have exacerbated these shortages, as thousands of psychiatric, detox and drug-rehabilitation beds were converted to serve patients with the virus.
• Children and adolescents face a uniquely dire shortage of care. Only about 20% of children with mental, emotional, or behavioral disorders receive care from a specialized mental health care provider. The pandemic has taken a serious toll on pediatric mental health: during the summer of 2020, hospitals saw a 20% increase in suicide attempts and more than a 40% increase in disruptive behavior disorders among children and youths. These vulnerable patients have unique behavioral health needs that require specialized facilities with appropriate equipment (e.g., child-size furniture) and space for safely addressing psychological, developmental, educational and neuropsychological concerns.
• Telehealth can improve access to care, but capacity is limited by upfront costs and lack of broadband infrastructure. According to the Federal Communications Commission, more than 20 million Americans still lack access to high-speed broadband. Further, many remote clinics — and patients’ own homes — lack adequate equipment to meet the needs of underserved patients; this includes sufficient two-way audio-video communication equipment and private and soundproof examination rooms. Telehealth has long been considered a clinically appropriate strategy to expand access to behavioral health services, but hospitals and health systems need support to scale up their telehealth services to meet heightened long-term demand.
• Compliance costs approach $2 billion annually. Mental illnesses carry an increased risk of self-harm, so psychiatric facilities are constantly working to keep patients safe; however, psychiatric facilities must juggle outdated regulations and inconsistent accreditation surveys in order to remain in compliance with federal mandates. Changing interpretations of regulations have forced psychiatric providers to retrofit their facilities in order to reduce unclearly defined safety hazards or face termination of their Medicare contracts. Facilities across the country have invested in new, specially designed and extremely expensive doors, bathroom fixtures, windows, ceiling tiles, beds and sensors in an attempt to avoid citations. In some instances, psychiatric units have closed permanently after determining they are financially unable to make these changes to their facilities.
• Crisis response programs keep people with behavioral health disorders out of jail and increase likelihood of connecting individuals to care, but are implemented inconsistently across the country. When employed appropriately, specially trained crisis response teams can reduce the risk of serious injury or death during an emergency interaction between individuals with behavioral health disorders and police officers. However, many crisis intervention programs operate through volunteer efforts, which limit their reach. To be most effective, crisis response programs need funding to equip providers with evidence-based training, safety equipment and ways to link individuals to appropriate clinical and social resources.
• Significant barriers remain for the adoption of EHRs by behavioral health providers. The 2009 HITECH Act incentivized EHR adoption with payments for providers who participate in the Medicare and Medicaid Promoting Interoperability Programs; however, psychiatric hospitals are ineligible for these programs. In addition to this financial pressure, the nature of behavioral health records — that is, that they are often narrative or follow a different structure than physical health records — as well as conflicting regulatory requirements regarding information sharing has led to far lower adoption of EHRs in psychiatric hospitals compared to general acute care hospitals.