Solving Mental Health Takes More than Race and Place

Articles illustrating the problems of minorities in areas such as mental health care access are quite popular. The authors and editors often chose such comparisons to gain attention, readers, and advertising as seen in black vs white, male vs female, physician vs nurse practitioner, and comparisons of good vs bad quality.

Such studies illustrate disparities, but a major question must be asked? Is a focus on race or ethnicity the best way to actually help America address mental health disparities?
Analysis Issues But is this difference or disparity about one specific area such as race/ethnicity? With additional factors included in the equations, race/ethnicity would decline in influence.

Patient and Population Factors Is this difference about social determinants such as income and education that are known to be different. This is also seen in rural populations and populations in different states or counties. Family structure (single parent, multiple children, working parents, grandparents raising children) can make it difficult to access mental health care. Studies note the lack of evening availability for appointments. Situations, relationships, and environments shape outcomes.

Behaviors, Attitudes Is this difference about attitudes, lack of trust, or stigma as also seen in rural and other populations? Do white populations, especially of higher income level, overutilize mental health as seen in other health services?

Workforce and Payment Design  Is this difference about lack of workforce in certain locations with minorities, difficulties finding a mental health provider, insurance process barriers, or the ultimate cause of lack of workforce - lowest paying insurance? 

Race, Ethnicity, or Place
Demographic data may be useful to illustrate reasons for deficits to exist. It is also useful to remember that the Kaiser reported study indicated mental health provided by mental health and primary care since half of mental health is provided by primary care.

County health and demographic data can be merged with physician databases and Area Resource file data. Counties can be stacked from top concentrations of physicians to lowest concentrations. Top concentration counties have concentrations of resources, physicians, and social determinants. These counties are often clustered together in one portion of a state or region leaving most counties with deficits.

Counties with lowest concentrations of physicians also have lowest concentrations of mental health providers (2013 data). 

The 10% of the population in the Top 79 Counties with highest physician concentrations had 19.9% of mental health providers (2 to 1). The Higher Physician Concentration 152 Counties with 20% of the population had 25.3% of mental health providers. The middle 286 counties with 30% of the US population broke even with 31.3% of MHP. The lowest 2621 counties by physician concentrations with 40% of US had 23.5% of mental health providers or almost 2 to 1 against. 

These lowest physician concentration counties with 32% of the urban population and 75% of the rural population have higher concentrations of elderly, poor, children in poverty, most complex health issues, and least healthy populations to go with lowest concentrations of health workforce and fastest growing populations. 

These counties did not have a larger share of uninsured (1.01 index) but their lowest paying insurance already defeats access having shaped lowest workforce and least access to care for decades. Additions of insurance with payments too low to offset accelerating cost of delivery and declining productivity are not helpful to resolving access barriers, particularly where lowest paying plan patients are concentrated.

And don't forget that the payment design insures that training outcomes fail to produce the generalists, mental health professionals, and general specialty careers that are over 70% of local workforce for these 2621 counties. Training does not have the ability to overcome overall deficits nationally and especially local constraints of payment.

Basically about 50% of the US population is found where all types of health workforce is lowest in concentration - and for the same reason.

Access Barriers Due to Payment Design
The places with lowest concentrations are found in close association with lowest cost of housing and lowest cost of living. These places concentrate the US patients with lowest playing plans - Medicaid, Medicare, metallic, and others. 

Places with concentrations of lowest paying insurance plans
cannot resolve workforce deficits without dealing with payments too low.
Fragmentation By Design Frustrates Local Access

Veterans are also concentrated in these counties. This is another population least supportive of local primary care and mental health because of fragmentation of the US design. Where deficits exist, it is important that all local populations can access local providers. Narrow networks add to the fragmentation.

Payment Deficits Defeat Access Many Ways
Payment for mental health is so low that many mental health providers cannot participate, choose not to participate, or participate on paper but not in reality. Government investigations have confirmed the lack of participation for those listed as participating in plans such as Medicaid.
Low cognitive/office/basic services payments shape workforce and access barriers many different ways all along the patient pathway to mental health. 

Final Questions

Can you address race or ethnicity as an intervention as compared to different approches such as improvements in cognitive payment, community resources, integration of mental health with primary care, or changes in the various attitudes and behaviors of insurers, providers, and patients?  

Our nation needs a focus on what can make a difference. Comparisons are useful with regard to awareness of disparities, but solutions require specific actions.

We need to focus on low cognitive payments to mental health. The same low payments also defeat primary care which provides 50% of mental health care (up from 47%). As mental health sunsets, it is likely that primary care is being more burdened directly from mental health care and indirectly with unmet mental health needs. Overutilization in costly emergent, urgent, and specialist services is also a function of poor mental health access. 

Statistical Questions

As an editor for a journal, there were times when studies were rejected or had to be substantially modified because the original submissions needed work in design, analysis, or interpretation. For example cancer data does have a location for a patient and their race/ethnicity, but not the income or education of the patient. Income or education or other data points from the location of the patient are often inserted as proxy variables based on zip code, census tract, or county location. This tends to magnify the influence of race/ethnicity as the differences involve more dimensions and degrees of differences that are not included. 

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016



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