The Right, and Wrong, Way to Scale Mental Healthcare Access

By Michael Boroff, Psy.D., and Stephen Ezeji-Okeye, MD

Back in 2019, one-in-five U.S. adults were found to suffer from mental health conditions, with employers bearing a substantial share of the costs, either directly or in the form of productivity loss or absenteeism. Depression alone cost employers between $17 and $44 billion a year. That was the state of things pre-COVID. Since then, the nation’s mental health has been severely tested and strained by the pandemic; four-in-ten adults, and nearly half of those aged 25-49, now report symptoms of anxiety or depressive disorder.

In response, there has been an explosion in demand for virtual mental health and a proliferation of wellness and mindfulness apps, text-based coaching, AI health bots, and other digital offerings as employers look for scalable solutions to keep largely remote workforces healthy and productive. With this urgent rush to meet demand comes a not insignificant risk of sacrificing quality and outcomes. After all, scaling access without measurable results will only drive up employer costs without moving the needle on mental health. Now is the time to take stock of what works, and what doesn’t, and re-set around proven, evidence-based models.

Evaluating integrated, employer-based mental health

At Crossover Health, mental health services are offered in the context of a fully integrated Primary Health approach, alongside primary care, physical therapy, and health coaching. To take stock of the clinical effectiveness of this model, and derive insights to help improve upon it, we conducted a first-ever study of integrated mental healthcare in an employer-sponsored setting, the results of which were published in the American Psychological Association’s Families, Systems, and Health journal.

The study, a retrospective analysis of patients seen in Crossover’s employer-based clinics throughout 2018, found that 65% of our patients with anxiety and/or depression experienced clinically significant improvements, with at least 30% achieving partial remission. This level of effectiveness is all the more striking given that 70% of patients received psychotherapy alone, with no reliance on antidepressants.

Patients also benefited from timely access. On average, they were able to see a provider within two days of scheduling, a dramatic improvement over the average 30-day wait period in the broader community. With faster initiation of care, patients were able to see a provider an average of 5.3 times in the first three months, compared to just 2.3 times in the community. And they reported a high degree of satisfaction with the care experience, with a net promoter score of 80.

5 principles for scaling outcomes alongside access

The XO model of mental healthcare is achieving these levels of clinical effectiveness, while highly validating, is not surprising to those of us who practice it with patients every day. In reflecting on why this model works, it comes down to a set of guiding principles for scaling mental health outcomes alongside access.

Integrated, not siloed
Mental health doesn’t occur in a vacuum. When we segment that care off from other dimensions of physical health it’s simply not as effective as whole-person approaches. For many, the stigma associated with therapy remains one of the leading barriers to accessing treatment. Even with a referral from a primary care physician, studies have shown that very few patients actually follow through. At Crossover, we’ve repeatedly proven that when a patient’s PCP can provide a warm hand-off to a mental health specialist on the same team — literally introducing them — that patient’s likelihood to follow-through on treatment increases dramatically.

Relational, not transactional
While apps focused on self-guided assessments can provide a measure of mental health self-support and skill development, they’re no substitute for the therapeutic effect of a trusted, invested provider relationship. Research on this effect, while limited, supports our intuitive understanding that a healing relationship and positive therapeutic alliance between doctor and patient lead to patient improvement over the course of treatment. In our practice, we’ve also found that patients are more likely to complete self-guided homework and benefit from it when it’s part of a structured physician-directed treatment plan.

Tailored solutions, not one-size-fits-all
Treating mental health issues in a monolithic manner is not only ineffective but costly for employers. Over the past year of isolation and working-while-parenting-from-home, we are all experiencing heightened stress and anxiety, some of us for the first time. Others who suffer from more severe depression or substance use issues have been especially challenged. While these scenarios each merit treatment, addressing them with similar solutions will only lead to under- or over-resourcing. In Crossover’s model, each engagement begins with a personalized assessment and treatment plan tailored to the individual’s needs and preferences. For one person, that plan might center on intensive one-on-one sessions; for another, it might center on lower-cost internet-based therapy involving mostly self-guided modules.

Lifelong health, not endless therapy
Our focus is always on enabling the development of self-care skills that lead to long-term health and wellbeing. Therapy therefore should be structured and time-limited, with measurable goals and milestones — not free-form with no end point. Payment models for providers should be tied to achieving evidence-based outcomes, not endless utilization. Even though some mental health conditions will require ongoing treatment, most patients can eventually self-manage and maintain wellness. As the results of our study show, if patients have a tailored plan tied to achievable personal goals, the support and encouragement of a provider relationship, and the tools to make progress at their own pace, they’re more likely to improve and develop the skills and confidence to stay well.

Measure success in outcomes, not volume
It seems we’ve become accustomed to increased volume — whether installs or visits —- being the indicator of success; as if more care is the end goal, not better health. But in the realm of virtual mental health, studies consistently report low engagement and retention with many of these offerings, and a near-absence of data on clinical effectiveness. One recent usage study of self-guided mental health apps, for example, found an over 80% decline in engagement after just 10 days, and very low retention a month into use. Employers need to be able to assess value, not volume, to know the solutions they invest in actually drive the clinical and financial outcomes we all care about.

Over the months and years ahead, employers can expect to see ever-rising demand for mental healthcare, while shouldering more and more of the cost burden. Scaling access while bending the cost curve will require more than self-guided apps and AI bots. It will require entirely new ways of designing, practicing, and paying for whole-person health, and evidence-based care models that prove their value through results.