Increasing equity in access to mental health care: a critical first step in improving service quality

As Kilbourne et al describe, measuring quality of mental health care serves as an important step towards reducing service inequities. However, quality measurement that predominantly focuses on treatment outcomes overlooks individuals with mental health needs who cannot access value-based treatments. Untreated mental health and substance use disorders are associated with premature mortality, productivity loss, high rates of disability, and increased risk for chronic disease. Thus, ensuring equitable access within a value-based framework is needed to not only close existing treatment gaps but also to improve patient outcomes. The degree of inequity in access to mental health care varies among countries with different models of health care system and welfare regimes. Findings from a study of seventeen low-, middleand high-income countries revealed low mental health care utilization despite documented high need: in each country, at least two-thirds of individuals with common mental disorders went untreated. Twelve-month service utilization rates also tended to be lower in less developed countries and to align with the percentage of gross domestic product spent on health care. Furthermore, members of socially disadvantaged groups such as ethnic/racial minorities and low-income patients have lower mental health service utilization compared with members of advantaged groups. Inequities in access to mental health care can arise due to myriad reasons, including: eligibility criteria to enter programs (e.g., receiving a specific required diagnosis); lack of linguistic capacity; policies that discriminate based on legal status (e.g., refugees, immigrants, racial/ethnic minorities); lack of information regarding where and how to obtain care; and logistical, psychological and economic barriers (e.g., transportation, childcare, beliefs about self-sufficiency, stigma-related concerns, concerns about privacy, long waiting times for services, high costs, or inflexible work schedules). To adequately document mental health care inequities, measures and procedures to evaluate access must be consistently and globally implemented across mental health care systems. But you cannot evaluate what you have not measured, and unmet need is typically absent from conventional administrative or service data. Methods of measuring access might focus on one’s potential ability to access care, including the package of benefits included under mental health coverage and the availability of appropriate and effective service providers within reasonable geographic proximity. Additionally, access measures should incorporate obstacles that arise once someone has decided to enter care, such as insufficient choice of providers, low doses of services, and ineffective or low-quality services. In a valuebased framework, both horizontal equity (understood as the provision of equal care for equal needs) and vertical equity (understood as different treatments for people with different needs or preferences) must be considered when striving for equitable access. Conducting national surveys of household and institutionalized individuals every five to ten years might offer a benchmark of those who need care and where they are located. Results of such investigations can also inform testable hypotheses about why some individuals do not receive services, including explanations related to specific preferences for care. Additionally, quick assessments obtained through computerized adaptive testing might simplify diagnostic evaluation and assure linguistic diversity, as well as afford more attention to differential item functioning (i.e., the extent to which an item measures different abilities for members of different groups), so that providers can adequately operate across cultures, diverse populations, and languages. Measuring both barriers and facilitators to mental health and substance use treatment access through geographic mapping can also provide a more comprehensive picture of specific areas in need of immediate intervention. Finally, overlapping measures of need with administrative service use data can facilitate allocation of resources, adjustments of risk for inclusion of underserved populations, and payment incentives for providers to reach those with unmet behavioral health needs. But, before these methods can be widely adopted, a shift in the purpose of medical records (i.e., from being used mostly for billing to being used predominantly to monitor access, quality, and patient’s service preferences) must come into vogue. Stratification by need level (e.g., those with comorbid conditions), age, race/ ethnicity, income, sexual orientation, gender, urbanicity, or linguistic subgroups can assist in isolating where there are inequities and who or what is responsible for them. However, it will likely be more difficult to make the health care system accountable for collecting these data, given the inadequate budgets and resources granted by ministries of health for mental health care. Despite having several potential methods to measure access to mental health and substance use care, systems may not utilize these methods in a meaningful way if they are not incentivized to do so. Although reporting requirements tied to provider accreditation or funding vary across oversight agencies, states and countries, they typically focus on service outcomes of those in care rather than outcomes of those eligible for services. Recommended performance metrics that include access to care have been proposed by several relevant organizations but, without some form of mandated accountability, health care administrators do not reliably collect or report this information. More research should focus on strategies to make service administrators and policy makers responsive to reducing access inequities and incentivized to develop