What States Need to Know About the Downstream Impacts of Inadequate Behavioral Health Treatment

With COVID-19 cases on the rise, significant behavioral health treatment needs and access barriers remain major threats to overall health and taxpayer dollars.


It is widely recognized that the lack of access to behavioral health treatment results in increased medical costs, as individuals frequent the emergency department and the hospital.

Out of 29 studies reviewed by the Government Accountability Office that compare healthcare costs associated with behavioral health treatment, nearly 70% found higher healthcare costs associated with untreated adults.

However, lack of access to behavioral health services can also affect our criminal justice, child welfare, and housing systems.

While the traditional healthcare sector is directly impacted, other state and local systems will ultimately reap the consequences as quality of life is diminished for individuals and their families.

  • Law enforcement and criminal justice systems

    Although the reasons behind this are complex, people with serious mental illness (SMI) are overrepresented in the justice system. Research suggests that the COVID-19 pandemic can contribute to the exacerbation of symptoms among those with SMI, which can lead to individuals experiencing mental health crises. When people experience a mental health crisis, they are more likely to encounter police than seek out medical help, and this may lead to increased law enforcement and criminal justice costs.
  • Public education/child welfare systems

    The COVID-19 pandemic is placing more stress on parents and caregivers resulting in extended periods of children being isolated in abusive homes. Experts are concerned that the stress and isolation may contribute to additional instances of child abuse. If this is the case, increased instances of abuse will ultimately require increased interventions from Child Protective Services, and potentially the foster care system, which may lead to increased future costs (e.g., medical, special education, criminal justice) for children who have been abused.
  • Local housing authorities/affordable housing providers

    When mental illness isn’t properly treated, it can exacerbate symptoms that interfere with activities such as maintaining employment or paying rent, contributing to housing insecurity issues. The COVID-19 pandemic is presenting further challenges to housing security due to the economic downturn and rising unemployment, requiring the need for more housing resources. Lack of housing contributes to poor physical and behavioral health outcomes, which can cause increased healthcare costs, thus continuing a costly cycle associated with behavioral health needs and lack of housing.

When considering the types of downstream cost impacts that are tied to lack of needed treatment, it’s more important than ever to invest in appropriate access to comprehensive behavioral health services and community engagement activities. Supporting appropriate access to behavioral health treatment will have a positive return on investment over the long-term.

As the COVID-19 pandemic continues, it is also important for states to increase attention on the quality of behavioral health services.

Key to this is identifying the most meaningful behavioral health-related performance measures and making necessary updates to track, report, and analyze ongoing behavioral health quality improvement activities.

1. Monitor key behavioral health-related performance measures

The Centers for Medicare & Medicaid Services (CMS) 2020 Core Set of Behavioral Health Measures can help states gauge trends in behavioral health treatment and identify where more attention is needed, including measures such as:

  • Antidepressant Medication Management
  • Screening for Depression
  • Follow-up after Emergency Department Visit for Mental Illness
  • Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment

2. Encourage providers to track and report population health metrics

To effectively monitor the progress of individuals needing behavioral health services over time, it’s important to work with providers to track ongoing activities. For example, in addition to monitoring the level of screening for depression, providers can monitor average actual PHQ-9 depression scores to determine if scores are improving as a result of their interventions with their patient population.

3. Assess healthcare-related strategies to account for COVID-19 impacts

Suicidal ideation, for instance, is increasing with the pandemic and there is an opportunity to review state suicide prevention strategies to consider:

  • Partnership and coordination among state agencies to update suicide prevention strategies
  • Partnership with Medicaid managed care organizations to deliver suicide prevention training to providers and community-based organizations
  • Enhancement of Medicaid managed care contract requirements to encourage follow-up with adults who have attempted suicide after discharge from emergency departments/psychiatric facilities and support care transitions and care coordination specific to those who have attempted suicide

With COVID-19 cases on the rise, significant behavioral health treatment needs and access barriers remain major threats to overall health and taxpayer dollars. Action from states is urgently needed to ensure appropriate providers and services are available to meet increased demand and mitigate the cost and quality impacts to healthcare and other social service systems.

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