Proposition 1 – Lessons for California Health Plans and Providers for Addressing Behavioral Health
Now that Proposition 1, the largest behavioral health legislation in the country is being implemented, here’s what you need to know. Read our article to discover actions that payors and providers can take to fully leverage this momentous opportunity.
In March 2024, California voters approved Proposition 1, a historic two-part initiative to reform and expand the state’s behavioral health system. The proposition significantly changes how California funds behavioral health services and related housing.
The first part of Proposition 1 created the Behavioral Health Services Act, replacing the Mental Health Services Act of 2004, and expands that act to include substance use disorders. The Second part authorizes bonds of $6.4 billion to finance behavioral health treatment beds, supportive housing, community sites, and housing for veterans with behavioral health needs.
To better understand the impetus for Proposition 1 and what providers and payers can now do, I spoke with Dr. Rachna Saralkar, a practicing psychiatrist, informaticist, and Physician Investigator for Clinical Trials. With vast experience delivering inpatient, outpatient and virtual psychiatric care, Dr. Saralkar is passionate about driving transformative change in mental health care delivery.
Addressing a Mental Health Crisis
Nationally, including California, we’re amid a mental health care crisis. About one in five U.S. adults (more than 50 million people) experience some type of mental health condition in a given year, according to the National Institute of Mental Health. In California, 5.5 million adults are estimated to have a mental health condition, according to the National Alliance on Mental Illness (NAMI) California.
A severe national shortage of mental health professionals is forcing patients to either forego care or seek it at overburdened emergency rooms. “One in five patients with a behavioral health condition present to the ED yearly, and one in four people diagnosed with a behavioral health condition in the ED receive NO other mental health services, other than that trip to the ER,” Dr. Saralkar said. “This obviously raises the cost of health care and is wildly insufficient when it comes to treatment.”
Amid such high demand for mental health services, Dr. Saralkar is especially worried about high-risk patients. “Patients that need specialized care like trauma, eating disorder or substance use services need a way to get that care faster without waiting and resorting to EDs,” she said. “Better identification of patients who need behavioral health intervention, followed by plugging them into a highly interconnected system where sub-communities are aware of their care gaps and how to fill them with online services — that’s what will eventually lead to communities where patients trust the system.”
How Health Plans Can Improve Access
Health plans play a major role in improving patient access to mental health services, according to Dr. Saralkar, citing virtual triaging as a means to expedite care access. “In times of need or crisis, patients sometimes have limited options. Health plans can implement a tiered virtual triage line which can improve quality of care,” she said. “There are a number of start-ups that are offering this as a service.”
Dr. Saralkar also advises that, “Plans should be analyzing their mental health provider networks. And analyze providers by location, service, and type to ensure there is adequate coverage. In addition, they should clearly understand the bottlenecks that patients face, including the next available appointment, quality metrics, and patient throughput.”
Lastly, health plans should evaluate their benefit designs to ensure mental health services are being covered, and providing members with various levels of benefits, based on need.
Tech to Improve Care Access, Reduce Disparities
With her experience using technology to improve healthcare access and reduce disparities, Dr. Saralkar is excited about technology’s impact on mental health care. “From creating new treatments to making diagnoses more efficient, and of course scaling access to care,” she said.
That said, while some tech advancements, like telehealth, have helped many, they’re not the solution for all. According to Dr. Saralkar, “Low-income groups do not always have access to the internet or even just the level of broadband needed for a quality telehealth encounter. Many appointments can be done over the phone, but again this excludes patients with more severe mental illnesses.”
Providers need to start thinking in terms of “asynchronous” care delivery to scale up access,” Dr. Saralkar said. “We have to stop relying on patients to ‘be on time’ for regular appointments when they are barely making ends meet. Let’s meet patients where they are, and at the same time reduce ER admissions and cost of care, without overburdening providers.”
Dr. Saralkar continued, “Payers might think about promoting subscription-based models to address lower-acuity diseases. These subscription-based services help patients manage non-acute issues immediately without going to more expensive treatment options such as ER.”
Data to Track Progress, Close Gaps
Dr. Saralkar advocates for payers and providers using baseline data to track disease prevalence and outcomes for their communities. But data-tracking is not easy with mental health care. “The problem is that diagnosis and treatment are still very subjective, a problem rooted in the fact that mental health is an evolving area of scientific discovery, compared to say oncology or cardiology,” she said.
A double standard has emerged when it comes to assessing mental health treatment. Mental health care treatment data currently relies on patient-reported outcome measures, which have become the basis for value-based payment systems for mental health. On the other hand, drug and therapeutics development requires that outcomes be assessed by clinician-reported outcome measures.
“We’d never ask patients to subjectively tell us how they feel their diabetes is doing, instead of getting blood glucose levels. We need to work toward the same level of objectivity in mental health,” said Dr. Saralkar.
In Conclusion
Now that Proposition 1 is being implemented, payers and providers should be assessing their populations’ behavioral health needs and developing supportive care plans. Organizations should also be coordinating with local governments and community-based organizations on the front lines of implementing Proposition 1.
