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Improving Access to Mental Health and Substance Use Care

Mental Health Topics

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Addressing Challenges as an Employer

Workplace mental health is a high priority for employers. Mental health conditions are common and costly. Take depression, the economic impact of depression is high at $210 billion annually in the U.S., consisting of direct health care costs, lost productivity and early death from suicide . In our nation, 1 in 5 working age adults lives with a mental health condition, yet more than 60% do not receive treatment.

Employees face tremendous challenges in locating and accessing timely and effective mental health and substance use treatment. Employers identified these factors as high priorities in national surveys on behavioral health published by Willis Towers Watson in 2017.

Employer Top Priorities 2017-2020
(Willis Towers Watson Survey: Employer Survey, March 2017)


  • Locate timely and effective treatment = 63%
  • Integrate BH case management with medical and disability case management = 61%
  • Provide better support for complex BH conditions = 56%
  • Expand Access to Care = 52%

These issues require urgent attention. Our nation faces a public health crisis with opioid deaths jumping 10% in 2017 to 72,000 and suicide deaths jumping more than 30% to 45,000 in 2016.

Employers are more engaged in raising awareness about mental health conditions and creating a climate and culture that encourages employees to seek help when they need it. Yet, despite these efforts, access to care remains extremely challenging.

This led the Center for Workplace Mental Health and the American Psychiatric Association to join forces in developing Recommendations for Improving Access to Mental Health and Substance Use Care. These recommendations were developed in consultation with thought leaders representing psychiatrists, large employers, health plans, business groups on health and other mental health professionals.

When employees access effective and timely mental health and substance use care, the result is a healthier, more productive, and higher performing workforce. Also, employers recognize that healthcare costs are climbing for employees with co-occurring mental health and other medical conditions. The cost for employees experiencing co-occurring mental health and medical conditions is 2 to 3 times higher than for those without mental health conditions.

In developing the recommendations, five priority areas were identified in which employers and health plans can play a key role in improving access to mental health and substance use care. The recommendations provide detailed steps that employers, employer coalitions and health plans can take to improve access to care. Below is a summary of the five areas, to supplement the recommendations, which provide more detailed steps:

Ensuring Network Adequacy

Employees who cannot access affordable care often go without, increasing the likelihood of missed work days, poor performance and a worsening condition. The recommendations call for health plans to provide employers with a detailed plan on steps they are taking to grow the provider network. This information will inform employers on network adequacy and open the opportunity to work together to overcome challenges in access to care.

Mental Health Parity Compliance

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) requires that coverage for health care services for mental health and substance use conditions be comparable to coverage for medical and surgical care. The Department of Labor and state officials have stepped up investigations of employment-based health plans to ensure parity compliance and enforcement of the federal law . In many cases, employers as plan sponsors maintain responsibility for parity compliance.

The Department of Labor’s Employee Benefits Security Administration (EBSA) has conducted more than 1,700 targeted investigations in connection with MHPAEA and cited more than 300 violations involving mental health and substance use benefits. The parity non-compliance violations involved but were not limited to the following:

Quantifiable treatment limits (QTLs):

  • impermissible annual and lifetime dollar limits
  • improper financial requirements
  • quantitative treatment limits like higher co-pays or lower visit limits

Non-Quantifiable treatment limits (NQTLs): limiting the scope or duration of benefits and representing the highest percentage of parity violations:

  • overly restrictive fail-first policies
  • prior authorization requirements
  • written treatment plan requirements
  • criteria used to admit providers to the plan network

Given concerns with non-compliance, the Department of Labor and other federal agencies continue to publish MHPAEA guidance to increase access to quality health coverage for mental health and substance use conditions.

The recommendations identify key questions employers can ask health plans to improve MHPAEA compliance and reduce risk of violations and penalties.

Advancing Measurement Based Care

There is a need to increase screening to ensure early detection of depression and other conditions. There is also a need to improve the quality of care delivered by closely tracking and reporting on treatment progress and outcomes for mental health and substance use conditions. The recommendations identify a process for collaborating to create greater accountability.

Expanding the Collaborative Care Model

Primary care providers play a key role in delivering mental health and substance use care, especially for common conditions like depression and anxiety. Yet the treatment outcomes are often not good . Integrating mental health and primary care offers the opportunity to improve access to care, outcomes and lower overall health care costs with a holistic approach to care.

This led to the development of the collaborative care model (CoCM) to effectively deliver mental health and substance use care in primary care. The CoCM works with a team that includes a primary care physician, the patient, a behavioral health care manager and a psychiatric consultant. There are more than 80 randomized control trials showing that the CoCM improves mental health and physical health outcomes. The ROI and business case for CoCM are clear – $6.50 is saved for every $1 invested in implementing the model.

The recommendations identify key steps health plans and employers can take to promote and expand the collaborative care model.

Expanding Telepsychiatry

Given the shortage of psychiatrists in communities around the country and the opportunity to effectively connect to care using technology, the recommendations identify the steps needed to promote and expand the use of technology for employees to connect to care.

The APA and APAF Center for Workplace Mental Health are joining forces with national groups and experts representing employers, employer coalitions, health plans and other key stakeholders to implement the recommendations. Together we can improve access to care and support the ongoing health and well-being of our nation’s workforce.

Last Updated 2020



  1. Greenberg, P. E., Fournier, A. A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The economic burden of adults with major depressive disorder in the United States (2005 and 2010). Journal of Clinical Psychiatry, 76, 155–162. doi: 10.4088/JCP.14m09298.
  2. NIMH Statistics.
  3. CDC Statistics.
  4. U.S. Department of Labor Report to Congress on Pathways to Full Parity 2018 (.pdf).
  5. U.S. DOL Report to Congress 2018.
  6. HHS Presentation by Jurgen Unutzer, M.D., Chair Psychiatry and Behavioral Sciences, Director, AIMS Center, University of Washington.
  7. The AIMS Center, University of WA, Building the Business Case.

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