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"I can't find a provider." These words, spoken by so many people struggling with mental health and substance use challenges, highlight a deep flaw in our healthcare system—one that causes real, unnecessary suffering.
Like most Americans, many employees face the frustrating reality of finding care for acute conditions, only to feel lost in a system not built to meet their needs. It’s like someone with diabetes not being able to find a doctor to help manage their condition. But what if solving this issue could transform lives and lower healthcare costs for employers?
As a 25-year veteran of the healthcare industry and now leading new ventures at Spring Health, I've witnessed both the devastating consequences of inadequate care for severe mental health conditions and the incredible change that specialized treatment can bring.
Almost everyone knows someone facing a serious mental health or substance use disorder. More than 14 million people in the U.S. are living with complex behavioral health issues, yet less than half receive sufficient care. The toll on families, friends, and coworkers is enormous. I’ve heard countless heartbreaking stories of people desperate for quality care but unable to find it or afford it.
Watching someone you love suffer without access to proper treatment is deeply painful. But there’s a better way—and it’s already helping millions of people improve their mental health.
Complex conditions require specialized support
We recently launched our new Specialty Care solution to support members in need of acute behavioral health interventions that are easily accessible, affordable, and simple to use. The program addresses over 50 conditions but broadly covers substance use disorders, eating disorders, acute mood and anxiety disorders, and/or trauma.
The reason behind this decision is clear: over 12 million members have access to Spring Health’s Employee Assistance Program (EAP), which includes hundreds of thousands of people dealing with severe mental health and substance use challenges.
For these individuals, traditional outpatient care can fall short of providing support for their journey toward mental wellbeing.
This is where specialty care comes in. It provides additional wraparound support through specialty care navigators and verified specialty providers who regularly treat more severe conditions. This ensures members receive rapid access to treatment at a fraction of the cost of what is often out-of-network care.
Out-of-network care is increasingly common
Imagine an employee struggling with both an eating disorder and severe anxiety. Typically, they face a gauntlet of access issues: finding someone who treats eating disorders, takes their insurance, has space, and can treat a co-morbid condition.
If they’re unable to secure an appointment or afford treatment in a reasonable period, their condition often escalates, leading to out-of-network emergency care that is typically much more expensive than other types of outpatient programs.
Spring Health’s internal data shows that out-of-network (OON) claims for complex behavioral health conditions have doubled, now comprising 32% of ALL OON claims for our customers. This trend highlights a critical gap in access to in-network care for those with acute needs.
The broken search for acute care
The current system for finding acute care is dysfunctional. People often receive a long list of providers through their health plan and have to resort to making a bunch of phone calls, only to find that a mere 10-15% are in-network, with just a third of those accepting new patients.
The average wait time for an in-person behavioral health appointment? A staggering 67 days.
This creates a scenario where people go without treatment, waiting until they're in distress before seeking emergency or OON care. Often, there's no better option than using OON providers found through a Google search.
In almost all cases, employers—who are typically self-insured—remain in the dark about their employees' struggles until a massive out-of-network claim lands on their desk. These claims, often reaching tens or hundreds of thousands of dollars, come without any assurance of the care's quality or effectiveness. Employers are left in the dark regarding:
- Was the provider reputable?
- Was the treatment appropriate?
- Did it even work?
The intersection of health equity and complex conditions
Such scenarios disproportionately affect those with fewer resources. Someone living paycheck to paycheck, dealing with housing instability or food insecurity, faces nearly insurmountable barriers to accessing in-network, quality care for an acute mental health condition.
These non-medical factors, known as the social determinants of health, play a crucial role in overall health and mental wellbeing, including for employed people.
Consider the living conditions of an individual with a lower income who has severe, treatment-resistant depression:
- Their disease may make it difficult to even get out of bed to function in work in life
- They're unsure about their next meal or rent payment
- They've tried multiple medications without success
- They can't find providers who take their insurance and are available for these more complex scenarios.
The energy required to navigate a complex healthcare system, find an appropriate provider in-network, and afford treatment is often beyond their capacity. This negative cycle perpetuates itself, leading to worsening conditions and costly emergency interventions.
How can we address acute conditions?
In the past, stakeholders have often focused on condition management as the endgame. But we believe there’s another key opportunity for intervention: intervening based on risk concerns and shifting care models to lower acuity care settings.
Here’s what this dual strategy looks like.
Risk management
The most effective model tracks member progress and outcomes using measurement-based care as the underlying paradigm. We can then stratify people who are at a higher risk of developing a severe behavioral health condition, do outreach to engage them in care, and address that condition before it becomes acute.
By intervening early, we can shift care from residential facilities to less intensive (and less expensive) outpatient programs.
Condition management
For those who do require speciality care, it's crucial to ensure fast access to quality treatment, followed by a smooth transition back to less intensive outpatient care to prevent relapses. This is an important and sometimes necessary step on the continuum of care.
But as things stand now, there’s no way to know what’s happening with people in acute care programs:
- Are they getting quality care?
- Where are they in the care regime?
- When they’re done with treatment, are they being down-stepped into some outpatient care to avoid relapse?
By building a therapeutic alliance with a specialty care navigator, members can be assured of follow up with their track treatment progress to determine when outpatient care is relevant and effective.
Integrating risk and condition management for better outcomes
An approach that centers risk management and condition management improves outcomes in any given population and significantly reduces the costs of cost care and those associated with leaves of absence, short-term disability, mandatory referrals, and fitness for duty evaluations.
By addressing both risk and condition rather than only reacting to acute conditions as they arise, workplace leaders can effectively bend the cost curve.
Bending the cost curve
Addressing complex behavioral health conditions offers clear return on investment (ROI) benefits. Employers can significantly reduce healthcare costs by proactively managing both risk and condition.
Our independently validated data shows substantial reductions in medical spend through proactive, high-quality mental health treatment, with even greater potential savings for complex conditions.
The current reliance on out-of-network (OON) care for acute behavioral health creates significant personal and financial challenges. It often leads to medical debt for individuals and unexpected, costly stop-loss claims for employers—sometimes reaching hundreds of thousands of dollars—with little insight into care quality or efficacy.
This lack of transparency unnecessarily burdens both employees and employers, perpetuating a cycle where care is accessed only when conditions become severe, resulting in costlier and often less effective emergency interventions.
Employers can break this cycle by investing in proactive, specialized care and supporting a healthier workforce while improving financial outcomes—essentially, aligning employee wellbeing with a sound financial strategy for ever-growing healthcare costs.
Actionable steps for employers
Complex mental health conditions cause immense suffering, and while there's no magic bullet, effective solutions do exist. Workplace mental health platforms can play a crucial role in connecting employees with specialized care that works when they include the following:
- Integrated care platforms: Ensure your mental healthcare solution includes a comprehensive specialty care component within outpatient services. Fragmented services often lead to treatment gaps and patient frustration.
- Social determinants of health solution: Choose platforms that integrate the social determinants of health into their approach. This is crucial for providing truly equitable care.
- Seamless care transitions: Implement systems that facilitate quick transitions from acute care to outpatient services to prevent relapses.
- Plan design changes: Consider removing copays and coinsurance for certain conditions, like substance use disorders, to prevent treatment dropouts due to financial constraints. We've seen a substantial percentage of members drop out of care when their copay or coinsurance kicks in, particularly for more severe mental health conditions, often leading to higher future costs with OON care.
- Measurement-based care (MBC): Utilize MBC across the entire solution as the underlying paradigm to stratify people at higher risk and keep track of progress.
Integrated specialty care reduces suffering
Behind every statistic is a story—a colleague silently battling an eating disorder, a team member grappling with severe anxiety, or a talented manager wrestling with trauma. While specialty care may touch a smaller percentage of your workforce, its impact deeply affects healthcare costs and the fabric of people’s lives.
By embracing integrated, proactive specialty care, you're doing more than managing costs—you're also throwing a lifeline to your most vulnerable employees. You're saying, "We see your pain. We value you. And we're here to help."
When we lift up our most vulnerable, we elevate everyone. Your action today can be the turning point in someone's life tomorrow. Isn't that a legacy worth building?
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