Letter to Premier Horgan: Investing in Mental Healthcare Results in an Overall Cost Savings
February 17th, 2021
ATTN: Honourable Mr. John Horgan
PO BOX 9041 STN PROV GOVT
VICTORIA, BC V8W 9E1
Dear Hon. John Horgan,
We write to you regarding your recent interview with CHEK News. It was very encouraging to hear you go on record stating you are open to finding a way to include the cost of registered psychologists within the healthcare system. This is a huge step towards improving the health and well-being of British Columbians. Consistent with our 2018 and 2020 proposals, the BC Psychological Association (BCPA) is ready to partner with you to make providing comprehensive healthcare a reality in our province.
In a recent study, 86% of British Columbians supported public funding for psychological services in the healthcare system. Further, 41% of British Columbians believe current wait times to see publicly-funded mental health care providers are unreasonable. Lack of access results in needless and sometimes unimaginable suffering - including the recent loss of Andre, the son of Denise Courtemanche, who tragically died by suicide last month after waiting over two years for mental health services. Depression, anxiety, and people contemplating suicide are at an all time high in Canada. As a consequence of lack of access to appropriate resources, individuals with unmet mental health needs seek ways to find relief from their pain, which includes over-utilizing the medical system. They are more likely to frequent family physicians’ offices, emergency rooms, and to develop complex medical and psychiatric illnesses that require prolonged and costly inpatient hospital admissions. The result is an increased cost to the healthcare system by a factor of nearly two. Moreover, with virtually no current prevention/early intervention programming within the system, individuals with mental health issues tend to receive care only when they are in acute crisis, and the care they receive is typically very short term and insufficient to effect lasting change.
Research from the last four decades demonstrates that integrating psychology into the healthcare system prevents suffering, loss of life, and significantly reduces overall health care spending by decreasing unnecessary healthcare utilization, mental health-related ER visits and costly hospitalizations. Within the primary care system, access to doctoral-level registered psychologists allows physicians to direct their time and resources to medical concerns rather than providing behavioral health services.
The demand for effective, high quality psychological services vastly exceeds the capacity offered by the current medical system, resulting in real and significant consequences to our citizens. As you are aware, most psychiatrists and family physicians typically have neither the time nor the expertise to regularly provide psychological and behavioural health interventions to patients. Allowing psychologists to be government-funded is a significant step towards filling this gap for the majority of British Columbians who do not have access to a psychologist. Importantly, lack of public access disproportionately harms vulnerable groups, who are more likely to suffer from poor mental and physical health due to systemic racism and other societal inequalities, but who are also much less likely to have access to mental health services (e.g., through extended health benefits or by having the means to pay privately). This further maintains the inequities in our society that both the Minister of Health and the previous Minister of Mental Health and Addictions have committed to changing.
Integrating psychology into the healthcare system is not theoretical. The integrated models of New Zealand, the United Kingdom, and the US Veterans Affairs system are just a few examples of the countries and systems that have demonstrated that this is a realistic, effective, and sustainable model of care. Moreover, the effectiveness of integrating psychologists within the healthcare system has already been tested right here in British Columbia. For example, a pilot program in 2016 undertaken at Vancouver Coastal Health showed that providing fewer than three 25-minute sessions with a registered psychologist improved patient outcomes. Patients had clinically significant reductions in anxiety, depression, suicidality and associated symptoms. They also decreased their overall use of healthcare services. However, psychologists are not only effective direct care providers - they are also trained in providing consultation and guidance to other mental and behavioral healthcare workers.
For example, when psychologists supervise bachelor- and masters-level healthcare workers to provide behavioural management services to patients with chronic health conditions (rather than having this task fall on overburdened family physicians), it not only reduces medical costs, it improves health outcomes and care. This type of innovative care delivery model is already happening here in BC with the Burnaby Primary Care Network (PCN) B-Well Behavioral Medicine Service. Launched in October 2020, the B-Well service consists of bachelor or master degree-trained behavioral health coaches who deliver tailored cognitive behavioral lifestyle treatments to manage multiple chronic health conditions. The psychologist acts as lead for the behavioural health team, providing supervision, education, consultation with the physicians and, when indicated, brief assessment and treatment for patients who require specialized care. The psychologist also conducts program development and evaluation services to help determine cost and program effectiveness. The B-Well Service is in the final stages of implementing an innovative technology platform to not just improve the patient experience, but to also create real time access between providers, and real-time patient and system analytics.
Focusing on well-being and prevention is also key. Both globally and here in Canada, research shows that lower life satisfaction is associated with higher chronic disease and death. Despite overwhelming evidence, the current healthcare system does not see the potential return on investing in well-being. In a recent editorial published in the Journal of General Internal Medicine, the authors said that “if kindness were a drug, the FDA would approve it.” To try and make the case, psychologist researchers at UBC have partnered with Thrive Health to conduct a clinical trial of a comprehensive, evidence-based well-being program (shown to improve positive affect, reduce negative affect - the biggest predictor of depression - and improve health) tailored to the current challenges people are facing during the current pandemic. The potential impact on BC residents is real.
Barriers to Mental Healthcare
Unfortunately, despite having over 3500 hours of training, knowledge, and experience prior to becoming registered, PhD-level psychologists are currently unable to bill for diagnosis, counselling, therapy, or behavioural health services. If psychologists could bill through the government, it would allow them to serve British Columbians who need the most specialized care. This would significantly increase the efficiency and effectiveness of mental healthcare delivery while at the same time lowering overall costs. Psychologists' unique combination of skills allow them to pinpoint which treatments will work for which patients and deliver that care with the highest level of expertise in the least amount of time. It is important to note that providing lower quality mental health services in a way that is not consistent with best-practice research can inadvertently worsen the situation, as these programs cost taxpayers money without relieving the mental health burden on society. Indeed, a BC study found that only 13% of individuals with depression received “minimally adequate” psychotherapy for their condition. As doctoral-level clinicians and researchers, psychologists are trained to provide not only treatments that work, but also supervision, consultation, and much-needed support to other front-line behavioral and mental healthcare providers who are currently experiencing unprecedented levels of burnout and distress due to unrelenting demand.
While increasing the number of salaried Health Service Authority (HSA) positions for psychologists may seem like an obvious solution to increase access, data would indicate this is not the case. Despite plenty of available positions within the HSA, which include benefits and retirement plans, positions often go unfilled. Why? Currently, HSA wages represent less than one third of what most psychologists earn in private practice or through contracts. Therefore, if the Health Authorities are unable to provide much needed market wage adjustments to psychologists, we need to explore alternative models that may provide reasonable compensation - including the fee-for-service MSP and the Alternative Payment Program reimbursement methods currently used by physicians and psychiatrists.
The financial burden of mental illness on our economy was estimated at $51 billion per year in Canada prior to COVID-19; the pandemic will only increase this financial and mental-health fallout for years to come. Including evidence-based behavioral healthcare within the medical system demonstrably decreases patient distress and saves lives while reducing total health care costs. Integrating clinical psychologists into the primary medical healthcare team can save 10.8% in costs per patient, increase the number of patients seen by family doctors by 42%, increase quality of care, decrease acute care utilization, and reduce physician burnout. According to the Mental Health Commission of Canada, every dollar invested into mental healthcare saves two dollars elsewhere in the medical system.
The BCPA looks forward to discussing and working with you on how funding psychological services within healthcare will save lives, reduce wait times for service, decrease the pain and suffering of British Columbians, reduce physician burnout, and lower overall healthcare expenditures. It’s time.
Dr. Lesley Lutes, R.Psych
Director of Public Advocacy, BC Psychological Association
Professor, Director of Clinical Training
Department of Psychology, University of British Columbia | Okanagan
Dr. David Mensink, R.Psych
President, BC Psychological Association
Alexina Picard, BSc.
Executive Director, BC Psychological Association
CC: Sonia Furstenau, MLA, Leader of the BC Green Party
CC: Shirley Bond, MLA, Leader of the BC Liberal Party
CC: Trevor Bolin, MLA, Leader of the BC Conservative Party