Psychedelic Medicalization: How Do We Get It Right?
As clinical trials for the use of medicines like MDMA and psilocybin in psychedelic-assisted psychotherapy (PAT) continue to advance through the U.S. Food and Drug Administration (FDA) review and approval process, there are a number of factors to consider as we prepare for the broader adoption and integration of these therapies within the larger health care delivery system.
This article is intended to highlight ways in which stakeholders in the psychedelic community and in the existing U.S. healthcare system can and should collaborate to support the successful adoption and implementation of PAT in communities around the country. While we will acknowledge some of the concerns about the medicalization of psychedelics– we will focus our attention principally on considerations that should help ensure maximum benefit is derived from the medicines, with a particular focus on access, education and treatment of the whole person.
I think we in the psychedelic community can agree that the current U.S. healthcare system does not sufficiently meet the needs of all people. Given that today’s system does not enable equal access and affordability for all, the psychedelic community has very valid concerns when considering poor or marginalized populations who might stand to benefit significantly from psychedelic medicines may be prevented from accessing them for lack of an ability to pay.
The U.S. healthcare system is complex; difficult to navigate; inefficient to administer; lacking in price transparency; and so expensive that even insured patients run the risk of potentially finding themselves drowning in medical debt. It is a system that leaves nearly 28 million people uninsured, creating major barriers to accessing care (Tolbert, et.al., 2019). Despite per capita spending that is nearly twice the average of other wealthy, developed countries, the U.S. system does not lead to better health outcomes, and in some common health metrics like life expectancy, infant mortality and unmanaged diabetes, actually performs worse (“How does the U.S. healthcare system compare”, 2019).
So why should the psychedelic community work towards integration with the healthcare system for the delivery of PAT?
If we adopt the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being,” it will be imperative that we introduce PAT as part of a broader, tightly coordinated continuum of services that also holistically addresses the physical and social needs of individuals. Recognizing that psychedelics are not a panacea, the following sections are intended to identify ways in which partnership and collaboration with existing healthcare service and community-based providers could not only lead to greater overall health of patients, but also play a significant role in transforming our broken delivery system.
Considerations for Insurance Model Design
One cannot begin a conversation about access to healthcare services without first addressing the issue of insurance coverage. According to a 2014 study published in JAMA Psychiatry, only about 55% of psychiatrists accept private or government-sponsored insurance. This is in comparison to an average of 89% for all health care professionals (Bishop, et.al., 2014). It is quite common to find psychologists and other mental health providers that do not accept insurance – a factor that is largely understandable given that, according to the American Psychological Association, many insurance companies have not increased reimbursement rates for 10 or even 20 years despite rising administrative costs (“Does Your Insurance Cover”, n.d.).
Given the significant time commitment (and therefore costs) involved in the delivery of PAT, it is possible that the only way millions of people will be able to gain access to the medicines is if they have insurance coverage that actually covers the costs of the therapies. Of course, it will be imperative that insurance models sufficiently reimburse PAT providers at rates that will incentivize them to participate as in-network providers for any given plan, while also ensuring efficient, non-cumbersome administration systems for providers to submit claims and receive payment.
As insurance models are designed to cover PAT, stakeholders should consider the comprehensive cost benefit analysis of the impact of the therapies to, in turn, justify the development of sufficient reimbursement rates that will be attractive to and accepted by providers. Today, mental health and substance use disorders are among the top ten leading causes of death in the U.S.; the leading cause of years lost to disability; and the leading cause of disease burden (Kamal, 2017). In 2020, annual spending on Mental and Substance Use Disorders is projected to total $280.5 billion (SAMHSA, 2014).
This, however, only paints a portion of the picture. People with mental and substance use disorders are more likely to have untreated and preventable chronic illnesses like hypertension, diabetes, obesity and cardiovascular diseases – increasing the likelihood that they may die decades earlier than the average person not to mention the high costs in treating them (“What is Integrated care?”, n.d.). National health care costs for chronic diseases totaled $1.1 trillion in 2016; and when lost economic productivity is included, the total economic impact was $3.7 trillion (Waters and Graf, 2018).
Thus, recognizing the promising research results that we are seeing in the treatment of mental and substance use disorders with psychedelic medicines, insurance model design needs to account for improvements that occur in both the mental and physical health of patients. This will require tracking reductions in total health care utilization costs across the full continuum of health care services, in addition to improvements in both mental and physical health outcomes.
Recognizing the improvements and cost reductions for any given patient will likely manifest over multiple years, we should anticipate challenges from payers to taking this long-term view, however. Given the turnover that payers experience as beneficiaries switch insurance carriers from one year to the next (e.g. with job changes, etc.), payers may push back on covering the expense for PAT if they run the risk of not recognizing cost savings. Alas – we must not shy away from the negotiations as we advocate for adequate coverage of mental health benefits for all.
Care Beyond the Healthcare Setting
Providers of PAT should be aware of the valuable roles that health care systems (particularly those that operate as not-for-profit, tax-exempt systems) can play for their patients that go far beyond the treatment of physical health issues.
Following the passage of the Affordable Care Act in 2010, tax-exempt hospital organizations are required to conduct a Community Health Needs Assessment (CHNA) every three years (IRS, 2019). The CHNA is a systematic, data-driven approach to identifying barriers and gaps in services and resources that improve the health and well-being of community residents. These comprehensive assessments typically evaluate the social determinants of health (SDoH) – factors that include availability and access to resources such as safe and affordable housing; healthy food; educational, economic and job opportunities; transportation; public safety; and social support systems. Data has demonstrated these SDoH often contribute more to a person’s health than clinical care, so it is critical to focus on these influencers of health as well.
Tax-exempt hospitals and health systems are required to develop implementation strategies that describe how they plan to address the health needs identified during the CHNA process. In developing these plans, they often find themselves engaging and coordinating with other community stakeholders (city and state health departments; housing, food and educational providers; churches and other community-based organizations; etc.) to address the needs identified in the CHNA.
As we work to ensure access to PAT for poor and marginalized populations in an effort to support their mental, emotional and spiritual health needs, PAT providers would be wise to build collaborative relationships with their local health systems that will, in turn, facilitate access to services that also meet their patients’ physical and social needs. These collaborative relationships may prove to be crucial to achieving and sustaining optimal outcomes from PAT for the most vulnerable in our society.
Diversity and inclusivity expert Ariel Vegosen also reminds us that another crucial factor in ensuring optimal outcomes from PAT for marginalized populations is the need for sufficient numbers of trained therapists who understand the specialized needs of these communities – including people of color, queer, trans and any community that is not represented in the dominant paradigm (Vegosen, 2019). Recognizing that broader plans for the training of sufficient numbers of therapists to meet the expected demand for PAT is an important topic – for purposes of this article we will focus discussion of training and education on other key stakeholders.
Educating the Mainstream
Despite growing attention in recent years, psychedelic medicines still carry significant stigma that is deeply rooted in moral, religious and cultural views of many in our society. To overcome this stigma, there is a need to develop a comprehensive array of educational materials with messages tailored for a variety of audiences – including other health care practitioners, administrators, payers, patients, government leaders, religious and spiritual leaders, and the community at large. This will be an incredibly important step requiring many efforts and time to fully re-educate.
At the very least, educational materials should include information on the definition of psychedelics; their history; an overview of how PAT works; key facts on safety and efficacy; and information on potential risk factors, side effects, and any potential for abuse. Certain audiences might also benefit from a section focused on dispelling myths or misinformation.
The time to develop and disseminate these educational materials is now. Given the pace at which decriminalization efforts are progressing in communities across the country, and the substantial increased attention that psychedelic medicines are receiving in the mainstream media, more and more people are finding their way to the medicines both inside and outside of the U.S., mostly via underground channels. In an effort to support harm reduction, health systems can and should take an active role in supporting their communities by assisting in the dissemination of educational materials and preparing their workforces to understand where to go to retrieve reliable information to share with their patients. Access to information is as critical to access to the treatments.
It will be especially important to develop detailed education that can be shared broadly with members of the medical and mental health professional communities as it is likely to become increasingly common for patients to approach health care professionals asking about the safety and efficacy of psychedelic medicines. Providers need to be equipped with information to share with patients who may have certain health conditions (e.g. cardiovascular, neurological or psychiatric conditions) and are interested in seeking out a psychedelic experience.
Recognizing that decriminalization efforts are occurring in parallel to efforts to advance the delivery of psychedelic medicines under medical models, it will be important for these movements to stay in close concert with each other as they each have potential to bring about substantial transformation and healing in communities throughout the country. As the psychedelic renaissance continues to play out, it is likely that individuals will have a variety of options by which to seek out psychedelic experiences – both inside and outside of the healthcare system. Community members will benefit from information that allows them to distinguish between their options so they can determine which is best for their personal circumstances.
Integrative Healing Models
As we begin structuring the PAT delivery system, there are concerns that medical models will neglect important aspects of the psychedelic experience that one may find in non-medical settings. For instance: is there room for spiritual practice (e.g. ritual and ceremony) to be incorporated into health care offerings? While there is precedent for the incorporation of spirituality in health care, spiritual practices with patients are most often reserved for pastoral care staff, clergy, and hospice and palliative care practitioners. Recognizing that psychedelic medicines are known to occasion mystical experiences that have lasting and meaningful spiritual impacts (Griffiths, et.al., 2006), it seems important that patients in a health care setting at least be given the option to approach the therapy in the context of a spiritual practice, while also ensuring that providers are adequately prepared to support them through the experience.
Other aspects of traditional ceremony that should be considered by the health care community include the opportunity for patients to experience interpersonal connection and learning by seeking PAT in a group setting. While much of the clinical research has focused on the impact of psychedelic medicines on the individual, many in the psychedelic community understand the deep healing and growth that can occur when the medicines are used with intention in a safe and supportive group environment. It is worth acknowledging that there is precedent for group therapy offerings in health care – particularly in the context of treatment for mental and substance use disorders, as well as through group education and support for the management of certain chronic diseases such as diabetes. Providing an option for group PAT sessions could not only serve to reduce the cost of treatment by creating efficiencies in the delivery system, it could also support the restoration of social connections within communities- a promising proposition in today’s digital age of social isolation and disconnection.
As psychedelic medicines are ushered into the health care system, it will be especially interesting to see which other integrative wellness modalities (yoga, meditation, breath work, acupuncture, etc.) are embraced more fully. It is my personal hope that the introduction of PAT, delivered in coordination with other primary and preventative health services, may be what it takes for us to finally transform the U.S. health care system from one that is more focused on the treatment of disease, to one that is focused on holistic wellness and the advancement of thriving individuals and communities.
Bishop, T. F., Press, M. J., Keyhani, S., & Pincus, H. A. (2014). Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA psychiatry, 71(2), 176–181. doi:10.1001/jamapsychiatry.2013.2862
Does Your Insurance Cover Mental Health Services? (n.d.) Retrieved from: https://www.apa.org/images/parity-guide_tcm7-171257.pdf
Griffiths, R., Richards, W., McCann, U., & Jesse, R. (2006). Psilocybin can occasion mystical-type experiences having substantial and sustained personal meaning and spiritual significance. Psychopharmacology (Berl). 187(3), 268-83.
How does the U.S. Healthcare System Compare to Other Countries? (2019, July 22). Retrieved from: https://www.pgpf.org/blog/2019/07/how-does-the-us-healthcare-system-compare-to-other-countries
IRS (2019). Community Health Needs Assessment for Charitable Hospital Organizations - Section 501(r)(3). Retrieved from: https://www.irs.gov/charities-non-profits/community-health-needs-assessment-for-charitable-hospital-organizations-section-501r3
Kamal, R. (2017, July 31). What are the current costs and outcomes related to mental health and substance use disorders? Retrieved from: https://www.healthsystemtracker.org/chart-collection/current-costs-outcomes-related-mental-health-substance-abuse-disorders/#item-start
SAMHSA (2014). Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from: https://store.samhsa.gov/system/files/sma14-4883.pdf
Tolbert, J., Orgera, K., Singer, N., & Damico, A. (2019). Key Facts about the Uninsured. Retrieved from: http://files.kff.org/attachment/Issue-Brief-Key-Facts-about-the-Uninsured-Population
Vegosen, A. (2019, February 7). Psychedelic Privilege: Report from the Women and Psychedelics Forum. Retrieved from: https://chacruna.net/psychedelic-privilege-report-from-the-women-and-psychedelics-forum/
Waters, H. & Graf, M. (2018). The costs of chronic disease in the U.S. Retrieved from: https://milkeninstitute.org`/sites/default/files/reports-pdf/ChronicDiseases-HighRes-FINAL.pdf
What is integrated Care? (n.d.) Retrieved from: https://www.integration.samhsa.gov/about-us/what-is-integrated-care#bmb=1