美国人每年在治疗焦虑、抑郁和压力等心理疾病上的支出高达2010亿美元，精神疾病也成了美国耗费最高的疾病之一。大约半数美国人在一生之中都会多多少少经历这些症状。

心理疾病并非只有在特定年龄段高发。无论男女老少，贫富贵贱，每个年龄段的人都有可能遭遇心理健康问题，从企业高管到普通工人概莫能外。因此，企业必须认识到心理健康问题的严重性，并作为员工管理的优先事项加以解决。

然而即便是对员工健康问题最热心、最睿智的企业，在向员工提供高质量心理健康服务的问题上也往往面临重重阻碍。鉴此，我所在的非盈利机构——支付改革催化剂（Catalyst for Payment Reform）携手AT&T、平权医保（Equity Healthcare）和国际工会775福利组织（SEIU 775 Benefits Group）等8家企业及医保服务采购共同研究这些阻碍，并致力于指导企业解决这些问题。虽然他们所代表的劳动力队伍在地域和人口特征上有很大差异，但他们都存在一些共同的“痛点”。

首先，美国的心理健康服务覆盖率是严重不足的。美国的精神病医生和心理医生相对匮乏，特别是农村地区尤其严重，病人每次常规就诊至少要提前六周预约，要么就只能开四小时的车去外地。由于心理健康服务供不应求，很多医院和医师甚至拒绝病人使用医保。如果员工无法负担高昂的自费成本，他们就有可能无法及时接受治疗，哪怕企业已经为他们购买了医保。

有了这些阻碍，难怪2017年美国有56%的成年心理疾病患者没有得到治疗。病耻感则是另一个导致心理疾病患者就诊率低的原因，很多患者耻于承认自己有心理问题，因而一开始并不愿意接受心理治疗。

即便员工确实接受了治疗，企业也很难评估和跟踪他们的治疗情况。美国的医疗系统在评估高血压和糖尿病的治疗质量上已取得了长足的进步，但我们现在对于抑郁症和焦虑症的治疗效果仍然没有明确的评估标准。由于对治疗质量缺乏相对统一的标准，企业哪怕想为员工选择一家高质量的心理健康治疗机构，往往也是心有余而力不足。

治疗质量的评估标准是一个重要问题，而且这个标准并不仅限于临床效果方面。一个参与研究的企业给我们讲了一个故事，他们的公司的一名员工第一次接受治疗时，是在一间地下室里与心理医生见的面，那名医生居然连鞋都没有穿，活脱脱一位“赤脚大仙”。在治疗心理疾病时，医生给患者的专业感、信任感与安全感是至关重要的。然而现在，这方面并没有人监督。

因此，心理健康医疗领域的创新势在必行。参加我们研究的每家企业都会经常遇到各种心理健康服务商向他们兜售自己的服务，称他们拥有数字化的、可扩展的解决方案，能够满足企业的各种需求。但要真正解决“痛点”，企业必须仔细研究哪些解决方案已在临床上证明能真正解决问题，并且想方设法确保有效利用这些方案。

比如，很多企业早就为员工提供了员工援助计划（EAP），作为员工医保的第一道防线，但是EAP的使用率却普遍不足。目前，美国有些地方创新开展了“消除病耻感”（Stamp Out Stigma）活动，以减少人们对于心理疾病的羞耻感，这或许将促进心理疾病的就诊率。同时，也有越来越多的医保计划公司和远程医疗服务公司开始提供电子心理健康服务。远程医疗有助于填补广大偏远地区心理健康服务的空白，同时它也为员工提供了一种更私人、更安全的选择，他们再也不用担心在候诊室里遇见熟人了。

但最终的解决方案或许在于如何将心理健康服务更好地与基层医疗进行整合。基层医疗机构在筛查抑郁症、焦虑症以及消除患者病耻感、指导患者向专业人士就诊等方面能够发挥无可替代的作用。一些企业和相关部门正在推动基层医疗部门与心理健康机构共同接诊，或是在同一家医保机构或医疗部门名下共同运营。另外，心理健康也应当与电子医疗、EAP、计算机认识行为疗法等各种行为健康解决方案更好地整合。2008年的一项研究显示，城市家庭医疗支出的增加，与心理疾病患者未接受治疗有直接联系。

当然，要提高心理疾病的就诊率和治疗质量，促进心理治疗与基层医疗整合，企业也有必要进行一些试验。总之，员工的心理健康问题如果不被重视，甚至不去治疗，所带来的风险、影响和成本都将是极高的。改变福利设计，推动医疗交付模式改革，制定详细的医疗质量评估标准，通过支付改革建立医保服务激励机制，这四条如果实施得当，每一条都会极大影响企业和员工的长期福祉。

本文作者Suzanne F. Delbanco是非盈利机构Catalyst for Payment Reform的常务理事。

译者：朴成奎

The U.S. spends an estimated $201 billion on mental illness, including anxiety, depression and stress, making it among the costliest health conditions in the country. Almost half of us will experience symptoms of these conditions in our lifetime.

Mental health impacts all demographics, from high-powered executives to factory workers. Employers need to recognize this and make mental health a major priority for their workforce.

Unfortunately, even the most committed and informed employers face sizable barriers to delivering quality mental health care to their employees. My nonprofit, Catalyst for Payment Reform, worked with eight employers and other health care purchasers, including AT&T, Equity Healthcare, and Service Employees International Union (SEIU) 775 Benefits Group, to expose these obstacles and determine how employers can overcome them. We were surprised to hear how many pain points this group shared, despite buying health care on behalf of populations with entirely different demographics and from different parts of the U.S.

To start, it is incredibly difficult to secure sufficient access to mental health services in our country. Shortages of psychiatrists and psychologists, especially in rural areas, mean that patients can face up to a six-week wait or four-hour drive for a routine appointment. Because these providers are in demand, many of them feel empowered to decline to accept insurance. This makes it difficult for employees to gain access to services if they can’t afford to pay out of pocket, even when they have employer-sponsored coverage.

Given these hurdles, it’s no wonder that 56% of adults with mental illness went untreated in 2017. Stigma is another widely acknowledged contributor, as many employees are uncomfortable seeking mental health care to begin with.

When employees do get treatment, employers struggle to measure and track the quality of the care they are receiving. While our health care system has made strides toward measuring quality of care for conditions like hypertension and diabetes, we have barely begun to define what “good” looks like for treatment of depression and anxiety. The lack of information about the relative quality of mental health providers leaves employers feeling helpless in their attempt to determine which providers can make a meaningful difference to the mental health of their populations.

The problem of assessing quality of care goes beyond clinical aspects, with one participating employer sharing an anecdote about an employee whose initial appointment took place in a basement with a psychiatrist who wasn’t wearing shoes. Professionalism, trust, and safety between a patient and a provider are vital when treating mental health and yet, today, can go unchecked.

Given these barriers, mental health care is ripe for innovation. Each purchaser in our group is inundated by vendors claiming to have digital or scalable solutions to meet their needs. To move the needle, employers need to take a close look at which solutions are clinically proven to address these conditions and find ways to drive meaningful usage of the ones that are effective.

Employers have long-provided employee assistance programs (EAPs), for example, to serve as the first line of support for employees, but they are ubiquitously underused. Creative campaigns like Stamp Out Stigma can reduce the shame people associate with seeking mental health treatment and can help jumpstart greater use of mental health services. More health insurance plans and telemedicine companies are starting to offer tele-mental health services too. Remote mental health care can help fill gaps in geographies where mental health specialists are not readily available or provide a more private way for employees to seek help without fear of running into someone they know in the waiting room.

But the real answer may lie in better integration of mental health services into primary care. Primary care providers are uniquely positioned to screen for depression and anxiety disorders during routine visits, reducing patients’ concerns about the stigma they may associate with seeking help from a mental health professional. Employers and other stakeholders are pushing for more primary care and behavioral health providers to co-locate their services or jointly operate under an accountable care organization or patient-centered medical home arrangement. Furthermore, better integrating medical care with various behavioral health solutions, such as telehealth, EAPs, or computerized cognitive behavioral therapy, may pay off. A 2008 study showed a direct link between untreated mental health issues and increases in medical costs for urban family medicine patients.

To enhance access to services, quality, and integration with medical care, employers will need to experiment. It is too costly and harmful to ignore the risks and impacts of untreated mental health conditions. Altering benefit designs, pushing for reforms to how providers deliver care, helping to devise more standard measures of the quality of care, and asking health plans to create incentives for those providers through payment reform each have potential to greatly impact the long-term well-being of people and businesses.

Suzanne F. Delbanco is the executive director of Catalyst for Payment Reform.