Making "Access" A Meaningful Part of Every Conversation about Psychedelic Therapy
Associate Dean for Research and Associate Professor, Columbia University School of Social Work
Part of our Year in Review series
Heidi Allen, MSW, PhD, is the Associate Dean for Research and Associate Professor at Columbia University School of Social Work. Dr. Allen was a speaker at the 2019 International Forum on Consciousness and serves on the Clinical Advisory Board at Usona. She studies access and affordability of health care in America, particularly for under-served populations. Her research has been published in prestigious journals such as Science, New England Journal of Medicine, JAMA, and Health Affairs. Dr. Allen is a Commissioner on the Medicaid and CHIP Payment and Access Commission, a non-partisan government agency that advises Congress and the Secretary of Health and Human Services on issues related to Medicaid and the Children’s Health Insurance Program.
Here, Psychedelic Alpha’s Josh Hardman interviews Allen on topics broadly pertaining to access in the context of psychedelic therapies.
As far as I understand, you were one of the co-investigators of Oregon’s Health Insurance Experiment. Do you think there’s a greater need for this type of social policy research in the psychedelics space? If so, what sorts of studies, interventions, or conversations do you deem to be among the highest in priority?
The Oregon Health Insurance Experiment was an ambitious data collection effort built around a natural policy experiment when Oregon offered limited spots in their Medicaid program via a lottery. The randomized access to health insurance allowed us to treat the coverage expansion like a randomized clinical trial, capturing the causal impacts of covering the uninsured on health care use, personal finances, and health and mental health outcomes. We mailed surveys and conducted in-depth in-person interviews where we also measured markers of physical health. To understand the financial impacts of health insurance, we examined credit reports, mortality data and emergency department and hospitalization records. At the end of the study, we used these multiple sources of data to describe the costs and benefits of Medicaid expansions, which remains an influential body of work in U.S. health policy.
Psychedelic-Assisted Therapy (PAT) will not be randomly allocated, but is very much a natural policy experiment with parallel paths occurring via the FDA and state ballot measures. To understand the implications, it is critical to implement a rigorous health services research agenda around who has access to PAT, how much it costs, the quality of care, and the impacts on health, mental health, and overall well-being (e.g. employment, social relationships, financial stability, etc.). This research will help us determine the cost-effectiveness of PAT. Most importantly, it will help us understand if PAT, which holds so much promise for improving mental health, is accessible to those who need it the most. If it isn’t, then we need to identify and understand the origins of these disparities so that we can address them. You can’t see what you don’t measure.
I strongly believe that we need to bring health services researchers together now, not later, to develop a health services research agenda related to PAT. We need to look at available sources of data to determine if it will be sufficient to measure access and quality of care and health and mental health outcomes, which it likely isn’t. We need to identify strategies for collecting data that doesn’t currently exist. For example, health care claims data (data that is generated when an insurer is billed) provides very accurate assessments of care people received, but it is useless for identifying unrealized access, care that was needed and never received. Claims data also tells us very little about social and structural determinants of health that might independently impact health and mental health outcomes. Importantly for PAT, where many people may be paying out of pocket at boutique retreat centers, there are no claims or unified electronic health records data at all. This will likely be true in Oregon and Colorado where therapy is occurring independent of the mental health system as we know it.
These are not unique challenges in health services research, but generally federal funding, specifically NIH funding, and federal survey data creates the necessary infrastructure for researchers to do an adequate job of monitoring health care access, quality, costs, and health outcomes. This scaffolding is not currently in place for psychedelics and if we wait for PAT to be rescheduled by the FDA, we won’t be positioned to do the rigorous research that is desperately needed.
What should the roll-out of psychedelic therapies prioritise: seeing them administered to as many people as possible, or focusing on reaching people with the most severe/intractable conditions that could benefit the most?
I believe that our priority should be making sure that the people who need these treatments the most are first in line to receive them. But this is not mutually exclusive of an aggressive scaling-up to position the supply of providers to meet broader demand. Covid vaccines and treatments offer an excellent model for holding these two principles at the same time: both vaccines and therapies were distributed first to the elderly and immunocompromised, but everybody else wasn’t far behind. The emphasis was on thoughtfully prioritizing some groups, not rationing broadly. I would like to see us apply these public health principles to psychedelics. To do so, we need to be thinking about access, access, access. I gave a whole talk about this at Horizons NYC 2022, which you can watch here.
Given what we know about socioeconomic drivers of mental health and so-called ‘diseases of despair’, do you envisage psychedelic therapy being durable in folks who continue to face challenging socioeconomic circumstances?
The causal relationship between socioeconomic status and health outcomes is dynamic, each influencing the other over the lifecourse. While engagement in psychedelic-assisted therapy will not break that cycle or directly change the systems and environments in which a lower income person lives, I wouldn’t want to presuppose they would benefit any less from PAT than someone in better financial circumstances. However, there is still much we don’t know. With the lack of longitudinal studies around long term efficacy of psychedelic-assisted therapy, as well as little research involving marginalized communities and comorbid diagnoses, it is difficult to draw any conclusions. Certainly, people living in poverty are more likely to experience recurrent traumatization and poverty comes with a myriad of other mental health risk exposures. That said, low-income populations may be poised to see the greatest benefits. Until we have evidence otherwise, I would presume PAT results would be similar across socioeconomic groups.
In short, might we expect psychedelic therapies to increase healthcare disparities? If so, how can we avoid this?
There is no reason to believe that any new treatment introduced into our inequitable mental health system will do anything other than replicate existing inequities. These disparities will widen if a new treatment is very effective and if the demand for the treatment is high and the supply of qualified treatment providers is low, which I anticipate will be the case with PAT. Additionally, there is the question of insurance coverage: will payers like Medicaid participate? Equally important, will PAT clinics and qualified providers accept Medicaid or any in-network insurance at all? Every actor in the medical psychedelic ecosystem must have the same goal: making sure that the populations who need PAT the most are first in line to receive it.
With generous funding from the Steven and Alexandra Cohen and the Joe and Sandy Samberg foundations, we have launched a partnership between Columbia School of Social Work and University of Pennsylvania School of Nursing to bring PAT training to social work and nursing degree programs. Scaling up a diverse and affordable PAT workforce, without requiring new professionals to incur additional high cost post-graduate training, is inherently an access initiative. We hope to share this curriculum with schools of social work and nursing broadly.
I hope to see access as a meaningful part of every conversation about psychedelic therapy. I hope to see partnerships with Federally Qualified Health Centers, a commitment from manufacturers to participate in the Medicaid Rebate Program (a criteria for Medicaid coverage) and a commitment from PAT therapists to accept all forms of insurance. If we make access to PAT someone else’s responsibility, we will all be complicit in the widening of disparities and the subsequent real harm to marginalized communities these disparities represent.
What timeline will payers like insurance companies be looking to recoup the likely five-figure costs of PATs? What about Medicare, Medicaid?
It would take thousands of words for me to do this justice, but it is such an important question.
First, I would gently challenge the implicit assumption that effective mental health treatments should have to pay for themselves. We don’t hold physical health care to this standard. In fact, the last year of life notoriously accounts for a significant amount of health care spending. We also pay for a lot of treatments where benefits are negligible (not that this is the ideal). Second, as individuals and as a society, we allocate enormous amounts of money for the health we are presumably buying. Money spent on health care is money that we don’t have to spend on other things that we value and so if PAT works, then this will be one of those happy occasions where we can actually see that we are getting what we paid for! The metrics to keep an eye on are Quality Adjusted Life Years (QALYs), which are used to determine the cost-effectiveness of new health treatments based on the impact of that treatment in obtaining additional healthy years of life, compared to existing treatment options. If a new treatment, even an expensive one, is highly beneficial, it is usually covered by all types of insurance.
A related question is could PAT potentially lead to such substantial increases in health care expenditures that insurers resist covering it until there is sufficient real world evidence? Insurers think of costs at a population, not individual, level. This is for good reason: people change jobs, employers switch insurance companies, and over time people move in and out of types of coverage (such as joining the Military or aging into Medicare). I would guess that on the average, insurance companies will not “break even”, at least not in a time frame that they would consider meaningful. Still, there will likely be high cost populations where savings will be realized. I would guess this will be the case for Medicare (end of life) and Veterans, as well as individuals with acute depression who are frequently hospitalized.
At five-figures, I think it is likely that insurers will impose barriers to access such as pre-authorization or requirements that other treatments are tried first. I also worry that there will not be “network adequacy”, a sufficient network of trained PAT providers, and we could see a situation where there is coverage but no meaningful access to care.
The above questions all pertain to the regulated, FDA-approved model. How do you think state-level initiatives like those seen in Oregon and Colorado might contour access to psychedelics (therapies) in the U.S.?
I’m hopeful that state-level clinical-use legalization efforts, decriminalization efforts, and federal rescheduling efforts may have some positive impacts on each other, despite the fact that they are three distinctly different paths. A potential benefit in the federal rescheduling effort is that the FDA bases its decision on the outcomes of the clinical trials. Should something not go well in Oregon or Colorado, it’s unlikely to have a direct impact on the actual rescheduling of psilocybin. However, federal rescheduling is only a piece of the puzzle. The perceptions of potential service-users, providers, insurers, policy makers, and other stakeholders are going to be very relevant to what happens in the steps between rescheduling and public access.
While there are a lot of differences between cannabis legalization and psychedelic legalization, one similarity is the need to overcome social stigma and misinformation. This is an area where OR and CO are going to be in the spotlight. Just one highly publicized unfortunate incident could undermine public trust in psychedelic therapy in general.
We will have a lot to learn from Oregon and Colorado in general. I am very interested in what these states can teach us about the PAT workforce and group prep and integration models. What kind of higher education, if any, is required to be an effective PAT therapist? Can unlicensed professionals with the right training get the same outcomes as licensed professionals? I would guess that education does matter, but this is an empirical question – one that we can measure with the right data and we definitely should.
Cite This Article
Allen, H. (2023, February 1). Making “Access” A Meaningful Part of Every Conversation about Psychedelic Therapy – Psychedelic Alpha. Psychedelic Alpha. https://psychedelicalpha.com/news/making-access-a-meaningful-part-of-every-conversation-about-psychedelic-therapy
Part of our Year in Review series
This content is part of our 2022 Year in Review, which looks back at the past year through commentary and analysis, interviews and guest contributions.
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