美國人每年在治療焦慮、抑郁和壓力等心理疾病上的支出高達2010億美元，精神疾病也成了美國耗費最高的疾病之一。大約半數美國人在一生之中都會多多少少經歷這些癥狀。

心理疾病并非只有在特定年齡段高發。無論男女老少，貧富貴賤，每個年齡段的人都有可能遭遇心理健康問題，從企業高管到普通工人概莫能外。因此，企業必須認識到心理健康問題的嚴重性，并作為員工管理的優先事項加以解決。

然而即便是對員工健康問題最熱心、最睿智的企業，在向員工提供高質量心理健康服務的問題上也往往面臨重重阻礙。鑒此，我所在的非盈利機構——支付改革催化劑（Catalyst for Payment Reform）攜手AT&T、平權醫保（Equity Healthcare）和國際工會775福利組織（SEIU 775 Benefits Group）等8家企業及醫保服務采購共同研究這些阻礙，并致力于指導企業解決這些問題。雖然他們所代表的勞動力隊伍在地域和人口特征上有很大差異，但他們都存在一些共同的“痛點”。

首先，美國的心理健康服務覆蓋率是嚴重不足的。美國的精神病醫生和心理醫生相對匱乏，特別是農村地區尤其嚴重，病人每次常規就診至少要提前六周預約，要么就只能開四小時的車去外地。由于心理健康服務供不應求，很多醫院和醫師甚至拒絕病人使用醫保。如果員工無法負擔高昂的自費成本，他們就有可能無法及時接受治療，哪怕企業已經為他們購買了醫保。

有了這些阻礙，難怪2017年美國有56%的成年心理疾病患者沒有得到治療。病恥感則是另一個導致心理疾病患者就診率低的原因，很多患者恥于承認自己有心理問題，因而一開始并不愿意接受心理治療。

即便員工確實接受了治療，企業也很難評估和跟蹤他們的治療情況。美國的醫療系統在評估高血壓和糖尿病的治療質量上已取得了長足的進步，但我們現在對于抑郁癥和焦慮癥的治療效果仍然沒有明確的評估標準。由于對治療質量缺乏相對統一的標準，企業哪怕想為員工選擇一家高質量的心理健康治療機構，往往也是心有余而力不足。

治療質量的評估標準是一個重要問題，而且這個標準并不僅限于臨床效果方面。一個參與研究的企業給我們講了一個故事，他們的公司的一名員工第一次接受治療時，是在一間地下室里與心理醫生見的面，那名醫生居然連鞋都沒有穿，活脫脫一位“赤腳大仙”。在治療心理疾病時，醫生給患者的專業感、信任感與安全感是至關重要的。然而現在，這方面并沒有人監督。

因此，心理健康醫療領域的創新勢在必行。參加我們研究的每家企業都會經常遇到各種心理健康服務商向他們兜售自己的服務，稱他們擁有數字化的、可擴展的解決方案，能夠滿足企業的各種需求。但要真正解決“痛點”，企業必須仔細研究哪些解決方案已在臨床上證明能真正解決問題，并且想方設法確保有效利用這些方案。

比如，很多企業早就為員工提供了員工援助計劃（EAP），作為員工醫保的第一道防線，但是EAP的使用率卻普遍不足。目前，美國有些地方創新開展了“消除病恥感”（Stamp Out Stigma）活動，以減少人們對于心理疾病的羞恥感，這或許將促進心理疾病的就診率。同時，也有越來越多的醫保計劃公司和遠程醫療服務公司開始提供電子心理健康服務。遠程醫療有助于填補廣大偏遠地區心理健康服務的空白，同時它也為員工提供了一種更私人、更安全的選擇，他們再也不用擔心在候診室里遇見熟人了。

但最終的解決方案或許在于如何將心理健康服務更好地與基層醫療進行整合?；鶎俞t療機構在篩查抑郁癥、焦慮癥以及消除患者病恥感、指導患者向專業人士就診等方面能夠發揮無可替代的作用。一些企業和相關部門正在推動基層醫療部門與心理健康機構共同接診，或是在同一家醫保機構或醫療部門名下共同運營。另外，心理健康也應當與電子醫療、EAP、計算機認識行為療法等各種行為健康解決方案更好地整合。2008年的一項研究顯示，城市家庭醫療支出的增加，與心理疾病患者未接受治療有直接聯系。

當然，要提高心理疾病的就診率和治療質量，促進心理治療與基層醫療整合，企業也有必要進行一些試驗?？傊?，員工的心理健康問題如果不被重視，甚至不去治療，所帶來的風險、影響和成本都將是極高的。改變福利設計，推動醫療交付模式改革，制定詳細的醫療質量評估標準，通過支付改革建立醫保服務激勵機制，這四條如果實施得當，每一條都會極大影響企業和員工的長期福祉。

本文作者Suzanne F. Delbanco是非盈利機構Catalyst for Payment Reform的常務理事。

譯者：樸成奎

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.