Health Care USA Chapter 10

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Chapter 10

Mental Health Services

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CHAPTER OBJECTIVES• Gain knowledge about the origins, basic components

and organization of the U.S. mental health services industry and its financing

• Understand the nature of mental illness, its prevalence and evolution of treatment modalities

• Gain appreciation for barriers to mental illness care• Review effects of the ACA on mental health services

access and reimbursement

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Current Background

• Mental health terminology changes:– “Mental health care” now often “behavioral

health care” with psychiatric care, a medical subspecialty, one aspect of integrated services

– “Patient” replaced by “consumer” or “person/people” with a psychiatric or substance abuse disorder or “mental health issue”

– “Problem-based” diagnosis model replaced with “strength-based” model in “Recovery Movement”

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Historical Overview (1)

• Colonial era to 1800s: mentally ill confined to almshouses, jails, hospitals with no treatment, decrepit conditions

• 1800s: Quakers advocated “moral treatment,” est. 1814 Philadelphia “asylum.”

• WWI: “shell shock” in returning military focused new attention on mental illness

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Historical Overview (2)• 1930s: First effective biological treatments:

insulin coma, drug-induced convulsions, electroconvulsive therapy

• Post WWII, National Mental Health Act of 1946:–National Institute of Mental Health–Dept. of Veterans’ Affairs psychiatric

hospitals and clinics

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Historical Overview (3)

• By 1950, still primarily inpatient-1/2 M+ in state, county mental hospitals

• New drugs for schizophrenia, other psychotic disorders allowed ambulatory treatment– Partial hospitalization– After-care programs– Transitional residences

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Historical Overview (4)

• 1955: Joint Commission on Mental Illness & Health est. by Congress, the first time a federal body considered resources for the mentally ill

• Attacked poor quality in county & state psychiatric hospitals

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Historical Overview (5)1960s• Mental health care reforms supported by

President Kennedy• Additional, new pharmaceutical treatments• Federal Mental Retardation Facilities, Community

Mental Health Centers Construction Acts• Medicare, Medicaid, SSI, Social Security Disability

& housing subsidies accessible for mentally ill

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Historical Overview (6)

1960s-1970s-Unproven assumptions guided care• Beliefs that 1) psychiatric disorders lie on a

quantitative continuum with severe mental illness not qualitatively different from lesser severe mental distress, 2) early intervention could prevent development of severe illness; both beliefs later proven invalid

• Federal financial investments in community-based services hoping to prevent severe mental illness through primary prevention

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Historical Overview (7)

• Until 1980s, payments on basis of units of service; no incentives for limiting treatments that went on for years; 1955-1980: treatment episodes quadrupled.– Insurers balked with payment limits, discounted

fee-for-service payments different from other medical care, “carve-outs” outsourcing coverage to specialty managers, and capitation; “non-parity” for mental health services was established to plague the mental health industry for decades.

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Historical Overview (8)• Deinstitutionalization (1970s-1980s)– Medicaid incentives to move patients from

psychiatric hospitals to community boarding and nursing homes; community mental health centers inadequately staffed for severely mentally ill

– Large numbers incarcerated, homeless– 1950: 77 % inpatient, 23% outpatient; 1990: 21%

inpatient, 7 % partial hospitalization, 67% outpatient

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Historical Overview (9)

• Breakthrough developments- 1980s– NAMI, NIMH, clinical researchers’ advocacy re-

defined mental illness from quantitative continuum to discontinuous in development; mental illness as biologically based, disorders more clearly defined requiring targeted treatments, not unfocused “talk therapies.”

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Historical Overview (10)• Carter’s Presidential Commission on Mental

Health sought applications of new research findings to benefit patients and reduce costs– Recommendations taken by Health & Human

Services to expand psychosocial rehabilitation programs under Medicaid; Medicaid payment for outpatient services expanded; severely ill eligible for SSI

– Expanded services severely curtailed in 1980s under Ronald Reagan

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Historical Overview (11)

• 1990-Present– Focus on severe mental illness with block grants,

federal support for research, training, treatment, not erroneous prevention strategies

– Medicare Act of 2003 expanded drug coverage; CHIP increased coverage for low-income children; Wellstone-Domenici Parity Act of 2008 advanced equitable coverage for mentally ill

– ACA of 2010 reinforced insurance parity.

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Recipients of Psychiatric and Behavioral Health Services (1)

• Epidemiological Catchment Area & Co-morbidity Studies report:– 26.2% of Americans will have a mental disorder

during any one year period, 57.7 M people– 6%, subgroup classified as having “serious mental

illness” with symptoms (excluding substance abuse) for at least 12 months.

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Recipients of Psychiatric and Behavioral Health Services (2)

• Neuropsychiatric disorders: the leading cause of disability in the U.S. and Canada measured in units encompassing the total burden of disease, defined as “Disability-adjusted life years” (DALYs); contribute 2x DALYS of cardiovascular disease & cancers.–DALYS = total number of years lost to illness,

disability, or premature death in a given population (Fig. 10-1)

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Recipients of Psychiatric and Behavioral Health Services (3)

• Diagnosis and Treatments– As effective as physical health treatments; criteria

provide predictability of natural history of illness and treatment

– Classified in 17 categories; diagnostic criteria for over 450 conditions

– Co-morbidity: the co-existence of two diagnoses; ~1/2 of mentally ill have an additional disorder; e.g. substance abuse of 23-80% with other disorders

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Recipients of Psychiatric and Behavioral Health Services (4)

• Mental illness costs– In addition to unquantifiable personal and

family suffering, $ 300 B annually for disability payments, health care expenditures and lost earnings.

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Treatment Services

• Who does and does not get treatment?–45.6 M people over 18 years met criteria for

one psychiatric disorder in the past 12 months…19.6% of adult population; only 38.2% able to access treatment.–Access to treatment worst among

underserved groups: minorities, low income, uninsured, rural

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Barriers to Care (1)

• Barriers: provider availability; financial, lack of health insurance; stigma; misunderstandings about treatability; personal & provider attitudes; cultural issues; poorly organized systems of care– Substance abuse and addictions: providers view as

“moral,” not chronic disease issues; removal from treatment often follows relapse

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Barriers to Care (2)

Children and Adolescents– Service use data available first in 1999 from NIMH

survey: only 9% able to access some services: half of those with diagnosed mental illness; school system is largest provider

– 2009 study: prevalence in 4-17 year olds increased 40% through diagnosis by primary doctors

– Clinical research for children & adolescents lags far behind adults; inadequate numbers of trained professionals for size of population at risk

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Barriers to Care (3)

• Older Adults- 25% with significant psychiatric disorders– Diagnosis & treatment difficult due to other

conditions– Complications from drugs to treat medical

conditions– Fear of stigma– Stereotypes about aging

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The Organization of Psychiatric and Behavioral Health Services

Four major delivery system Sectors:1. Psychiatric and behavioral health 2. Primary care 3. Human services 4. Voluntary support network

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Psychiatric and Behavioral Health Sector (1)

• Behavioral health professionals, e.g. psychiatrists, psychologists, psychiatric nurses, psychiatric social workers, behavioral health clinicians; also “peer specialists”– Provide majority of outpatient care in private or

public clinics; acute care in designated in-patient hospital beds in community and public hospitals; residential treatment centers for children and adolescents

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Psychiatric and Behavioral Health Sector (2)

– Multi-service facilities provide or coordinate a range of outpatient, intensive case management , partial hospitalization, or inpatient services.

– Increased focus on independent living accommodations in apartments with case managers to assist with daily living skills

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Primary Care Sector

• Health care professionals, e.g. private practice internal medicine, family practice doctors, nurse practitioners, pediatricians, clinics, hospitals, nursing homes– Often the initial and only point of contact for

mental health services– Rates of mental illness diagnosis in primary care in

past decade: doubled for children and increased almost 30% for adults

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Human Services Sector (1)

• Staff of social services agencies, school-based counseling services, residential rehab services, vocational rehab services, criminal justice/prison-based services, religious professional counselors– 2008 recession reduced state funding & increased

barriers to care from this sector with loss of support for housing, medical care and medications

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Human Services Sector (2)

– Increased homelessness; lost medication support led to recurrence of symptoms among those previously stable – Increased petty crimes and incarcerations in

prison system ill-equipped for treatment, with very high costs

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Volunteer Support Network Sector

• Self-help groups, family advocacy groups– Powerful in shifting public attention to people

with persistent and severe mental illness– Major impacts on Congress and funding

appropriations for research on mental illness and substance abuse through the NIMH

– State legislature lobbying against cuts in service programs and general assistance for mentally ill

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Paradigm Shifts (1)

• Since 2008, shifts toward turning the mental health system into a more integrated, effective care system

• Recovery Oriented Systems of Care (ROSC)– Initiated by Bush’s “Freedom Commission on

Mental Health.” 2004 National Consensus Conference cited “recovery” as most important goal for transforming mental illness care in America.

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Paradigm Shifts (2)

• Recovery Oriented Systems of Care, cont’d– Focus on choice, consumer strength-based

empowerment, establishing hope for a better life to guide treatment planning; goal to empower with choices and vision for hopeful future; link consumers’ strengths with family, community resources.

• Patient Protection and Affordable Care Act (ACA)– Provides psychiatric benefits with parity

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Paradigm Shifts (3)

• Patient Protection and Affordable Care Act, cont’d– ACOs’ care continuum will benefit mental health

service recipients with coordination of services through primary care and with multiple providers

• Integration of Primary Care and Behavioral Health Services– ACA provisions on parity support service

integration;

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Paradigm Shifts (4)

• Integration of Primary Care and Behavioral Health Services– ACA provisions on parity support service

integration, diffusing prior issues with behavioral health professional reimbursement for primary care services

– PCMH puts behavioral health practitioners on the “team” of providers eligible for reimbursement

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Financing Psychiatric and Behavioral Health Services (1)

• Funding sources: private health insurance, Medicaid, Medicare, state and county funding, contracts and grants– “Non-parity” existed for many years, denying the

chronic nature of mental illness compared with medical conditions; dates to 1950s

– Parity: requirements that insurers cover mental health at the same levels as general medical care

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Financing Psychiatric and Behavioral Health Services (2)

• Mental Health Parity Act, 1996:– Equated aggregate lifetime limits, annual limits

with general medical care– Allowed cost-shifting loopholes: e.g., limits on

psychiatric inpatient days, prescription drugs, raising co-insurance & deductibles; did not require employers to offer mental health coverage or coverage for substance abuse disorders

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Financing Psychiatric and Behavioral Health Services (3)

• Mental Health Parity and Addiction Equity Act, 2008 (built upon 1996 Act)– End health insurance benefit inequity between

mental health/substance abuse plans and medical/surgical plans

– Equal coverage applicable to all deductibles, copayments, coinsurance and out-of-pocket expenses and all treatment limitations

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Financing Psychiatric and Behavioral Health Services (4)

• Mental Health Parity and Addiction Equity Act, 2008 (built upon 1996 Act), cont’d– Parity for annual & lifetime dollar limits– Broad definition of mental health & substance

abuse benefits– MH coverage not mandated, but if offered must

be equal with medical coverage– Out-of-network coverage must be equal– Preserves existing state parity laws

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Financing Psychiatric and Behavioral Health Services (5)

Public Funding of Mental Health Care• Recession effects on State budgets: unemployment,

financial markets impact• Kaiser 50-state study:– Sharp Medicaid outlay increases due to recession,

declines in employment – American Recovery and Reinvestment Act

assistance insufficient to stem state crises

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Financing Psychiatric and Behavioral Health Services (6)

Public Funding of Mental Health Care, cont’d• Rockefeller Institute Study of Gap scenarios after

federal stimulus:– “Low gap”: $ 70 B shortfall: 4% of expenses– “High gap”: $ 100 B shortfall: 7% of expenses

• States are reducing psychiatric hospital & behavioral health services funding in response to budget shortfalls

• Negative effects likely for 2-4 years post-recession

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Financing Psychiatric and Behavioral Health Services (7)

• The ACA is a “game-changer”– $100 B appropriation over 10 years & $100 B

discretionary funds will extend insured health services to millions of mentally ill persons

– ACA health insurance exchanges and Medicaid expansion will open care access to many mentally ill adult, child and adolescent persons

– Use of “non-quantitative treatment limitations” by insurers to curtail benefits must be monitored and addressed

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Financing Psychiatric and Behavioral Health Services (8)

• Cost Containment Mechanisms– Managed care systems (public and private) tightly

control & monitor services for mentally ill; use subcontractors, “Managed Behavioral Healthcare Organizations” (MBHOs) to manage behavioral health patients through “carve-outs;” research indicates that MBHOs successfully facilitate service access and coordinate care for patients in need.

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The Future of Psychiatric and Behavioral Health Services

• Shift to a “Recovery Model” provides for a strength-based system with client-directed goals paramount

• Move toward psychiatric care more integrated with primary care

• ACA will assure Americans of access to services and bring disenfranchised mentally ill persons into the “system.”