Treatment Perspectives:

Cost and Quality

Alexander S. Young, M.D., M.S.H.S.

VA VISN 22 Mental Illness, Research, Education, and Clinical Center (MIRECC)

UCLA Research Center on Managed Care for Psychiatric Disorders

Healthcare in the U.S.:Cost

Treatment costs– 14% of GNP (up from 7% in 1970)

» highest per-capita spending in the world

– $1,000,000,000,000 per year» half of corporate pre-tax profits

– 2.5% for treatment of schizophrenia

Healthcare in the U.S.:Quality

Health status outcomes (of 13 nations)– infant mortality: 13th

– life expectancy: 10th at 40 years, 7th at 65 years

– overall: 12th

Potential explanations– many with no insurance (> 40 million)

– expensive treatments with minimal effectiveness

Depression & Anxiety

Major Depression, Dysthymia Generalized Anxiety Disorder, Panic

Disorder Effective Treatments

– medications: antidepressant and antianxiety

– psychotherapy

Depression & Anxiety: Two Thirds Receive No Effective Care

Depressive or Anxiety Disorder (n=1641) %

Effective medication 21

Effective counseling 18

Either effective antidepressant or effective counseling 31

RACE AGE

% with no effective medication or counseling

63%

81%76% 79%

69%62%62%

67%

White Black Hispanic 20 30 40 50 60 70

76%

Older, Younger, and Minorities Receive Worse Care

Schizophrenia

Effective Treatments– antipsychotic medications

– PACT

– family/caregiver involvement

– vocational rehabilitation

Stigma and disadvantage

Schizophrenia: Quality Problems Are Severe and Differ By

Organization

Medication Management

Severe symptoms or side effects

Poor quality medication management

CMHC VA

43%

31%

55%

44%

SPMI: Key Quality Problems 50 – 70% receive no treatment

– incarceration

Mortality and morbidity Treatment organizations

– substantial cost

– consumers with little power over service provision

– medication management: > 1/3 with poor care

– family/caregiver involvement, PACT, vocational rehabilitation: usually not provided

Methods for Improving Care Improve policy

– how can we change policy so that it supports effective, efficient care for serious mental illness?

Managed care Reduce system fragmentation

– RWJF experiment

Monitor performance– NCQA: HEDIS

– VA: report card

Methods for Improving Care (cont.)

Improve clinicians’ competencies Implement disease management

– change division of labor and responsibilities

– increase focus on clients’ needs

Really empower consumers– self-help and peer support

– recovery model

Panel Steve Segal, Ph.D.

– School of Social Welfare, UC Berkeley

Barbara Havassy, Ph.D.– Department of Psychiatry, UCSF

Judge Harold E. Shabo– Los Angeles Superior Court

Dave Hosseini– Sacramento Consumer Self-Help Centers and

Office of Patients' Rights

References

– Starfield B: Is US health really the best in the world? JAMA. 2000; 284: 483-5.

– Young AS, Sullivan G, Burnam MA, Brook RH: Measuring the quality of outpatient treatment for schizophrenia. Archives of General Psychiatry. 1998; 55: 611-7.

– Young AS, Forquer SL, Tran A, Starzynski M, Shatkin J: Identifying clinical competencies that support rehabilitation and empowerment in individuals with severe mental illness. Journal of Behavioral Health Services & Research. 2000; 27: 321-333.

– Young AS, Klap R, Sherbourne CD, Wells KB: The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry. 2001; 58: 55-61.

For further information

– Alexander S. Young, MD, MSHS

– VISN 22 MIRECC, West Los Angeles Veterans Healthcare Center & UCLA, 11301 Wilshire Blvd. (210A), Los Angeles CA 90073; phone: (310) 478-3711 x42460