Download Mental Health (Care) Systems

Mental Health (Care) Systems
From the Lunatic Asylum to a “Modern” Mental Health System
Barbara A. Schindler, M.D.
Vice Dean, Educational and Academic Affairs
Professor of Psychiatry
Learning Objectives
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Be able to describe the components of the mental health delivery system
Explain how mental health costs are covered
Describe the overall burden of illness of mental disorders
Outline the barriers and limitations to obtaining comprehensive mental health
coverage
Describe the disparities between the scientific knowledge base of mental
illness/treatment and how mental health care is actually delivered
Costs of Mental Illness
Top Ten Causes of Disability Worldwide Include:
 Unipolar
Major Depression
 Bipolar Disorder
 Schizophrenia
 Obsessive Compulsive Disorder
Global Burden of Illness
Indirect & Direct Costs:
The Global Burden of Disease
Indirect Costs
 $17
Billion loss in US economy
 $63 Billion morbidity cost
 $12 Billion mortality
 $4 Billion incarceration costs
Direct Costs
 $943
Billion total direct treatment health care costs
 $99 Billion for mental disorders ($69 Billion), addictive
disorders ($13 Billion) and dementia ($18 Billion)
 7% total spending only when leading cause of disability
Delivery of Mental Health Services
Providers & Sites
Delivery Systems from a Historic Perspective
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Asylums (Colonial times)
– Otherwise jails, almshouses, workhouses
Moral Treatment* (early-mid 1800’s-Dorothea Dix, Horace Mann))
Mental Hygiene Movement (Post-Civil War) with collapse of public asylums (no
$’s & overcrowded)
State Care Acts (early 1900’s) States assume responsibility for care resulting in
growth of state hospital system
General Hospital Inpatient Units (post WWII)
Community Mental Health System (1960’s)
Deinstitutionalization with change in commitment laws (1970’s)
Medicare (SSD) and Medicaid (1965)
*Return of individual to “reason” using psychologically oriented therapy
Current Mental Health/ Illness System
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Amalgamation/hybrid of public and private sector providers in variety of sites, e.g. hospitals,
clinics, pvt offices, ER’s, prisons, shelters, residential programs
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No single guiding or organizing set of principles. What you can access depends a lot on what you
can afford.
– Fragmentation and gaps in care for children*
– Fragmentation and gaps in care for adults with serious mental illnesses*
– High unemployment and disability for people with serious mental illnesses*
– Lack of care for older adults with mental illnesses*
– Lack of national priority for mental health and suicide prevention*
*President’s New Freedom Commission on Mental Health (2002)
Patient Presentations
 Single
Episode
 Recurrent episodes
 Seriously and persistently ill (Schizophrenia, Bipolar, Major Depression,
Anxiety disorders, Alzheimer’s, Substance Abuse or Dual Dx)
 Responding to acute stressors/trauma
 Developmental disabilities
 Dementias/late onset brain failure
 Relationship problems
 Adaptation problems
Sectors of Care & Utilization by Sector
(15% Adults Use System in any given year)
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Specialty Mental Health Sector (5.5%)
Human Services Sector (5%)
General medical/primary care sector (5.5%)
Voluntary Support Network Sector (3%)
1) Specialty Mental Health Services Sector
 Psychiatrists
 Psychologists
(Prescribing controversy)
 Psychiatric Social Workers
 Psychiatric Nurses
 Settings: Offices, clinics, private or public hospitals,
CMHC’s, prisons, other agencies, schools
2) General Medical/Primary Care Sector
 Internists
 Family
Practice MD’s
 Pediatricians
 Consultation psychiatrists
 Social Workers
 Nurses
 PA’s
 Settings: Hospitals, offices, clinics, nursing homes, hospices, prisons
3) Human Services Sectors
 Social Welfare System
 Criminal Justice System
 Educational, Religious, Charitable services
 Settings: Shelters, prisons, boarding houses, churches,
schools
4) Volunteer Network
 Self-Help groups
– AA, NA, Reach for Recovery, Zipper Club, other medical Dx
groups
 Public
Awareness
 Fund Raising
 Lobbying for increased $$’s
 Examples; NAMI, NMHA, Bazelon Center for MH Law
Delivery Systems:
Public & Private
Sites of Care Based on Duration of Care
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Acute
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Private office or clinic
ER
Psychiatric unit of a general hospital
Psychiatric hospital
General Hospital scatter beds
Acute partial programs
Long Term
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State hospitals
Mental health clinics
Residential programs (nurse, case managers)
Boarding Houses (nurse, case managers)
Home
Nursing home
Utilization of Services
Adult Utilization of Mental Health Services
 28% US adult population has diagnosable mental or Substance abuse
disorder
 1/3 patients receive MH services
 Majority get no MH services
Child & Adolescent Utilization of Mental Health Services
 21% Child and Adolescent Population utilize MH Services
 9% in Health Care Sector
 17% in Human Service Sector, mostly schools
Financing Mental Health Services
Funds for Mental Health Programs
 State
and local government major payers thru Medicare &
Medicaid
 Additional federal initiatives
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CMHC Block Grants
Addiction Treatment Grants
Community Support Programs
PATH (homeless MI)
Comprehensive Mental Health Services for children and their
families
Source of Funding for Mental Health Services
Mental Health Payment Costs by Provider Type
Types of Accepted and Funded Treatment
 Psychosocial
– Psychotherapy: Cognitive/Behavioral, psychodynamic, supportive
– Group, individual, family, couples
 Psychopharmacologic
 Both
usually more effective than either separately
 Split Treatment: challenge of dual treators
Cost Control Efforts
 Hospital lengths of stays
 Increasing numbers of inpatient beds
 Emergence of managed care in non-psychiatric medical care and MH
carve outs for MH services, usually inadequate MH benefits.
 Formularies
Current Managed Mental Health System
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Increasing enrollment
MH and SA merged into Managed Behavioral Health Organization (MBHO)
mostly private (except Philadelphia=CBH)
– Formulary & laboratory with medical MCO
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Fewer MBHO’s with larger and larger contracts and increase financial difficulty
Both Medicare and Medicaid increasingly managed
Tight control of access
Higher co-payments in some plans
Quality And Management Efforts
 Credentialing
 Access
requirements
 Strong utilization review procedures
 Monitoring patient satisfaction
 System expected to maximize convenience for patients
 Wait time for appointment specified
 NCQA developing behavioral health standards
Changes in Spending for
Mental Health Services Over Past Decade
 Declined as a % of overall health care
 Increased amount by public rather than private payers
(from 49% to 53%)
 Outpatient prescription drugs grew by 9% (Usually covered
under general medical expenses and only 1/3 Rxed by
psychiatrists)
 Increased barriers to service: stigma & vulnerable
population
Parity
 Mental
Health Parity Act of 1996 - ineffective
 Mental Health coverage at same level as physical health for
lifetime and annually
 No limits on hospital stays and physician visits -same co-pays
and deductibles
 Employers circumvent the law by adding new benefit plan
restrictions on the number of outpatient visits or inpatient
days
 Ongoing conflict re: costs despite data
Caring Together Program
A Dual Dx Program for Women and Their Children
 Components
– Intake evaluation, Psychiatric evaluation and treatment, individual and group
addiction treatment, specialized groups (TREM, Life Skills)
 Staff: Psychiatrist, Social Worker, Addiction Counselors, Early Childhood
Development Specialist, Case Manager,
 Funding
– CODAAP (Philadelphia) from Federal Grant to State –Set aside $$’s for
women’s and children’s programs (2/3 budget)
– 1/3 budget from clinical income thru CBH
Major Trends in Mental Health Care Last 25 Years
 Explosion in scientific knowledge: brain and behavior; growth of
NIMH budget
 Increased range of effective treatments for most mental disorders
 An approach to organization and financing of mental health services
(MC carve outs, parity)
 Emergence of powerful consumer and family groups decreasing
stigma, increasing access and research
 Influence of pharmaceutical industry
Consumer Movement Books to Read
A
Mind that Found Itself- Clifford Beers (1908)
 I Never Promised You a Rose Garden- Hannah Green (1964)
 On Our Own- Judi Chamberlin (1978)
 Darkness Visible: A Memoir of Madness-William Styron (1990)
 A Brilliant Madness: Living with Manic Depressive Illness (1997)
 An Unquiet Mind-Kay Redfield Jamison (1997)
Challenges
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15-20% population uninsured for MH services
Lack of parity for MH services
Stigma
Barriers to access
Coordination of care for most seriously ill
Managing split between primary care and mental health treatment
Integrating treatment when psychotherapy and pharmacologic treatment split
Informed consent for clinical trials
Access to appropriate care e.g. MCO formulary restrictions
Non-compliance (side effects, cost, stigma)
Hopelessness associated with mood disorders
Take Home Messages
 Ideal mental health system does not yet exist
 Presidential
Goals (2002)*
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Understand that mental health is essential to overall health
Mental health is consumer & family driven
Disparities in mental health services are eliminated
Early mental health screening, assessment, and referral to services are
common practices
– Excellent mental health care is delivered and research is accelerated
– Technology is used to access mental health care and information
*http://www.mentalhealthcommission.gov/reports/FinalReport
Take Home Messages
 Leading
cause of disability/morbidity & mortality but significant
under funded when compared to other high profile illnesses, e.g.
CVD, cancer
 Split treatment increases costs to individual patients and society, but
saves insurers $$’s
 Sharp contrast between scientific knowledge base & ability to deliver
quality mental health care to all in need.
Mental Health
A Report of the Surgeon General
Executive Summary
DEPARTMENT OF HEALTH AND HUMAN SERVICES
U.S. Public Health Service
http://www.surgeongeneral.gov/library/mentalhealth/summary.htm
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