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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 • • • • • 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 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 Amalgamation/hybrid of public and private sector providers in variety of sites, e.g. hospitals, clinics, pvt offices, ER’s, prisons, shelters, residential programs 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) • • • • 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 Acute – – – – – – Private office or clinic ER Psychiatric unit of a general hospital Psychiatric hospital General Hospital scatter beds Acute partial programs Long Term – – – – – – 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 – – – – – 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 Increasing enrollment MH and SA merged into Managed Behavioral Health Organization (MBHO) mostly private (except Philadelphia=CBH) – Formulary & laboratory with medical MCO 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 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)* – – – – 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 l