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Chapter 10

Mental Health Services

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:

Psychiatric and behavioral health

Primary care

Human services

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.”

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