Changing Patterns of Mental Health Care

1
Changing Patterns of Mental Health Care
David Mechanic, Ph.D. Institute for Health,
Health Care Policy and Aging Research Rutgers,
the State University of New Jersey Prague, May
21, 2007
2
The Aspiration
To achieve the promise of community living
for everyone, new service delivery patterns
and incentives must ensure that every
American has easy and continuous access to the
most current treatments and best support
services. The Presidents New Freedom Commission
on Mental Health July, 2003
3
More Progress Than Generally Perceived

• Improved medications and more evidence-based
• treatments
• Broader insurance coverage for behavioral
  health
• Enormous growth in mental health personnel
• Increased public support for mental health
  services
• More people seek care although most with DSM
• disorders do not
• Care available in less restrictive settings
• Comorbid disorders now a major focus of concern
• Improved models of community care and
• evidence-based practice but too rarely
  implemented

4
Mental Health Care Episodes in Mental Health
Organizations
Millions
Source Center for Mental Health Services
5
Clinically Trained Mental Health Personnel By
Year (Rough Estimates)
Psychiatry 29,000 36,000 40,000
--- (40-45,000
est) Psychology 45,000 56,000 73,000
77,000 88,000 est Social
Work --- 86,000 93,000
96,000 Psychiatric Nursing 10,000
15,000 18,000 25,000
est Counseling 61,000
108,000 Marriage and Family Therapy
45,000 Psycho-social rehabilitation 21,000
35,000 100,000 School
Psychology 24,000
26,000 31,000 FTEs in
Mental Health Org (Patient Care) 347,000 (1986)
371,000 532,000
427,000 1982-84 1989-94
1996-98 1999-2000 2004-2006

6
A Majority of U.S. Mental Health Expenditures
are Public
All Private 43
All Public 57
7
Financing Programs and IncentivesShape Patterns
of Services

• Insurance coverage and cost-sharing are
• major determinants of use
• Movement from demand-side controls to
• supply-side controls through managed care
• Mental health financing is now integrated
• into general health care financing through
• Medicaid and Medicare
• (mainstreaming of mental health)

8
Major Changes in Mental Health Care U.S.

• Most care provided in outpatient settings
• Inpatient care increasingly concentrated in
  specialized
• psychiatric, alcohol and chemical dependency
  units in
• general hospitals (with low LOS)
• Care for SMI financed through Medicaid,
  SSI/SSDI and
• other large federal programs
• The scope of mental health services increased
  to cover
• housing, psychosocial rehabilitation,
  supported employment
• Patient/family advocacy increasingly important
• Pharmaceuticals account for growing proportion
  of costs

9
Pharmaceutical Use and InfluencesIncreasingly
Dominate Mental Health Care

• Massive increases in prescriptions adults,
  children, elderly
• Prescriptions largest cost center in most state
  Medicaid
• programs
• Pharmaceuticals marketed aggressively
• Detailing to physicians
• Direct-to-Consumer advertising
• Encouraging new diagnoses and uses
• Funding professional education and consumer
• advocacy groups
• Pharmaceutical companies dominate clinical
  trials
• Withhold publication of negative results
• Bias scientific literature
• Selectively promote studies with positive
  results

10
Big Profits at Stake Profitability Among
Pharmaceutical Manufacturers Compared to Other
Industries, 1995 - 2004
Source Kaiser Family Foundation and Sonderegger
Research Center, Prescription Drug Trends A
Chartbook Update, November 2001, Exhibit 4.11
11
Outpatient Treatment for Depression, United
States, 1987 and 1997
1987 1997 Rate for 100 persons 0.73
2.33 Treatment Characteristics of Persons Treated
for Depression Pharmacotherapy
47 79 Anti-depressants 37 75
SSRIs 0 58 Other 37 28
Benzodiazepines 16 10 Psychotherapy
71 60 mean of visits 13
9 Psychotherapy and Antidepressants
23 45
12
Proportion of National Expenditureson
Pharmaceuticals Vary GreatlyExpenditures on
Pharmaceuticals as a Percentage of Total
Expenditure on Health (1997)

Note Data is for 1997, except for Norway,
Ireland, Australia, Luxembourg, Japan, Greece,
Hungary (1996) Source OECD Health
Data 1999 Adapted OECD, 2002
10
13
Many (Most) with Mental DisordersDo Not Receive
Tx

• Mood and anxiety disorders are common and
  often
• disabling
• These disorders are commonly not reported or
  recognized
• in primary care
• When recognized, often not treated or treated
  with
• inappropriate medications
• When treated with correct medications, often
  doses
• sub-optimal
• Most care fails to meet adequate standards
• Drug adherence is poor

14
All Systems Depend on Primary Medical CareAs A
Major Source of Mental Health Services

• Major efforts for improvement made over
  several decades
• High dependence on prescription medication
• Focus on depression and anxiety disorders
• Care is generally suboptimal
• Barriers to effective primary care treatment
  include
• patient and clinical factors

15
Adequacy of Treatment Among Persons with
12-Month Major Depressive Disorder - United
States National Comorbidity Survey Replication
(2001-2002)
Adapted from Kessler, et al. JAMA, 2003.
16
Patient Factors

• Ignorance about disorders and their treatment
• Stigmatization of entities associated with
• mental illness
• Reluctance to report psychological symptoms
• or seek care for such symptoms
• Inadequate insurance coverage or high rates
• of cost sharing

17
Lifetime DSM III Disorders in ECA (1980-1984) And
Probability of at Least One Visit With A Mental
Health Professional
with Lifetime with
Disorder Disorder and At Least One
Visit Education Grammar school and less
47 11 Some high school 39 20 High
school graduate 31 25 Some
college 31 35 College graduate
29 43 Race Non-white 43
17 White 33 27 Income lt 10,000
41 21 10 14,999 35 23 15
19,999 33 25 20 24,999 33
31 25 34,999 31 30 35,000
29 37
Howard et al., Archives of General Psychiatry,
53(8) 696-703, 1996
18
Receipt of Any Treatment For A Mental Health
Problem among Persons with Serious Mental
Illness (National Comorbidity Study, 1990-1992)
with Any Treatment Education
0 11 35 12 39 13 15
30 16 57 Income Lowest
30 Low 43 Medium 34 High
41 Highest 48 Race Non-Hispanic
Black 39 Hispanic 26 Non-Hispanic
White 43
Wang, Demler and Kessler, American Journal of
Public Health, 92(1) 92-98, 2002
19
Clinician Factors

• Ignorance of and lack of interest in
  psychiatric
• issues
• Time pressures in primary care
• Lack of incentives or rewards for good
• management and treatment
• Fear of alienating patients because of stigma
• Patients with psychiatric morbidity commonly
• seen as blockers in maintaining practice
  pace

20
Major Challenges in Providing Care to Persons
with Severe/Persistent Mental Illness

• Insuring access to care
• Providing and coordinating the essential
  elements
• of care
• Maintaining stable and appropriate housing
• Monitoring and assuring quality and
  accountability
• Community integration and the reduction of
  stigma
• Avoiding criminalization
• Managing difficult/resistant clients
• Substance abuse comorbidity
• Poor treatment adherence

21
Good Treatment for the SMI isMore Than
PharmaceuticalsDimensions of a Long-Term
Treatment Orientation

• Linkage to social and rehabilitative services
• Attention to stable housing
• Medication management
• Illness and medication education
• Family involvement
• Substance abuse treatment
• Psychosocial rehabilitation supported
  employment

22
Usual Care for Patients with Schizophrenia Compare
d to Evidence-Based Standards
Evidence-Based Criteria Inpatient Care
Outpatient Care Antipsychotic
medication for acute symptoms
89 --- Antipsychotic dose in appropriate
range 62 --- Antipsychotic
medication maintenance care
--- 92 Antipsychotic dose in appropriate
range --- 29 Anti-Parkinson
medication for side effects
54 46 Antidepressants for depressed
patients 32 46 Psychotherap
y/counseling 97 45 Family
education/support 32 10 Vocational
rehabilitation 30 23 Adapted
from Lehman (1999) Results from Schizophrenia
Patient Outcomes Research Team Client Study
23
Goal

To develop payment structures that encourage
thoughtful cost-effective high quality care
without providing incentives for either over or
under utilization.
24
227 Million People in BHMCOs
Organizations with the Largest Behavioral Health
and Employee Assistance Programs Enrollment,
2002-2003
Source Open Mind Survey - 2002/03 (http//www.ope
nminds.com/pressroom/mbhoymrbook02.htm)
25
Mental Health / Substance Abuse Number of
Hospital Days per 1000 Employees - 1987 to
1994 Xerox Corporation
Before Utilization Review
After Utilization Review
Days of Care
26
Mental Health / Substance Abuse Average Length of
Stay per Admission - 1987 to 1994 Xerox
Corporation
After Utilization Review
Length of Stay
Before Utilization Review
27
Average Length of Stay in General Hospitals by
Hospital Ownership
28
MBHCOs Strategies for Managing Care
1994 Indemnity 1995 MBHO Referrals
Referrals 85 Psychiatrists 11
10 Psychologists 33 5 Social
Workers 56 Reimbursements Average
Reimbursements 150 Psychiatric visit 90
100 Psychologist visit 75
85 Social work visit 65
Chart created by Clarke Ross, Mental Health, US,
2000
29
Future Challenges toPublic Mental Health Care

• Maintaining commitment to MH services within
  overall
• health expenditures (MH expenditures falling
  as a
• proportion of all health expenditures)
• MH/SA services more tightly managed than other
• medical services
• MC inadequately differentiates among level of
  severity
• and need
• Insufficient evidence-based appropriate
  treatment
• Inadequate monitoring and evaluation

30
State Medicaid Challenges

• Defining the appropriate network of services
• Setting a fair (realistic) capitation level
• (with risk adjustment)
• Establishing norms for access, evidence-
• based tx, intensity of care, patient
  satisfaction, etc.
• Insuring the data that allow monitoring
• performance
• Limiting risk selection and cost-shifting
• Defining risk arrangements