Treatment Perspectives: Cost and Quality

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Treatment PerspectivesCost 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

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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

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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 (gt 40 million)
• expensive treatments with minimal effectiveness

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Depression Anxiety

• Major Depression, Dysthymia
• Generalized Anxiety Disorder, Panic Disorder
• Effective Treatments
• medications antidepressant and antianxiety
• psychotherapy

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Depression Anxiety Two Thirds Receive No
Effective Care
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Older, Younger, and Minorities Receive Worse Care
81
79
76
76
67
69
62
63
62
White Black Hispanic 20
30 40 50 60 70
RACE AGE with no
effective medication or counseling
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Schizophrenia

• Effective Treatments
• antipsychotic medications
• PACT
• family/caregiver involvement
• vocational rehabilitation
• Stigma and disadvantage

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Schizophrenia Quality Problems Are Severe and
Differ By Organization
55
44
43
31
CMHC
VA
Medication Management
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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 gt 1/3 with poor care
• family/caregiver involvement, PACT, vocational
  rehabilitation usually not provided

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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

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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

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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

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• 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