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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. Be able to describe the components of the mental health delivery system

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Mental Health (Care) Systems

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  1. 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

  2. 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

  3. Costs of Mental Illness

  4. Global Burden of Illness

  5. % Ischaemic heart disease 12.2 Cerebrovascular disease 9.7 Lower respiratory infections 7.1 COPD 5.1 Diarrhoeal diseases 3.7 HIV/AIDS 3.5 Tuberculosis 2.5 Trachea, bronchus, lung cancers 2.3 Road traffic accidents 2.2 Prematurity, low birth weight 2.0 % Lower respiratory infections 6.2 Diarrhoeal diseases 4.8 Depression 4.3 Ischaemic heart disease 4.1 HIV/AIDS 3.8 Cerebrovascular disease 3.1 Prematurity, low birth weight 2.9 Birth asphyxia, birth trauma 2.7 Road traffic accidents 2.7 Neonatal infections and other 2.7 Leading Causes of Mortality and Burden of DiseaseWorld, 2004 Mortality DALYs

  6. Ten leading causes of burden of disease, world, 2004 and 2030

  7. Leading causes of disease burden for women aged 15–44 years, high-income countries, and low- and middle-income countries, 2004

  8. Top Ten Causes of Disability Worldwide Include: • Unipolar Major Depression • Bipolar Disorder • Schizophrenia • Obsessive Compulsive Disorder ©2003-7 Barbara Schindler, MD DUCoM

  9. Indirect & Direct Costs: The Global Burden of Disease ©2003-7 Barbara Schindler, MD DUCoM

  10. Indirect Costs • $17 Billion loss in US economy • $63 Billion morbidity cost • $12 Billion mortality • $4 Billion incarceration costs ©2003-7 Barbara Schindler, MD DUCoM

  11. 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 ©2003-7 Barbara Schindler, MD DUCoM

  12. Delivery of Mental Health ServicesProviders & Sites ©2003-7 Barbara Schindler, MD DUCoM

  13. 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 ©2003-7 Barbara Schindler, MD DUCoM

  14. 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) ©2003-7 Barbara Schindler, MD DUCoM

  15. 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 ©2003-7 Barbara Schindler, MD DUCoM

  16. 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%) ©2003-7 Barbara Schindler, MD DUCoM

  17. 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 ©2003-7 Barbara Schindler, MD DUCoM

  18. 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 ©2003-7 Barbara Schindler, MD DUCoM

  19. 3) Human Services Sectors • Social Welfare System • Criminal Justice System • Educational, Religious, Charitable services • Settings: Shelters, prisons, boarding houses, churches, schools ©2003-7 Barbara Schindler, MD DUCoM

  20. 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 ©2003-7 Barbara Schindler, MD DUCoM

  21. Delivery Systems : Public & Private ©2003-7 Barbara Schindler, MD DUCoM

  22. 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 ©2003-7 Barbara Schindler, MD DUCoM

  23. Utilization of Services ©2003-7 Barbara Schindler, MD DUCoM

  24. 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 ©2003-7 Barbara Schindler, MD DUCoM

  25. 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 ©2003-7 Barbara Schindler, MD DUCoM

  26. Financing Mental Health Services ©2003-7 Barbara Schindler, MD DUCoM

  27. 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 ©2003-7 Barbara Schindler, MD DUCoM

  28. Source of Funding for Mental Health Services ©2003-7 Barbara Schindler, MD DUCoM

  29. Mental Health Payment Costs by Provider Type ©2003-7 Barbara Schindler, MD DUCoM

  30. 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 ©2003-7 Barbara Schindler, MD DUCoM

  31. 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 ©2003-7 Barbara Schindler, MD DUCoM

  32. 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 ©2003-7 Barbara Schindler, MD DUCoM

  33. 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 ©2003-7 Barbara Schindler, MD DUCoM

  34. 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 ©2003-7 Barbara Schindler, MD DUCoM

  35. Parity: New Federal Law 2008 Passed • Mental Health Parity and Addiction Equity Act of 2008. Effective date: Jan 1, 2010; regulations to be developed • Initial 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 with fewer than 50 employees and individual health policies exempt. • Costs issues persist despite data; premiums up 0.4% • 1999 Surgeon General: $70B direct business cost from lack of parity: lost productivity from absenteeism & sick leave, increase use of health services. ©2003-7 Barbara Schindler, MD DUCoM

  36. Caring Together ProgramA 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 DevelopmentSpecialist, 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

  37. 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 ©2003-7 Barbara Schindler, MD DUCoM

  38. 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)

  39. Challenges • 15-20% population uninsured for MH services • Lack of true parity for MH services (Law passed Oct 2008) • 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 ©2003-7 Barbara Schindler, MD DUCoM

  40. 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 ©2003-7 Barbara Schindler, MD DUCoM

  41. 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.

  42. WHO Mental Health Gap Action Program http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html

  43. Mental Health A Report of the Surgeon GeneralExecutive SummaryDEPARTMENT OF HEALTH AND HUMAN SERVICESU.S. Public Health Service http://www.surgeongeneral.gov/library/mentalhealth/summary.html ©2003-7 Barbara Schindler, MD DUCoM

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