Mental Health Care for Mothers

1. Sherry Glied, Ph.D. Department of Health Policy and Management Mailman School of Public Health Columbia University Mental Health Care for Mothers Thanks to Sarah Downs for her extraordinary help in preparing this presentation.

2. Outline • Overview of the problem • Harlem and Northern Manhattan • Trends in mental health care • Local challenges and developments • What can be done? • Ongoing Efforts in NYC • Policy advocacy • Innovative programs • Immediate responses

3. Women and Depression • 21% of women suffer from depression at some point in their lives • <40% seek care

4. Maternal Depression • Rates are higher – about 10% -- during pregnancy and in the postpartum period • Many cases begin before birth • Negative effects on women and on their children • Higher prevalence of depression among lower income women • Rates are similar by race and ethnicity

5. Recognition and Treatment of Maternal Depression • Simple and validated tools for maternal depression screening exist • Interventions – both Rx and psychotherapy – can successfully treat depression during pregnancy and the post-partum period • Variety of modalities for delivery of these services

6. Barriers to Access • passive stereotype • lack of information • cultural obstacles • depression itself • financial burdens • time burdens • child care • stigma • service availability

7. Financial Access: Health Insurance Coverage • 1.8 million New York City residents are uninsured • Problem is worse in Harlem: • Less likely to be insured • Less likely to have a primary care doctor • More likely to be experiencing psychological distress

8. Even for the Insured: Copayment Barriers

9. Managed Care Growth • General and specialized managed care • Carve-outs cover almost 80% of insured • Utilization management substantially decreased LOS by over 40% for MH • HMO paid for over 3X more visits for depressed women in 1996 than 1985

11. Mental Health in Managed Care • Receive care mainly from GPs • GPs may not be adept at diagnosis and treatment • Concerns over division between primary and specialty care • Utilization review

12. Additional Financing: Public Mental Health Systems • State funded – grants (+ insurance + Medicaid) • Community Mental Health Centers • OMH licensed outpatient clinics

13. Public Mental Health System: Population Served • The majority of NYC clients are Medicaid enrollees: • 71% of clients, ages 0-17 • 74% of adult clients, ages 18-64 • 71% of the NYC outpatient population are minority: • 27% Non-Hispanic Black • 37% Hispanic • 3% Asian • 5% Other/Multiracial

14. Trends: Improvement • Use • Financing • Quality

15. Treated Prevalence in Epidemiologic Studies

16. Changes in Recognition: Women with Depression • In 1987, 1.9% of women diagnosed with depression • In 1996, 6.1% diagnosed

17. Changes in Treatment: Women with Depression • Rate of diagnosis w/o prescription didn’t change from 1987 to 1996 • All additional diagnoses included prescription for a psychotropic • Pharmacotherapy • Psychotherapy

18. Trend: Changing Co-Payment Patterns – OOP Share

19. Quality of Care • Depression – adherence to guidelines up 15% since 1991 • Attention Deficit/Hyperactivity – care likely to be effective up from 18 to 50%, 1975 to 1997 • Schizophrenia – Care consistent with guidelines up from 22 to 42%, 1975 to 1997 • Anxiety, Bipolar, etc.

20. Summary: Mental Health Access • Absolute and % of OOP • Diagnosis rate • … but still below epidemiologic estimates • … but still above rates for physical health • … and total MH spending has decreased too • Quality • … but still well below desirable levels

21. Harlem/Northern Manhattan • Local challenges • Local developments: NYS Parity • Local opportunities

22. Local Challenges • Access to care • For those who do seek treatment, delays of up to 8 weeks reported between screening and access to a professional therapist

24. Policy Development: Timothy’s Law -- Parity in MH Coverage • Passed 12/22/06; Effective 1/1/07 • Requires all private insurers to cover 20 outpatient/30 inpatient visits - same as current Medicaid benefit • Requires that cost-sharing and other requirements be the same for mental health and other services

25. Will Parity Solve the Local Problem? • Private insurance only • Increased financial protection -- Decreased out-of-pocket spending for MH service users • Access to care – not greatly affected by parity itself • Parity + MBHO = increased service use among those with mild or moderate mental distress

26. Managed Care in NYC • Almost all insured NY’ers are enrolled in managed care • Mandatory for most Medicaid • Mandatory for FHP • Now also mandatory for SSI population • Plans pay providers directly at negotiated rates

27. Expanding the Specialist Provider Pool • Raise NYS Medicaid reimbursement for mental health treatment to encourage more providers • But doesn’t affect managed care contracts

28. How Much can Specialists Do? • 4000 births per year in Central and East Harlem •  About 400 women with need for services for depression • Unlikely to handle this many in specialty care

29. Public Mental Health System:Harlem & Northern Manhattan Facilities • Approximately 50 different OMH licensed outpatient programs are located in Harlem and Northern Manhattan • 10 of these programs limit their practice to children and adolescents • Only 10% of the treated outpatient population is female, ages 13-34.

30. Open New Public Programs: NYS Medicaid Neutrality • Can only use existing funds to open new facilities (e.g., must close an old facility to open a new one) • Only applies to mental health • Effectively blocks any new Article 31 (OMH-licensed) facilities • Questionable value

31. NYS Medicaid Neutrality: Fiscal Implications • Outdated policy • DOH can also license mental health providers (e.g., hospital outpatient clinics) • DOH payment rates are higher • The trend may also decrease quality of care, since the DOH mental health providers are not regulated by OMH, an agency with mental health expertise

32. NYS Medicaid Neutrality: Response • The NY assembly • Legislation was introduced by James Brennan in January 2005 but did not proceed beyond the Ways & Means Committee

33. Potential Significance for Depression in Mothers? • Important for most severe cases • Population is not a strategic priority • Not well integrated

34. What Else Can Be Done? • Expanding access through other providers • Current Programs in New York City • Innovative Programs • Immediate Responses

35. Train Alternate Providers • Most mental health professionals are not specifically trained to understand the unique aspects of depression in pregnant and post-partum women. • Need is great and immediate. • Stigma is a significant barrier to the use of specialized services.

36. Non-Specialized Providers can Treat Many in this Population

37. Ongoing Efforts NYC • NY DOHMH “Take Care NY” Campaign • TCNY #5: Get Help for Depression • To make depression screening and management standard practice in all primary care settings in New York City. • To increase the rate of New Yorkers in treatment for depression by 10% by 2008. • Development/promotion of PHQ-9 screening tool

38. Ongoing Efforts NYC • HHC includes depression screening tool in EMRs of Diabetes patients, to be expanded to other chronic conditions • Simultaneously PCPs are trained to treat mild and moderate depression so treatment closely follows screening • Private insurers and managed care organizations also commit PHQ-9 as standard screening tool

39. Innovations from other states:Illinois Medicaid Reimbursement • Implemented in December 2004 • Goal: improve children’s health by improving maternal mental health • Providers who use designated screening tools are reimbursed $14.50 for their efforts, whether while providing an adult service or at an child’s acute care or well-child visit. • Women must either be • A) Pregnant or post-partum Medicaid enrollees • B) Mothers of infants <1yr who are Medicaid eligible

40. Innovations from other states:Illinois Medicaid Reimbursement • Can bill mother’s Medicaid id or INFANT’s ID • Physicians were provided with extensive referral resources, including a statewide Perinatal Mental Health Consultation Service accessible via toll-free phone number

41. 80% of pediatricians rely on observation alone to detect depression. Only 8% ask mothers about depression symptoms These methods fail to detect half of mothers suffering from depression Dartmouth study evaluates feasibility of a 2-question screening tool during well-child visits Innovations from other states: Dartmouth screening efforts

42. Innovations from other states: Dartmouth screening efforts • Screening rates reached 70%. • 1/20 mothers screened positive for depression • 10% of encounters prompted physician action (referrals or further discussion) • <2% of encounters required conversations longer than 10 minutes

43. Innovations within NYS:Pay-for-Performance • New York State’s Medicaid incentive program offers financial and other incentives to Medicaid managed care programs that perform well on specific measures • Monthly premiums are increased by 0.25-1% for meeting certain goals • For the ‘03-’04 FY, state-wide payments totaled $7 million with some plans receiving bonuses of over $1 million

44. Innovations within NYS:Pay-for-Performance 2006 New York State Managed Care Plan Performance Report :http://www.health.state.ny.us/health_care/managed_care/qarrfull/qarr_2006/

45. Innovations within NYS:Pay-for-Performance • 2006 measures included management of anti-depressant medication, mental health inpatient utilization, follow-up after hospitalization for mental illness, drug treatment, etc.

46. Immediate Action • Most pregnant women and mothers with newborns are enrolled in or eligible for public insurance programs • Most public insurance programs employ managed care contracts

47. Getting Coverage • Many are already eligible for public programs (Medicaid or FamilyHealthPlus) • http://www.nyc.gov/html/hia/html/home/home.shtml

48. Enforcing Contract Obligations

49. Contract Obligations

50. How to Complain • Managed care plans certified by the Department of Health must have a process to receive and respond to complaints and grievances. • Community Services Society (CSS) is the lead agency for New York City Medicaid Managed Care Consumer Assistance Program (MCCAP) -- http://www.nycmccap.org/.