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Change does not come quickly or easily to mental health policy. One is reminded of that by the number of findings and recommendations in the New Freedom Commission's report that resemble those with which we were bedeviled in the past and unfortunately still are. Full parity of mental health benefits is but one example—long wished for and sought after but elusive. In fact, one might wish that the report emphasized the need for parity more strongly. Full parity continues to languish in a purgatory between enactment and oblivion.
The work of managed behavioral health organizations would be significantly enhanced by more comprehensive benefits, as would the mental health services available to the patient population about which the Commission is most concerned. With parity, the task of trying to find that combination of services that works best to meet the needs of adults with serious mental disorders and children with serious emotional disturbances would be easier and more productive. Benefit limitations—essentially a form of rationing—are particularly onerous in the treatment of people with such disorders. These individuals have problems that too often transcend the benefits and therefore the magnitude of the services available to them. Arbitrary benefit limits do not help anyone—payers, providers, patients, or care managers.
The Commission's report is a strong reminder of the need for supportive sheltered living arrangements for people who have serious mental illnesses. We learned many years ago in the community mental health center movement that getting people out of institutions is easier than keeping them out, and if they are to be kept out, they need to be provided with the services and supports necessary for a decent life. The paucity of supportive low-cost housing, which was exacerbated by the housing policies of the Reagan Administration, has been a serious problem for a long time. To those of us in managed behavioral health care, it is apparent that the lack of such housing is a significant contributor to the rehospitalization of people who could otherwise be maintained in the community. It is bad treatment and bad economics.
Failure to adhere to a medication regimen is a major factor in rehospitalization and is much more likely when the living environment outside the hospital does not reinforce the need to do so. In the important area of housing, I am afraid that the Commission's recommendations fall short of what is needed. Nowhere in the report is the Commission's lack of freedom to recommend anything that would cost money more evident. In this context, the term "New Freedom" in the Commission's name is ironic.
Where will the "150,000 units of permanent supportive housing" that the report recommends come from? No amount of "collaboration" or "transformation" or reduced "fragmentation" (popular words in the report) or, for that matter, "enhanced access" to something that does not exist will produce more low-cost supportive housing. There is no doubt that the Commissioners understand this, and there is also no doubt that more housing for people who are seriously mentally ill will cost money—a lot of it. But the report does not say so, nor does it recommend allocating any additional funds for the 150,000 needed housing units. Without adequate housing, how likely is it that one of the report's important recommendations—to "end unnecessary institutionalizations"—will be accomplished?
Quite correctly in my judgment, the Commission points to the need for a larger and more competent mental health workforce "to address the severe shortage of practitioners." But the report does not sufficiently differentiate between the mental health disciplines. In some parts of the country, particularly the rural areas, there continues to be a shortage of all mental health professionals. However, our experience in managed behavioral health care clearly demonstrates that in terms of the shortage of mental health professionals, the shortage of psychiatrists is by far the biggest problem.
A report by the American Psychiatric Institute for Research and Education presented at the 2003 annual meeting of the American Psychiatric Association and cited in Psychiatric News (1) states that "Psychiatrists are aging, increasingly in short supply, and spending less time per week with each patient." Prompt access to a psychiatrist for patients with major depression, who need at least a medication evaluation, is increasingly difficult. And there does not appear to be anything on the horizon that is likely to help with this problem. Evidence-based practice suggests that people with major depression need psychoactive drugs and psychotherapy, but their access to psychiatrists is much too limited, and their access to psychiatrists who are willing—and trained—to provide both medication and psychotherapy is even more so. Access to primary care practitioners who are qualified to prescribe psychoactive drugs is also very limited, particularly for persons whose care is covered by Medicaid or Medicare. One wishes that the Commission's findings and recommendations had been more directed at this issue.
Easy access and early detection and intervention are key to effective mental health treatment and are strongly endorsed by the Commission. These values are and certainly should be entirely compatible with the principles and practices of managed behavioral health organizations. Our experience at United Behavioral Health is that prevention works and that identifying and treating mental health problems early leads to better care at lower costs.
I found myself wishing that the report more fully addressed social policy and economic problems that are major factors in causing or exacerbating mental disorders. Suicide is one example. As the report suggests, public education to change people's attitudes about suicide is useful and should be supported. What the report does not mention is the availability of guns in this country and the frequency with which guns are used in completed suicides. Gun control can be an effective approach to suicide prevention.
With regard to the effects of economic conditions, we have long known from Brenner's (2) work "that even minor recessions were the single most important factor in increased rates of admissions to State mental hospitals and, conversely, that economic upturn slowed admissions." In our experience at United Behavioral Health, the economic malaise over the past few years has resulted in a significant increase in the number of our members who seek help for problems exacerbated by economic and work-related issues.
The Commission quite correctly reaffirms the disparity pointed out in the Surgeon General's report (3) between what is known through research about treatments that work best and what in fact is done in practice. At United Behavioral Health, our daily and extensive interactions with mental health clinicians across the country support such findings. It sometimes seems as if one needs a geologic time perspective to see much progress toward more extensive use of evidence-based practices. A few years ago, I characterized this gap between research and practice in an article in Health Affairs titled "Strangers in the Night" (4). The Commission's recommendation to "change reimbursement policies" as a way to enhance the adoption of evidence-based practices is an important one that is as yet unfulfilled. Managed behavioral health organizations can and should play a leading role in this area. Economic incentives to bring about such behavioral change among mental health clinicians is a promising approach.
The Commission's strong and often reiterated support for a much greater role for the states in bringing about substantial improvements in mental health services across America causes me some concern. The report recommends greater flexibility for the states, in effect positioning them as the dominant if not superordinate authority over the organization and administration of mental health services. As a former federal government mental health official, I have experienced firsthand, along with many others, the major differences in expertise, ideology, and values between state mental health systems. For a managed behavioral health organization with programs and members across the country, significant differences between states in regulatory requirements, policies and procedures, and the like are a source of confusion and complexity with no apparent benefit. A number of the national corporations with which we work are of a similar mind. Development of greater uniformity between the states and higher standards in states where they are needed is an important and necessary endeavor.
Bringing about major policy changes in mental health services is no small task. Nonetheless, changes in funding and in the structures through which mental health services are provided, such as Medicaid, child guidance centers, and community mental health centers, have taken place. The appointment of a commission as a vehicle to help in the change process is not without precedent. But it seems to me that what is unprecedented, unfortunately, are the formidable restrictions that were placed on this Commission: it had only one year to complete its very difficult task, and it was unable to propose new spending. One wonders what the Commission's report would have been like without such restrictions.
Dr. Feldman is chief executive officer of United Behavioral Health, 425 Market Street, 27th Floor, San Francisco, California 95105 (e-mail, firstname.lastname@example.org). This paper is part of a special section on the New Freedom Commission's report.
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