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News and Notes   |    
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.9.1078
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In 2002 approximately 33 million persons aged 18 years or older—just over 15 percent of the U.S. adult population—had a serious mental illness or a substance use disorder. Of these, 40 percent (13 million) had a serious mental illness only and 47 percent (16 million) had a substance use disorder only. More than 12 percent, or four million, had dual diagnoses, according to a report released by the Substance Abuse and Mental Health Services Administration (SAMHSA). Nearly one in four adults with serious mental illness (23.2 percent) also had a substance use disorder. One in five adults with a substance use disorder (20.4 percent) had a serious mental illness.

For the report, serious mental illness was defined as a past-year mental, behavioral, or emotional disorder that met DSM-IV criteria and that resulted in "serious impairment"—a Global Assessment of Functioning score of less than 60. Substance use disorder was defined as dependence on or abuse of alcohol or illicit drugs. The report is based on data from the 2002 National Survey on Drug Use and Health (NSDUH), formerly known as the National Household Survey on Drug Abuse. Between January and December 2002 a total of 44,467 interviews were completed with a representative sample of persons aged 18 years or older. NSDUH obtains information from residents of households and noninstitutional group quarters (shelters, rooming houses, and dormitories) and civilians living on military bases. Together these groups make up 98 percent of the U.S. population over the age of 12.

The rate of serious mental illness among adults who did not have a substance use disorder was relatively low—7 percent. The rate was much higher among those with an alcohol use disorder (19 percent), even higher among those with a drug use disorder (29 percent), and highest among adults who met criteria for both drug and alcohol use disorders (30 percent).

Persons with only serious mental illness were about nine times as likely as those with only a substance use disorder to receive treatment, according to the report. In 2002, of the 17.5 million adults with only serious mental illness, an estimated 8.4 million, or 48 percent, received treatment in the previous year. Of the 16 million adults with a substance use disorder only, 886,000, or 5.6 percent, received substance abuse treatment of any type, and even fewer—525,000, or 3.3 percent—received specialty substance abuse treatment.

Mental health treatment was defined as receipt of inpatient or outpatient care or a prescription medication for problems with emotions, nerves, or mental health, excluding treatment for substance use. Substance abuse treatment was defined as treatment to reduce or stop use or for medical problems associated with use received at any location. Specialty substance use treatment is treatment received at a hospital, a rehabilitation facility (inpatient or outpatient), or a mental health center.

When the report was released, SAMHSA Administrator Charles Curie said, "The time has come to ensure that all Americans who experience co-occurring mental and substance use disorders have an opportunity for treatment and recovery. Clearly our systems of services must continue to evolve to reflect the growing evidence base that promotes integrated treatment and supportive services. Both disorders must be addressed as primary illnesses and treated as such."

However, the report found that only 13.5 percent of those with co-occurring disorders—548,000 people—had received both types of treatment in the past year. More than half of those with co-occurring disorders—52 percent, or about 2 million people—received neither mental health nor substance abuse treatment.

Serious Mental Illness and Its Co-occurrence With Substance Use Disorders is available at www.oas.samhsa.gov.

The complexity of the 678-page Medicare Prescription Drug, Improvement, and Modernization Act of 2003—especially the Part D prescription drug program—will require a massive outreach and education effort to 41 million Medicare beneficiaries to help them choose prudently among many options when the Part D program is implemented in 2006. A new report from the Kaiser Family Foundation points out that the task will fall largely to the State Health Insurance Assistance Programs and state Medicaid programs and that the funding earmarked for this purpose in 2005 falls far short of what is needed to adequately inform beneficiaries, of whom four million have Alzheimer's disease and 12 million have less than a high school education. The 36-page Kaiser report identifies other areas in which consumer protections in the legislation are absent or weak, such as marketing, enrollment, and cost sharing.

The Kaiser report notes that beneficiaries will be required to take a more active role in making health care decisions. The report outlines the standard Part D benefit package as follows: in 2006 enrollees will be required to pay an estimated monthly premium of $35, a $250 deductible, 25 percent of the cost of drugs up to an initial limit of $2,250, and all of the costs of covered drugs between $2,251 and $5,100 (referred to as the "donut hole"). Once this catastrophic limit has been reached, drugs will be covered at an amount of $2 for generic drugs and $5 for other drugs or at a coinsurance rate of 5 percent, whichever is greater. These details and the program's on-off-and-on-again structure will be hard for many beneficiaries to comprehend, notes the report.

Under the Part D program, beneficiaries will obtain drug benefits either through new stand-alone prescription drug plans (PDPs) or through private insurers called Medicare Advantage-Prescription Drug (MA-PD) organizations, previously called Medicare+Choice (M+C) plans. The legislation envisions a marketplace in which PDPs and MA-PDs compete to enroll beneficiaries. Higher Medicare payment rates will create an attractive new market for insurers, pharmacy benefit management entities, and large drugstore chains, according to the report. Medicare beneficiaries will be inundated with mailings and media advertising, which will require strict enforcement of marketing regulations.

The report describes documented problems with Medicare's past oversight of M+C marketing materials and with the sales practices of these private plans, including use of materials with misleading information and enrollment of mentally confused persons. Many PDPs have no experience of direct marketing. Marketing problems have already been found in the transitional Medicare-sponsored drug discount card program that began in June 2004, according to the report. The Office of the Inspector General of the Department of Health and Human Services (HHS) has found that proposals by card sponsors to pay pharmacists for enrolling beneficiaries are probably in violation of the federal anti-kickback statute.

Although the legislation prohibits door-to-door marketing and discriminatory practices in Part D, the Kaiser report calls for additional protections, such as required training for marketing agents and a ban on cold calling. The report also points out that for the first time in Medicare's history, the HHS Secretary is permitted to waive privacy protections to "facilitate efficient marketing" and promote enrollment.

The Kaiser report outlines concerns in the area of enrollment, in particular a late enrollment penalty and a mechanism that locks in beneficiaries to their chosen plan for nine months even if their medication needs change or their plan raises prices or drops their medications from its formulary. Although Part D is a voluntary program, beneficiaries who do not have comparable drug coverage and who do not sign up initially are penalized with higher monthly premiums if they enroll at a later date. The penalty is designed to encourage healthy beneficiaries to enroll when they first become eligible. However, the penalty may disproportionately affect those who have cognitive impairments or low incomes or who are not native English speakers. The report also notes that the nine-month lock-in provision, which begins in 2007, is a troubling change: beneficiaries enrolled in Medicare HMOs and other private Medicare plans have always had the freedom to change plans at any time. Although beneficiaries will be locked in to drug plans, the plans will not be locked in to offering a specific formulary or network of pharmacies.

An important measure of success will be the program's ability to control drug costs, the Kaiser report notes. However, large numbers of elderly and disabled beneficiaries may find the program too expensive. Annual increases in Part D premiums and other cost-sharing features are linked to increases in program costs, which are expected to grow at an annual rate of 9 percent—much faster than the 3 percent annual rate of growth of Social Security benefit payments for retirees.

The report describes the "donut hole" as an especially controversial feature of the legislation. Beneficiaries are required to pay the entire cost of drugs when their annual spending is between $2,251 and $5,100—a category that accounts for about 30 percent of Medicare beneficiaries with drug spending. Furthermore, the legislation specifically prohibits Part D enrollees from purchasing insurance, such as a Medigap policy, to pay for cost sharing. Employer retirement plans are also prohibited from paying retirees' drug costs. According to the report, the legislation is vague about the help beneficiaries can obtain—only the enrollee and "another person, such as a family member" can pay for drugs until the $5,100 catastrophic limit is reached. It is not clear whether churches and charitable organizations are regarded as "another person." In addition, the legislation prohibits state assistance programs from interfering with the Part D "tools for effective cost management." Currently, assistance programs in more than 30 states help elderly and disabled persons pay for drugs.

Consumer Protection Issues Raised by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 deals only briefly with the special concerns of "dual eligibles"—low-income elderly beneficiaries and persons with disabilities who are enrolled in both Medicare and Medicaid. In January 2006, the more than six million persons in this population will lose their Medicaid drug coverage and must enroll in Medicare Part D. The Kaiser Foundation has issued a separate 22-page report outlining concerns about the ability of the Part D program to meet the complex and varying needs of this population, which includes people with severe disabilities, such as severe mental illness and mental retardation, and those with chronic diseases, such as HIV-AIDS. The New Medicare Prescription Drug Law: Issues for Dual Eligibles With Disabilities and Serious Conditions addresses four questions: Will these beneficiaries be able to get the drugs they need? Will coverage be affordable? Will they receive adequate information to select an appropriate plan? Will Part D provide a workable appeals process?

Both reports are available on the Kaiser Family Foundation Web site at www.kff.org/medicare.

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