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News and Notes   |    
Psychiatric Services 2005; doi: 10.1176/appi.ps.56.11.1471
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The American Psychiatric Association and 15 other advocacy organizations are urging Congress not to act on several proposed cuts to the Medicaid budget that would have a serious impact on beneficiaries with severe mental illness. The reductions in spending were recommended by the bipartisan Medicaid Commission, which was created earlier this year to find ways to trim the Medicaid budget by $10 billion over the next five years.

Medicaid currently serves more than 50 million Americans. The overall Medicaid caseload has increased 40 percent over the past five years. The program accounts for an average of 22 percent of each state's budget and is the single largest expenditure item for states. The program pays for more than half of the care delivered through community mental health programs.

The 16 advocacy groups, partners in the Campaign for Mental Health Reform, sent a joint letter to the Senate Finance and House Energy and Commerce Committees, which will attempt to reach consensus over the Commission's proposed cuts as part of the 2006 Budget Reconciliation package. The letter warns that some of the proposed cuts "would have a devastating impact on individuals with mental illness and undermine state mental health systems…. In particular, we are deeply concerned about recent proposals to narrow the definitions of rehabilitative services and targeted case management (TCM) services eligible for Medicaid reimbursement, as well as a proposal to lower the reimbursement rate to States for TCM.

"Rehabilitative services and TCM are core elements of the public mental health system in every State. Adults and children with serious mental disorders require a range of intensive community-based services in order to avoid institutionalization. Medicaid rehabilitative and targeted case management services are the vehicles for providing Medicaid-eligible persons with comprehensive community-based mental health services.

"Rehabilitative services include intensive community services such as crisis services, medication management, skills training, and other remedial services to enable an individual to live in the community. Targeted case management links beneficiaries not only to needed medical services but also to educational, housing, social services, and other services they need. TCM case managers coordinate and monitor the provision of services.

"Without the intensive community services that are typically funded through these two Medicaid options, many more people with serious mental illnesses will end up institutionalized, in jails, or homeless—at significant public expense—and will lose access to the care that can save their lives and put them on the road to recovery."

The Campaign for Mental Health Reform also raised concerns about cost-sharing proposals that would increase beneficiaries' copayments and that would promote stricter use of state formularies. The concerns over higher copayments are based on accumulating evidence that even modest increases in cost-sharing drive many individuals off the rolls of public health insurance. A frequently cited study followed a representative sample of about 1,400 Oregon Medicaid enrollees after beneficiaries' premiums were increased on a sliding scale that ranged from $6 to $20 per month and copayments were introduced that ranged from $5 for an outpatient physician visit, $50 for an emergency department visit, and $250 for a hospital admission. In the six months after these changes were implemented, 44 percent of the study participants left the program, nearly half of whom cited an inability to afford the new premiums or copayments. These findings were borne out by Medicaid administrative data that showed a 46 percent drop, from 88,874 to 47,957 covered lives, in the state during the same period.

Under current Medicaid rules, states can decide whether to exempt psychotropic drugs from cost-control efforts that include the use of state formularies of preferred drugs and higher copayments for nonpreferred drugs. The Medicaid Commission's proposals would continue to give states this authority, and many advocates fear that chronically ill patients who have been helped by treatment with a specific drug will be forced to switch medications if that drug is categorized as nonpreferred. Earlier this year the National Governor's Association made recommendations for cutting Medicaid expenditures that favored closed formularies (www.nga.org/files/pdf/0502medicaid.pdf).

The Medicaid Commission was also charged with developing recommendations for stabilizing Medicaid over the long term, and a second report is due by the end of the year.

Numerous initiatives and demonstration projects have sought to better integrate mental health care into primary care for persons with mild to moderate mental disorders. A new report from the Bazelon Center for Mental Health Law fills a gap by focusing primarily on integration of care for people with serious mental illnesses.

The center reviewed studies over the past 30 years that have documented high rates of serious health problems and premature death among people with serious mental illnesses. The report cites recent findings that as many as 75 percent of persons with schizophrenia have high rates of serious physical illnesses, such as diabetes, high blood pressure, and respiratory, heart, or bowel problems. High rates were also seen for vision, hearing, and dental problems. Despite these risks, detection of physical health problems in this population is poor.

"The wall between physical and mental healthcare perpetuates a public health crisis," said Chris Koyanagi, the report's author and policy director at the Bazelon Center, a Washington-based advocacy group. "The lack of integration can leave chronic medical conditions undetected and lead to higher healthcare costs and needless suffering." The report notes that in a recovery-oriented mental health system, physical health care is as central to an individual's service plan as housing, job training, or education.

Get It Together: How to Integrate Physical and Mental Health Care for People With Serious Mental Disorders describes barriers to integration, discusses models studied by center staff who made site visits to programs around the country, offers recommendations for integrating care, and spells out policy initiatives that public health and mental health systems can adopt to nurture integration of services in each of the models.

The center found an encouraging number of approaches to integrated care, which the report defines as the delivery of health and mental health services in a unified, holistic manner—as opposed to coordinated care, which occurs when information is shared and separate providers are linked through special initiatives or policies. Two models of integrated care—"primary care embedded in a mental health program" and "unified programs"—are particularly effective in promoting greater access to prevention and treatment services, reducing reliance on emergency departments and other crisis-oriented health services, improving consumers' satisfaction, and enhancing cost-effectiveness.

The first model, embedding primary care in a mental health program, ensures strong working linkages between primary care and mental health providers and is particularly appropriate for adults with serious mental illnesses, according to the report. Embedded programs allow extra time in primary care visits for providers to deal with more complex medical issues. Many of the programs are staffed with physician assistants and nurses.

When providers are co-located, daily interactions lead to more collegial work and higher-quality care, the report notes. In an embedded model, primary care providers develop a better understanding of why patients do not follow through on health care advice, and they create more effective strategies to encourage patients to take an active role in their care. One of the most striking findings from site visits to embedded programs was that many barriers to integration, particularly those that stem from cultural differences or lack of provider training, are overcome without special initiatives.

Providers in embedded programs report greater satisfaction and feel that integration has improved access and quality, according to the Bazelon report. They note improved diagnosis and treatment of previously unreported but significant illnesses. Consumers report more comfort with primary care providers who work in a program for people with serious mental disorders.

The second model, combining publicly funded primary care and behavioral health care into a unified program, is the most seamless approach, according to the report, because it integrates not only delivery of care but also administration and financing. Bazelon staff visited three sites, each providing a full range of behavioral health and primary care services by using integrated teams of several providers. One of the strengths of the unified approach is that it overcomes barriers related to time and resources for collaboration, the report notes. Providers are paid through the agency for time that is required for collaboration, such as attendance at case-planning meetings. Unified arrangements are economically efficient, offering opportunities for administrative savings and physical plant efficiencies. Cultural barriers are overcome in the unified programs, as in the embedded programs, and for similar reasons.

Access, continuity, and quality of care improve in unified programs, according to the report. For consumers, these programs provide a single point of access whether the individual is seeking care for a physical or a mental health problem. Consumers find the "no wrong door" approach more friendly and less stigmatizing.

In addition to the integrated models, the report also describes efforts by four state Medicaid systems—in Massachusetts, Michigan, Oregon, and Oklahoma—to coordinate primary and behavioral health care across multiple agencies for people with serious mental disorders. Strategies used to improve collaboration include use of case managers, financial incentives, managed care contract requirements, and provider training. The report praises these efforts and notes that collaboration rather than integration causes the least disruption to traditional practice; however, this approach presents many challenges and constraints that are yet to be fully addressed in such programs.

The executive summary of the full report is available online on the Bazelon Web site at www.bazelon.org. The 68-page report can be ordered for $14, plus $4 shipping and handling, online or by calling the Bazelon Center's publications desk at (202) 467-5730, ext. 110.

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