Warning of declining resources for mental health, Nelba Chavez, Ph.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), said mental health must become a top priority in public policy, health care services and coverage, training of health care professionals and community education.
"Resources for mental health in this country have decreased, and it is hurting the folks that all of us care about-individuals who have mental illness," Chavez said at the recent 50th Institute on Psychiatric Services of the American Psychiatric Association.
In support of her comment, Chavez reviewed findings from a recent study, National Expenditures for Mental Health, Alcohol and Other Drug Abuse Treatment, 1996. Designed to provide direct comparisons with figures for national health care spending produced by the Health Care Financing Administration, the study revealed that the percentage of overall health care spending for mental health and substance abuse declined from 9% in 1986 to 8.1% in 1996. Similarly, the average annual growth of expenditures for treatment of mental health, alcohol and other drug abuse was 7.2% between 1986 and 1996, notably slower than the 8.3% average annual growth rate for national health care expenditures for the same period. The study also found that the public sector is picking up an increasing share (49% in 1986 to 54% in 1996) of the total $79.3 billion funding for treatment services in 1996.
Physicians as Advocates
While acknowledging that psychiatrists are busy and often exhausted with maintaining their practices and teaching, Chavez urged her audience to become active advocates for mental health policy. She cited reasons for prioritizing mental health and offered suggestions for influencing public policy.
"One in five American children and adolescents has a serious, diagnosable emotional or behavioral disorder, yet today in this country 60% of them do not receive the services that they need," she said. "For example, at SAMHSA we had a line item of about $72 million for mental health services for children. Now, that may seem like a lot of money, but I think it is a disgrace that is all we've got for children who have a serious, diagnosable mental illness."
Beyond the children, only one quarter of the 50 million Americans who may experience a mental disorder at any time in a given year actually receive treatment, Chavez reported.
She also expressed concern about the effect of managed care plans on access to treatment.
"We know that as of today, we have more than 150 million Americans who are enrolled in employer-managed care-sponsored plans. And many of the individuals enrolled in these plans are at risk because of the distorted attitudes and the beliefs that only limited services are available," she said. "Many employers cover chronic, disabling illnesses such as heart disease [and] diabetes. However, we and you know that many people who are employed with depression, alcoholism, bipolar disorder, etc., are often out there on their own, not covered by any of these managed care programs or any of these systems."
We are paying for this lack of care "in terms of needless suffering, compounded medical conditions, unemployment and crime," she said. "There are a lot of these costs out there, and I don't think we have done a very good job in terms of being able to translate what that means."
One of the ways psychiatrists can help, Chavez advised attendees, is by providing input on Healthy People 2010, the nation's blueprint for improving the health of the American people.
"Many of you may think it doesn't impact you," she said, "[but] it impacts every single one of us in this room. Currently, Healthy People 2000 is used for policy, for resources; it is incorporated in every single grant agreement that comes out of HHS [U.S. Department of Health and Human Services] programs."
In past publications of Healthy People, Chavez noted that objectives for addictions and mental health often have been an "footnote or addendum."
"[HCFA] and the National Institutes of Health have been pushing to ensure that mental illness and addictions have their appropriate place. So you need to look at goals and objectives and give comments. Are these [objectives] critical? Can we reach them by the year 2010?"
For example, one of the 24 objectives for mental health care is: "Reduce the absolute number and relative rank of unipolar major depression as causing lost years of healthy life without a commensurate increase in the absolute numbers for other health conditions."(A draft of Healthy People 2010 objectives is available for public comment on the Web at web.health.gov/healthypeople/2010Draft/object.htm )SAMHSA's Role
Much of Chavez' presentation summarized several of the agency's current initiatives, including its participation in the Surgeon General's Report on Mental Illness, documenting the economic viability of parity, providing experts on mental illness and addictions to HCFA, publishing a handbook to help state and local agencies improve their managed care procurement practices, and encouraging the use of practice guidelines and best practices.
"Surgeon General David Satcher, has made mental health one of his big priorities [and Health and Human Services] gave SAMHSA the responsibility for the Surgeon General's Report," Chavez noted. "We also have the National Institute of Mental Health as our partner and a few others. Our goal is to have it [the report] out by the end of 1999.
"All of the other Surgeon General's reports have had tremendous impact in terms of policy and funding. You should not expect anything less from this report," Chavez explained. "Look at what the Surgeon General's Report on Tobacco did for us."
Last spring, SAMHSA published The Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits, which showed that equal coverage for mental health and substance abuse services is not going to break the bank, Chavez said.
"We found parity would increase family premiums less than 1% in insurance plans with tightly managed care. In plans of all types, the increase would average about 3.5%. Because we focused on some states that already had parity, we found that parity costs did not shift from the government to the private sector, and that employers did not avoid parity laws by becoming self-insured. [They] really were not passing on the low-cost of parity to employees."
To provide more expertise about mental health to HCFA, Chavez said, "Last year we took one of our most seasoned staff persons, Frank Sullivan, Ph.D., and placed him at HCFA in Baltimore. The reason we did that is because I felt that even though there [are] a lot of dollars that go into mental health through Medicaid, mental health is not one of the priorities." Chavez continued, "We are involved in training their staff on managed care and mental health and managed care and substance abuse."
SAMHSA also has implemented a series of training sessions with HCFA for state mental health commissioners, substance abuse directors and Medicaid officials.
State and community agencies receiving money for mental health and substance abuse treatment are assisted in negotiating more effectively with managed care companies through a guide developed by SAMHSA, Contracting for Managed Substance Abuse and Mental Health Services: A Guide for Public Purchasers.
"One of things that we have found is that many of the states do not know how to negotiate with managed care firms that have been in business for a long time," Chavez said. "So we have developed a guide...that helps them negotiate contracts with managed care firms."
The guide offers recommendations for improving pre-procurement planning, development of requests for information and requests for proposals, as well as the actual contract. Issues addressed include whether the managed care organization can withdraw coverage when clients do not follow treatment plans because of substance abuse and mental health problems; whether the managed care organization will provide "wraparound" services, such as transportation, child care or housing assistance; and how to determine what is "medically necessary" care.
To improve quality of care in managed care settings, Chavez said SAMHSA is working with the APA to "encourage the adoption of practice guidelines that have been developed for the treatment of depression and anxiety."
Chavez noted that SAMHSA is using its "limited resources" to award priority action grants and identifying best practices. For example, $1.5 million in priority action grants were awarded last October to 11 Hispanic community-based organizations. The grants will support development and implementation of exemplary prevention and treatment practices for Hispanic adults and adolescents with mental health and/or substance abuse problems.
(Information on the reports mentioned in this article can be obtained on SAMHSA's Web page at www.samhsa.gov or through SAMHSA's National Clearinghouse for Alcohol and Drug Information at (800)729-6686-Ed.)