- Each area of medicine has unique features but none to the extent that mandate independent service locations and independent reimbursement.
- Moving from a carved-out to a unified health system requires basic adjustments in the way that psychiatric disorders are handled.
- If value-added programs become a significant feature, reimbursement for mental health services will improve while total health care costs go down.
- A central focus is quality of care and health improvement in association with lower total health-related cost and less impairment.
Ninety percent of patients with psychiatric disorders are seen in the general medical sector. Two-thirds of these patients receive no treatment for their psychiatric illness. Of the one-third that does, only one-tenth is provided minimally adequate treatment.1 Furthermore, nontreatment or nonevidence-based treatment of psychiatric disorders in the primary care setting is associated with at least double the total health care costs for patients, mainly from increased general medical care and nonpsychiatric prescriptions.2,3
The plight of patients seen in the psychiatric setting with concurrent physical health problems, who need general medical services, is no better. There is substantial evidence that these patients have difficulty accessing services in the general medical sector. This is associated with quicker progression of physical disease and, ultimately, premature death.4,5
Karen, 34 years old, has been treated by her primary care physician for the past few months. She came in for diffuse muscle aches, frequent throbbing headaches, crampy abdominal pain, and dizziness. She was given a muscle relaxant, butalbital combined with caffeine and aspirin for headaches, and a hypnotic for sleep.
Noticing the number of prescription refills 4 months later, her physician became concerned and asked Karen about the number of pills. Karen reported tension and anxiety. She confided that she had been molested as a teen and sometimes had nightmares that made it hard to sleep and explained that clonazepam improved her sleep, decreased nightmares, and helped with muscle aches. Her physician renewed the prescription and usage escalated. At 6 months, her doctor again expressed concern about medication overuse.
Karen revealed that she had been hospitalized 9 months earlier for suicidal ideation and that she struggled with depression. With no access to psychiatric records, Karen’s physician knew nothing of this history and suggested that Karen return to her mental health practitioner. Karen explained that she had discontinued seeing her psychiatrist because his care was not covered by her insurance. She had tried to get a new psychiatrist through her insurance provider directory but after 7 calls, the best she could do was to get an appointment in 8 weeks with a nurse clinician at a clinic 15 miles away. At that point, she decided to stick with her primary care provider for mental health care. She did not ask her physician for depression medication because her family already thought she was taking too many pills.
Her primary care physician requested Karen’s psychiatry records, but they could not be released without special permission. While processing the paperwork to get the records, Karen continued to use large amounts of clonazepam. She also started consuming alcohol heavily. One afternoon, she became suicidal and was taken under duress to the local emergency department (ED) for psychiatric evaluation.
Michael, 46 years old, has been hospitalized in the psychiatry unit for hyperactivity, heavy spending, sexual indiscretion, lack of sleep, and pressured speech. His symptoms were controlled with lithium and other medications. At discharge, Michael’s lithium level was 1.2 mEq/L. A 10-day postdischarge follow-up was arranged with a psychiatrist on Michael’s insurance provider list.
Six weeks after discharge, Michael visited his primary care physician (Dr S) for potential treatment of hypertension. Dr S prescribed hydrochlorothiazide
25 mg/d and recommended a low-salt diet. He encouraged Michael to continue seeing a psychiatrist for mental health issues and psychotropic prescriptions. A week later, Michael called Dr S to report nausea, fatigue, and loose stools and was treated for mild gastroenteritis with hydration and rest.
Within 3 days, Michael became confused, had difficulty in walking, and had slurred speech. He was taken to the ED. Informed of Michael’s recent inpatient mental health admission, the ED physician thought symptoms were related to psychosis and called a psychiatrist who suggested that Michael’s lithium level be measured: it was found to be 3.7 mEq/L. Michael was admitted to the ICU for acute lithium intoxication.
1. Wang PS, Berglund P, Olfson M, et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:603-613.
2. Kathol RG, McAlpine D, Kishi Y, et al. General medical and pharmacy claims expenditures in users of behavioral health services. J Gen Intern Med. 2005;20: 160-167.
3. Thomas MR, Waxmonsky JA, Gabow PA, et al. Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO. Psychiatr Serv. 2005;56:1394-1401.
4. Druss BG, von Esenwein SA. Improving general medical care for persons with mental and addictive disorders: systematic review. Gen Hosp Psychiatry. 2006;28:145-153.
5. Miller BJ, Paschall CB 3rd, Svendsen DP. Mortality and medical comorbidity among patients with serious mental illness. Psychiatr Serv. 2006;57:1482-1487.
6. Rosenheck RA, Druss B, Stolar M, et al. Effect of declining mental health service use on employees of a large corporation. Health Aff (Millwood). 1999;18:193-203.
7. Zuvekas SH, Cohen JW. Prescription drugs and the changing concentration of health care expenditures. Health Aff (Millwood). 2007;26:249-257.
8. Kathol R, Saravay S, Lobo A, Ormel J. Epidemiologic trends and costs of fragmentation. In: Huyse F, Stiefel F, eds. Medical Clinics of North America. Vol 90. Philadelphia: Elsevier Saunders; 2006:549-572.
9. Kathol RG, Melek S, Bair B, Sargent S. Financing mental health and substance use disorder care within physical health: a look to the future. Psychiatr Clin North Am. 2008;31:11-25.
Kathol R, Saravay S, Lobo A, Ormel J. Epidemiologic trends and costs of fragmentation. In: Huyse F, Stiefel F, eds. Medical Clinics of North America. Vol 90. Philadelphia: Elsevier Saunders; 2006:549-572.
Thomas MR, Waxmonsky JA, Gabow PA, et al. Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO. Psychiatr Serv. 2005;56:1394-1401.