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Meeting the Mental Health Needs of Patients With Chronic Medical Illness: A Crisis in Access

Meeting the Mental Health Needs of Patients With Chronic Medical Illness: A Crisis in Access

According to recent estimates,
chronic medical conditions
account for 7 of every 10 deaths
in the United States and have been found
to severely limit daily functioning in more
than 1 of 10 Americans, or 25 million
people.1 This tremendous disease burden
accounts for most of the dollars spent
on health care annually in the United
States.1 Patients with chronic medical
diseases represent a population at particularly
high risk for mental disorders.

There is abundant evidence that patients
with chronic illnesses, including cardiovascular
disease, cancer, and diabetes
mellitus, experience high rates of psychiatric
disorders, which range from 20%
to 67%, depending on the medical illness.
In addition, depression and other mental
disorders significantly impact quality of
life and the ability of patients to adhere
to treatment regimens.3

However, access to and reimbursement
of psychiatric and other mental
health services are severely limited for
these doubly burdened, comorbidly ill
patients, despite abundant evidence that
psychiatric and psychosocial interventions
have positive economic and clinical
outcomes. Furthermore, several
federal commissions and boards,
including the President's New Freedom
Commission on Mental Health, the
Institute of Medicine (IOM), and the
President's Cancer Panel, and a national
organization, the National Comprehensive
Cancer Network4-9 (NCCN)
have recently called attention to the
evidence and the need to deliver mental
health care to this population.

Why, then, is access to this care so
limited? The reasons for the lack of
recognition, diagnosis, and application
of appropriate treatments are many: the
stigma of mental illness; the busy clinics
that reduce the physicians' time to
inquire about psychiatric or psychological
symptoms; the reluctance of
patients to bother the physician and
distract him or her from the primary
clinical problem; and the fact that mental
health services are the first to be eliminated
in budget crises and, hence, are
often unavailable.

Insurance shortcomings

However, leading the list of obstacles--
and resulting in a cascade of barriers
that prevent the deliverance of these
services--is the absence of an appropriate
and well-articulated insurance
benefit for patients with co-occurring
mental and physical illnesses. The absence of an insurance benefit and the
presence of carved-out mental health
care have led to payment as an exception
only and very low reimbursement
for psychological, psychiatric, and
social services by both private and
public payers. When there is some reimbursement
for mental health services,
it is usually administered through a
mental health carve-out that separates
reimbursement for these services from
the medical care reimbursement--
resulting in patients being unable to
receive care in the medical setting and
not having access to experienced professionals
capable of treating complex
medical and psychiatric conditions.

Medical benefit plans vary, but most
private insurance plans cover only limited
psychiatric consultations and treatment.
Mental health (behavioral) benefits are
far more limited than benefits for other
medical conditions. The Mental Health
Parity Act, designed to provide mental
health benefits equal to those for other
medical conditions, did not affect many
self-insured and small employers.

Some employee assistance program
benefits fill gaps for psychosocial and
family support. State Medicaid
programs cover acute care consultations,
ambulatory visits, and some psychosocial
needs of patients who have serious
medical conditions as well as mental
illnesses. The federal Medicare program
covers psychiatric consultations and
psychosocial visits with clearly delineated
diagnostic and billing codes.
However, Medicare pays 80% for physical
health care services but only 50%
for mental health services. Gaps exist
in free care programs unless delivered
in emergency or hospital settings.

To compound the problem, the
administration of claims under both
private and public insurance programs
frequently imposes a substantial documentation
burden on physicians who
seek payment for psychosocial services.
Many nonpsychiatric physicians (eg,
oncologists) who have attempted to
provide a mental-health professional in their practice group have found that the
time and paperwork required to request
reimbursement for psychosocial services
far exceed the moneys paid, and
hence, they cannot afford to provide
these services.

While, strictly speaking, mental
health services may be covered in an
insurance benefit program, use of behavioral
health benefits is controlled by
managed care organizations. To limit use of benefits, these organizations typically
apply a number of utilization
management tools, including strict
medical necessity criteria, outpatientvisit
capitation, prior authorization for
psychiatric consultations (where no
prior authorization may be required for
other medical consultations), copayment
by patient (often greater than for
medical illness), and prescription prior
authorization or preferred drug list
restrictions. Public insurance programs
may add other restrictions: behavioral
benefits limited to priority populations,
medical and social necessity criteria,
outpatient-visit limits for patients without
chronic mental illness, and physician-
consultation limits. These tools, in
short, make it difficult to obtain benefits
without a sustained effort to challenge
the application of the rules, at the
very time when an ill person is most
vulnerable and least able to do so.

Public health initiatives

Several key public health initiatives
have provided some focus to this issue.
The NCCN, a group of National Cancer
Institute-designated cancer centers, in
its 2003 standards of care,9 addressed
the need to assess and treat distress for
all patients throughout and beyond their
cancer illness and, furthermore, to use
evidence-based interventions when
interventions are indicated. In 2
reports,6,8 the IOM has affirmed that
practice guidelines are available that
should dictate the standard of care for
both physical and psychosocial symptoms.
Care systems, payers, standard
settings, and accreditation bodies
should strongly encourage the guidelines'
expedited development, validation,
and use.

The President's New Freedom
Commission on Mental Health4 clearly
states that mental health must be
addressed as aggressively as physical
health and that meeting the mental
health needs of individuals with primary
medical conditions is an unfulfilled critical
issue. Furthermore, on June 4, 2004, the President's Cancer Panel, stated,
“The federal government should implement
comprehensive health care reform,
whose provisions should include coverage
for psychosocial services both
during and after treatment and reimbursement
for a range of follow-up
care, including that provided by
nonphysicians.”5 Most recently, the US
Congress appropriated funds for a report
to be developed that reviews the delivery
of psychosocial services to cancer
patients, with a special focus on barriers
to access.


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