The American Psychiatric Association has developed a sweeping vision for reforming mental health care in the midst of a fiscal crisis that it says threatens a wholesale collapse of the system. The plan calls for an investment in mental health services equal to the level of disability that mental disorders cause, an end to behavioral health carveouts and better integration between psychiatry and primary care.
Achieving these goals would require laws that establish parity coverage for mental illness, an end to restrictive utilization-management practices by insurance companies and the ability to convince policy-makers and the public that the costs of not having an adequate system of care far outweigh the investment in building one.
An APA task force report called A Vision for the Mental Health System stated, "At a time when treatment for psychiatric illness has never been more effective, access to that care is fragmented, discontinuous, sporadic and often totally unavailable." The document, which was endorsed by the APA's Board of Trustees in March, served as the rallying point for the presidential address by outgoing president Paul S. Applebaum, M.D., at this year's APA conference in San Francisco.
One of the main purposes of the vision statement was to influence the work of the President's New Freedom Commission on Mental Health. The commission's report is expected to shape the course of mental health care policy for the next quarter-century. As of press time, it had been submitted to the White House for final approval but had not been made public.
The APA vision statement presents 12 guiding principles for the mental health care system. The core philosophy is that every American with significant psychiatric symptoms is entitled to:
An accurate and comprehensive diagnosis;
An individualized treatment plan delivered in the right time and place, in the right amount, and with appropriate supports;
Care based on continuous healing relationships that emphasize the whole person rather than a narrow-symptom-focused perspective;
Timely access to care and continuity of care; and
A continuum of services that encourages maximum independence and quality of life.
The purpose of the vision statement was to clearly articulate a vision for the mental health care system and to help develop an advocacy agenda for the APA and mental health care groups in general, Steven S. Sharfstein, M.D., APA chairman of the task force, told Psychiatric Times.
The New Freedom Commission's interim report has a strong emphasis on recovery and rehabilitation. While the APA task force respects that approach for people with chronic disorders, Sharfstein said, it wanted to emphasize the importance of the medical perspective in shaping the nation's mental health care system. The APA document stresses the need for expert diagnosis, an individualized treatment plan, continuity of care and a meaningful physician-patient relationship. The report also addresses the special needs of traditionally neglected populations such as children and adolescents, the elderly and minorities.
The genesis of the current crisis in the mental health care system is inadequate payment for psychiatric care, Applebaum said in his May 18 address. "So poorly are psychiatrists, clinics and hospitals compensated for the treatment they render that relying on insurance payments for patients' care is often literally a losing proposition."
In response, the mental health care system has seen the closure of psychiatric inpatient units, service cutbacks at clinics and an inability for psychiatrists and other mental health professionals to support their practice with insurance payments. The utilization-review practices of the managed care industry have worsened the problem. Taken together, the result is "a critical inability of patients to access needed psychiatric care."
People needing outpatient care face waiting lists of weeks or months, as many private practitioners who can no longer afford to accept new patients at managed care rates opt out of the system, he said. The situation has worsened since Applebaum addressed the issue at last year's APA conference. Reimbursement rates for psychiatrists remain low; the nation's largest managed behavioral health care company, Magellan Health Services, has filed for bankruptcy; Medicare payments have decreased at a time when most specialties saw an increase; and Medicaid, which pays for 20% of the nation's psychiatric care, has taken a beating as states struggle with massive budget deficits.
"In a country in which only 20% of persons with a mental disorder receive any treatment in a given year, even more people are having trouble accessing care than was the case a year ago," Appelbaum told the audience.