One major step toward addressing inadequacies in the current system would be the passage of a new federal mental health parity law. The APA vision statement takes the issue of parity one step further, Sharfstein said, by extending it to non-discrimination in managed care utilization review. Private insurance benefits have experienced dramatic cutbacks in inpatient and outpatient benefits, mostly through the utilization-review process.
Private-practice psychiatrists who work on a fee-for-service basis and don't take managed care payments are somewhat outside of the mental health care system, Sharfstein said. "But anyone who's taking third-party payments through general private insurance or public insurance is impacted by some of the financial and clinical restraints that we are under."
A growing number of psychiatrists have decided not to take third-party payments because they don't like the discounts, the fee structures and the administrative hassles, he said. "If the system were fairer and constructed more along the principles we articulate in this report, more private psychiatrists would be part of the overall system and treating patients regardless of their financial situation."
Patients covered by managed care systems are not able to select who will treat them, nor are their referring physicians able to select who will treat them. Instead, patients typically call a toll-free number and are given three or four names from which to choose. Some of those psychiatrists may either not be taking new patients or are no longer in the network. Further, these doctors may be difficult to reach and usually do not have a relationship with the person's primary care doctor.
"It is a completely disorganized system right now and shouldn't be," Applebaum told PT.
For a couple of years now, the APA has explicitly opposed carve-outs because of the destructive effects on the mental health care system, such as the disjunction between general medical care and specialty psychiatric care.
Magellan's Chapter 11 bankruptcy filing in March hasn't helped matters. Magellan, which covers about 68 million Americans, has said the reorganization is running smoothly and won't disrupt payments to providers, but psychiatrists remain wary.
"It does demonstrate the potential for chaos when we will allow one not terribly stable for-profit company to control a huge portion of the mental health insurance market," Applebaum said. "There is still enormous concern in the field about what happens if this reorganization in fact fails and this huge entity crashes."
Reimbursements from managed care companies in many cases are below the cost of delivering care, so there's a clear disincentive to spending enough time with patients for thorough evaluations, good diagnoses and appropriate treatment plans, Applebaum said. "Part of putting more resources into psychiatric care is actually paying what it costs to deliver that care."A Call to Integration
In order to realize a system that achieves the goals of the APA's vision statement, psychiatric care must be delivered within the context of the general health system, according to Appelbaum. Instead of being threatened by the number of prescriptions for mental disorders that are being written by primary care doctors, psychiatrists need to embrace it as an opportunity to strengthen treatment through an integrated system of care.
Meeting demand will require more medical expertise than psychiatrists can offer, he said. The National Comorbidity Survey found that 80% of people with mental disorders receive no care in a given year, including more than 50% of people with major psychiatric disorders. Involving primary care physicians to help meet this need will require training and the availability of psychiatrists to provide consultation to every primary care setting, preferably on-site.
However, multiple systemic obstacles stand in the way of that goal. Behavioral health carveouts mean that primary care physicians often can't get reimbursed for dealing with psychiatric problems, and psychiatrists don't get compensated for providing consultation on patients they don't see directly. Also, because most health plans don't allow other physicians to make direct referrals to psychiatrists, "the relationships on which a consultive model depends can never develop," Appelbaum explained.
A primary care-based system can succeed only if every person has health insurance coverage, Applebaum said. To that end, universal health insurance is more crucial than ever. Non-discrimination for mental health care must include not only parity laws but also "the mechanisms of review for authorizing care." The rates paid for treating psychiatric disorders must also take into account the real costs of delivering care.Resource Allocation
Sharfstein says he has guarded optimism that more people are going to want and demand psychiatric care. "There's some momentum to expanding resources."
At present, however, getting Congress to pass a new version of the mental health parity bill has become a major battle. Medicaid programs across the country are suffering from budget cutbacks. Physicians continue to face problems with managed care rationing. However, Sharfstein believes the pendulum is beginning to swing to the other side.
The challenge is convincing the American public and its political leaders that the investment is worthwhile. The APA task force proposes using the "global burden of disease model" developed by the World Health Organization and the World Bank as the basis for designing a rational mental health care system. It uses disability adjusted life years (DALYs) as a way to compare the resources necessary to treat psychiatric disorders in relation to the impact of other medical conditions. The measure, which looks at years of life lost and years living with a disability, shows that mental disorders account for 20% of the total disease burden in the United States, but only 5.7% of health expenditures go toward treatment of these disorders.
"This is potentially very powerful argument for increased resources devoted to psychiatric illness that has not really been made in an effective way before," Applebaum said.
In advocating for system change, it is also important to emphasize that the costs of untreated mental illnesses shift to other parts of society, he said. Correctional systems, hospital emergency departments and social-welfare systems all bear the burden of untreated mental illness. Patients' families also suffer. "Were the financial resources now being consumed to compensate for the deficiencies of the current mental health system utilized to provide quality psychiatric care," Applebaum said, "we could afford to implement the vision of a genuine system of care."
A Vision for the Mental Health System can be downloaded from the APA's Web site at <www.psych.org>.