Vision Offered To Overhaul Nation's Mental Health Care System

August 1, 2003

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.

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.

Presidential Address

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.

Discriminatory Practices

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>.