mental health (care) systems from the lunatic asylum to a “modern” mental health system barbara...
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Mental Health (Care) Systems
From the Lunatic Asylum to a “Modern” Mental Health System
Barbara A. Schindler, M.D.Vice Dean, Educational and Academic Affairs
Professor of Psychiatry
Learning Objectives
1) Be able to describe the components of the mental health delivery system
2) Explain how mental health costs are covered3) Describe the overall burden of illness of mental
disorders4) Outline the barriers and limitations to obtaining
comprehensive mental health coverage5) Describe the disparities between the scientific
knowledge base of mental illness/treatment and how mental health care is actually delivered
Costs of Mental Illness
Global Burden of Illness
Percent of Total DALY’s*All Cardiovascular Conditions 18.6
All Mental Illness 15.4All Cancer 15All Respiratory Conditions 4.8All Alcohol Use 4.7All Infectious and Parasitic Diseases
2.8
All Drug Use 1.5*DALY’s=Disability Adjusted Life Years (Years lost to premature death or lived with disability) Murray & Lopez, 1996
Leading Causes of Mortality and Burden of DiseaseWorld, 2004
%
1. Ischaemic heart disease 12.2
2. Cerebrovascular disease 9.7
3. Lower respiratory infections 7.1
4. COPD 5.1
5. Diarrhoeal diseases 3.7
6. HIV/AIDS 3.5
7. Tuberculosis 2.5
8. Trachea, bronchus, lung cancers 2.3
9. Road traffic accidents 2.2
10. Prematurity, low birth weight 2.0
%
1. Lower respiratory infections 6.2
2. Diarrhoeal diseases 4.8
3. Depression 4.3
4. Ischaemic heart disease 4.1
5. HIV/AIDS 3.8
6. Cerebrovascular disease 3.1
7. Prematurity, low birth weight 2.9
8. Birth asphyxia, birth trauma 2.7
9. Road traffic accidents 2.7
10. Neonatal infections and other 2.7
Mortality DALYs
Ten leading causes of burden of disease, world, 2004 and 2030
Leading causes of disease burden for women aged 15–44 years, high-income countries, and low-
and middle-income countries, 2004
©2003-7 Barbara Schindler, MD DUCoM
Top Ten Causes of Disability Worldwide Include:
Unipolar Major Depression Bipolar Disorder Schizophrenia Obsessive Compulsive Disorder
©2003-7 Barbara Schindler, MD DUCoM
Indirect & Direct Costs:
The Global Burden of Disease
©2003-7 Barbara Schindler, MD DUCoM
Indirect Costs
$17 Billion loss in US economy $63 Billion morbidity cost $12 Billion mortality $4 Billion incarceration costs
©2003-7 Barbara Schindler, MD DUCoM
Direct Costs
$943 Billion total direct treatment health care costs
$99 Billion for mental disorders ($69 Billion), addictive disorders ($13 Billion) and dementia ($18 Billion)
7% total spending only when leading cause of disability
©2003-7 Barbara Schindler, MD DUCoM
Delivery of Mental Health Services
Providers & Sites
©2003-7 Barbara Schindler, MD DUCoM
Delivery Systems from a Historic Perspective
Asylums (Colonial times)– Otherwise jails, almshouses, workhouses
Moral Treatment* (early-mid 1800’s-Dorothea Dix, Horace Mann))
Mental Hygiene Movement (Post-Civil War) with collapse of public asylums (no $’s & overcrowded)
State Care Acts (early 1900’s) States assume responsibility for care resulting in growth of state hospital system
General Hospital Inpatient Units (post WWII) Community Mental Health System (1960’s) Deinstitutionalization with change in commitment laws (1970’s) Medicare (SSD) and Medicaid (1965)*Return of individual to “reason” using psychologically oriented therapy
©2003-7 Barbara Schindler, MD DUCoM
Current Mental Health/ Illness System Amalgamation/hybrid of public and private sector providers in variety of
sites, e.g. hospitals, clinics, pvt offices, ER’s, prisons, shelters, residential programs
No single guiding or organizing set of principles. What you can access depends a lot on what you can afford.– Fragmentation and gaps in care for children*– Fragmentation and gaps in care for adults with serious mental
illnesses*– High unemployment and disability for people with serious mental
illnesses*– Lack of care for older adults with mental illnesses*– Lack of national priority for mental health and suicide prevention*
*President’s New Freedom Commission on Mental Health (2002)
©2003-7 Barbara Schindler, MD DUCoM
Patient Presentations Single Episode Recurrent episodes Seriously and persistently ill (Schizophrenia, Bipolar,
Major Depression, Anxiety disorders, Alzheimer’s, Substance Abuse or Dual Dx)
Responding to acute stressors/trauma Developmental disabilities Dementias/late onset brain failure Relationship problems Adaptation problems
©2003-7 Barbara Schindler, MD DUCoM
Sectors of Care & Utilization by Sector(15% Adults Use System in any given year)
1) Specialty Mental Health Sector (5.5%)
2) Human Services Sector (5%)
3) General medical/primary care sector (5.5%)
4) Voluntary Support Network Sector (3%)
©2003-7 Barbara Schindler, MD DUCoM
1) Specialty Mental Health Services Sector
Psychiatrists Psychologists (Prescribing controversy) Psychiatric Social Workers Psychiatric Nurses Settings: Offices, clinics, private or
public hospitals, CMHC’s, prisons, other agencies, schools
©2003-7 Barbara Schindler, MD DUCoM
2) General Medical/Primary Care Sector
Internists Family Practice MD’s Pediatricians Consultation psychiatrists Social Workers Nurses PA’s Settings: Hospitals, offices, clinics, nursing
homes, hospices, prisons
©2003-7 Barbara Schindler, MD DUCoM
3) Human Services Sectors
Social Welfare System Criminal Justice System Educational, Religious, Charitable
services Settings: Shelters, prisons, boarding
houses, churches, schools
©2003-7 Barbara Schindler, MD DUCoM
4) Volunteer Network
Self-Help groups– AA, NA, Reach for Recovery, Zipper Club,
other medical Dx groups Public Awareness Fund Raising Lobbying for increased $$’s Examples; NAMI, NMHA, Bazelon
Center for MH Law
©2003-7 Barbara Schindler, MD DUCoM
Delivery Systems : Public & Private
©2003-7 Barbara Schindler, MD DUCoM
Sites of Care Based on Duration of Care
Acute– Private office or clinic– ER– Psychiatric unit of a general hospital– Psychiatric hospital – General Hospital scatter beds– Acute partial programs
Long Term– State hospitals– Mental health clinics– Residential programs (nurse, case managers)– Boarding Houses (nurse, case managers)– Home– Nursing home
©2003-7 Barbara Schindler, MD DUCoM
Utilization of Services
©2003-7 Barbara Schindler, MD DUCoM
Adult Utilization of Mental Health Services 28% US adult
population has diagnosable mental or Substance abuse disorder
1/3 patients receive MH services
Majority get no MH services
©2003-7 Barbara Schindler, MD DUCoM
Child & Adolescent Utilization of Mental Health Services
21% Child and Adolescent Population utilize MH Services
9% in Health Care Sector
17% in Human Service Sector, mostly schools
©2003-7 Barbara Schindler, MD DUCoM
Financing Mental Health Services
©2003-7 Barbara Schindler, MD DUCoM
Funds for Mental Health Programs
State and local government major payers thru Medicare & Medicaid
Additional federal initiatives– CMHC Block Grants– Addiction Treatment Grants– Community Support Programs– PATH (homeless MI)– Comprehensive Mental Health Services for
children and their families
©2003-7 Barbara Schindler, MD DUCoM
Source of Funding for Mental Health Services
©2003-7 Barbara Schindler, MD DUCoM
Mental Health Payment Costs by Provider Type
©2003-7 Barbara Schindler, MD DUCoM
Types of Accepted and Funded Treatment
Psychosocial– Psychotherapy: Cognitive/Behavioral,
psychodynamic, supportive– Group, individual, family, couples
Psychopharmacologic Both usually more effective than either
separately Split Treatment: challenge of dual treators
©2003-7 Barbara Schindler, MD DUCoM
Cost Control Efforts
Hospital lengths of stays Increasing numbers of
inpatient beds Emergence of managed care in
non-psychiatric medical care and MH carve outs for MH services, usually inadequate MH benefits.
Formularies
©2003-7 Barbara Schindler, MD DUCoM
Current Managed Mental Health System
Increasing enrollment MH and SA merged into Managed Behavioral Health
Organization (MBHO) mostly private (except Philadelphia=CBH) – Formulary & laboratory with medical MCO
Fewer MBHO’s with larger and larger contracts and increase financial difficulty
Both Medicare and Medicaid increasingly managed Tight control of access Higher co-payments in some plans
©2003-7 Barbara Schindler, MD DUCoM
Quality And Management Efforts
Credentialing Access requirements Strong utilization review procedures Monitoring patient satisfaction System expected to maximize convenience for
patients Wait time for appointment specified NCQA developing behavioral health standards
©2003-7 Barbara Schindler, MD DUCoM
Changes in Spending for Mental Health Services Over Past Decade
Declined as a % of overall health care Increased amount by public rather than
private payers (from 49% to 53%) Outpatient prescription drugs grew by 9%
(Usually covered under general medical expenses and only 1/3 Rxed by psychiatrists)
Increased barriers to service: stigma & vulnerable population
©2003-7 Barbara Schindler, MD DUCoM
Parity: New Federal Law 2008 Passed Mental Health Parity and Addiction Equity Act of 2008.
Effective date: Jan 1, 2010; regulations to be developed Initial Mental Health Parity Act of 1996 ineffective Mental Health coverage at same level as physical health for
lifetime and annually No limits on hospital stays and physician visits; same co-pays
and deductibles Employers with fewer than 50 employees and individual
health policies exempt. Costs issues persist despite data; premiums up 0.4% 1999 Surgeon General: $70B direct business cost from lack of
parity: lost productivity from absenteeism & sick leave, increase use of health services.
Caring Together ProgramA Dual Dx Program for Women and Their Children
Components– Intake evaluation, Psychiatric evaluation and
treatment, individual and group addiction treatment, specialized groups (TREM, Life Skills)
Staff: Psychiatrist, Social Worker, Addiction Counselors, Early Childhood Development Specialist, Case Manager,
Funding– CODAAP (Philadelphia) from Federal Grant to
State –Set aside $$’s for women’s and children’s programs (2/3 budget)
– 1/3 budget from clinical income thru CBH
©2003-7 Barbara Schindler, MD DUCoM
Major Trends in Mental Health Care Last 25 Years
Explosion in scientific knowledge: brain and behavior; growth of NIMH budget
Increased range of effective treatments for most mental disorders
An approach to organization and financing of mental health services (MC carve outs, parity)
Emergence of powerful consumer and family groups decreasing stigma, increasing access and research
Influence of pharmaceutical industry
Consumer Movement Books to Read
A Mind that Found Itself- Clifford Beers (1908) I Never Promised You a Rose Garden- Hannah
Green (1964) On Our Own- Judi Chamberlin (1978) Darkness Visible: A Memoir of Madness-
William Styron (1990) A Brilliant Madness: Living with Manic
Depressive Illness (1997) An Unquiet Mind-Kay Redfield Jamison (1997)
©2003-7 Barbara Schindler, MD DUCoM
Challenges 15-20% population uninsured for MH services Lack of true parity for MH services (Law passed Oct 2008) Stigma Barriers to access Coordination of care for most seriously ill Managing split between primary care and mental health
treatment Integrating treatment when psychotherapy and
pharmacologic treatment split Informed consent for clinical trials Access to appropriate care e.g. MCO formulary
restrictions Non-compliance ( side effects, cost, stigma) Hopelessness associated with mood disorders
©2003-7 Barbara Schindler, MD DUCoM
Take Home Messages
Ideal mental health system does not yet exist
Presidential Goals (2002)*– Understand that mental health is essential to overall
health– Mental health is consumer & family driven– Disparities in mental health services are eliminated– Early mental health screening, assessment, and referral
to services are common practices– Excellent mental health care is delivered and research
is accelerated– Technology is used to access mental health care and
information*http://www.mentalhealthcommission.gov/reports/FinalReport
Take Home Messages
Leading cause of disability/morbidity & mortality but significant under funded when compared to other high profile illnesses, e.g. CVD, cancer
Split treatment increases costs to individual patients and society, but saves insurers $$’s
Sharp contrast between scientific knowledge base & ability to deliver quality mental health care to all in need.
WHO Mental Health Gap Action Program
http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
©2003-7 Barbara Schindler, MD DUCoM
Mental Health
A Report of the Surgeon GeneralExecutive Summary
DEPARTMENT OF HEALTH AND HUMAN SERVICES
U.S. Public Health Service
http://www.surgeongeneral.gov/library/mentalhealth/summary.html