Lawmakers Building Support For Medicare MH Reform

The offices of Sen. Jon Corzine (D-N.J.) and Rep. Pete Stark (D-Calif.) hosted a briefing on Medicare and mental health last month on Capitol Hill.

The forum was part of an effort to promote the Medicare Mental Health Modernization Act of 2003 (S 646/HR 1340), which the two members introduced in March. The legislation would eliminate the 190-day lifetime cap on inpatient services in psychiatric hospitals and reduce Medicare’s discriminatory copayment for outpatient mental health services from 50 percent to 20 percent. Both Senate and House bills have been referred to committees.

Like the recently introduced Medicare Mental Health Copayment Equity Act (S 853) (Psychiatric News, May 2), the Medicare Mental Health Modernization Act of 2003 addresses inequities in coverage for mental illness for Medicare beneficiaries (Original article: see box on facing page for other legislative provisions and APA reaction).

At the briefing, Joel E. Streim, M.D., president of the American Association for Geriatric Psychiatry, argued that mental illness in older people is a major and rapidly growing public health problem that produces negative consequences for many areas of society.

He told of a 75-year-old widow who had lived independently prior to hospitalization for pneumonia. The disease was treated successfully, but the depression that followed remained untreated.

The woman lost energy, stayed in bed, “deconditioned,” and ended up in a nursing home because she was no longer able to take care of herself (see chart).

According to Streim, evidence exists that the presence of depression is associated with worse outcomes for hip fractures, myocardial infarction, and cancer.

Older people are at greater risk for suicide than those in younger age groups. Streim cited 1999 data that show that older people accounted for 18.8 percent of suicides, although they made up 12.7 percent of the population (Psychiatric News, May 2).

Untreated mental illness in older people can also affect their caregivers. They are at high risk for “caregiver depression,” according to Streim, and show increased rates of utilization of health care services.

Streim said that nursing homes had become de facto institutions for elderly people with mental disorders.

“From 80 to 90 percent of nursing home residents have a diagnosable mental disorder,” he said. The most common disorders are dementia, depression, anxiety, and psychosis. “But,” he said “nursing homes are not designed, staffed, or reimbursed to provide mental health services.”

In fact, only 4.5 percent of mentally ill nursing home residents received mental health services during a one-month period, according to a study reported by Streim.

Ron Manderscheid, Ph.D., chief of the Survey and Analysis Branch of the Substance Abuse and Mental Health Services Administration, relayed the results of a study that contrasted the level of payments through Medicare for mental health with the level of payments through Medicaid in four states that used fee for service as a method of payment at the time of his study.

The populations studied included those who used mental health or mental health and substance abuse benefits, but not substance abuse benefits only.

Manderscheid excluded costs of prescription drugs and long-term care through Medicaid. He included institutional inpatient, outpatient, and physician costs. Several findings demonstrate the negative effect of Medicare reimbursement rates on access to mental health care.

When adjusted for inflation, dollars spent through Medicare on mental health and substance abuse services declined from approximately $7.5 billion in 1995 to approximately $6.5 billion in 1999.

He said, “The penetration rate for Medicare mental health services into the population of beneficiaries is not as high as would be expected.”

For the three years for which he reported data, 1995-1997, Manderscheid found that the percentage of Medicare beneficiaries who used mental health services remained relatively flat, between 8 percent and 9 percent. By contrast, the percentage of Medicaid beneficiaries using those services increased, ranging between 12 percent and 16 percent for the four states in 1997.

He also found that for those same years, Medicare’s physician payments per mental health claimant were lower than Medicaid physician payments in all four states.

Manderscheid concluded, “Service use patterns of Medicare mental health claimants are due to the copayments required for the different kinds of benefits.”

His analysis did not take into account the effect of managed care on access to services through Medicaid or the effect of recent Medicaid cuts in mental health services.

The text of the Medicare Mental Health Modernization Act of 2003 can be accessed on the Web at thomas.loc.gov by searching on the bill number S 646 for the Senate version and HR 1340 for the House version. ▪