Key Principles of System Reform

APA Vice President Steven Sharfstein, M.D., testified before the New Freedom Commission on Mental Health last month as a member of the panel “Dealing With Fragmentation in the Service Delivery System.” In his written testimony, he described principles upon which a reform of the mental health system should be based:

• The medical/scientific model is necessary to the understanding and treatment of mental illness. Mental illness is a no-fault brain illness that has acute and chronic manifestations that require comprehensive medical and psychosocial management.

• Care should be based on “continuous healing relationships,” a term from the Institute of Medicine Report ”Crossing the Quality Chasm” (2001). [Providing] the continuous healing relationship is the most critical problem facing the mental health system today. Continuity of care remains. . .a cornerstone of quality, as we encourage the continuum of care in community-based settings.

• Privacy and confidentiality are essential. Patients will not come for treatment if their information is widely shared without their explicit permission.

• Efficiency and cost containment are important principles, but “neutral budgets” do a disservice for resources for mental health treatment and support. Unless costs are interpreted broadly to include budgets of criminal justice, general health care, and welfare and disability systems, we will find ourselves starved for the resources we need.

• Integration of care must include systematic efforts to integrate substance abuse and mental illness treatment, developmental disabilities with mental illness treatment, primary care with specialty mental illness treatment, and medication management with psychotherapy and psychosocial supports. The fragmentation in funding for care leads directly to the fragmentation of our service system. [B]ringing together these funding streams. . .is an urgent priority for patients’ families and dedicated clinicians.

• Payment for care should be nondiscriminatory. Cost containment principles should apply identically to health and mental health. Medicare should eliminate all discriminatory aspects in its payment (especially the 50 percent copay), which may be the largest contributor today to the precarious financial situation of many of our community and clinical systems across the country. Medicaid programs should also be nondiscriminatory and focus on reimbursing adequately the continuum of care, including hospital treatment.