More People Getting Treatment, But Often by Nonpsychiatrists

David Mechanic, Ph.D., surveyed the gains and losses in mental health services over the past two decades and identified challenges for the future in the Benjamin Rush Lecture at APA's 2004 annual meeting in New York in May.

Mechanic, the Rene Dubos Professor of Behavioral Sciences at the Institute of Health, Health Care Policy, and Aging Research at Rutgers University, said that there has been “more progress than is generally perceived.”

Mechanic, who has received numerous awards for his work in sociology and health services research, also directs the National Institute for Mental Health Center at Rutgers for Research on the Organization and Financing of Care for the Severely Mentally Ill.

Among the improvements in care that he cited are better medications and treatment, “enormous growth” in the number of mental health personnel and the number of people seeking treatment, increased public support for mental health services, a focus on comorbid disorders, and improved models of community care and evidence-based practice.

Mechanic noted, however, that those improved models were “rarely implemented.”

Treatment Incidence and Workforce Grow

Mechanic cited data from the federal Center for Mental Health Services (CMHS) showing an increase in the number of care episodes in mental health organizations from slightly fewer than 2 million episodes in 1955 to approximately 13 million episodes in 2000.

The percentage of children with a “treated disorder” has grown from 5 percent in the mid 1980s to 8 percent in the late 1990s, he said.

The percentage of people receiving treatment for depression has also increased. In 1987, 0.73 percent of the population received outpatient treatment for depression. In 1997, the percentage had grown to 2.33.

The absolute number of mental health personnel has increased since the 1980s, and the characteristics of the workforce have changed as well.

Managed Care Remakes System

When listing the major changes that have occurred within mental health care, Mechanic observed that “most behavioral health care is now managed.” Among the well-known strategies employed by managed behavioral health care organizations (MBHOs) to control costs are reducing the rate of reimbursement to those providing care and shifting that care to less-expensive personnel.

Mechanic showed a chart that contrasted reimbursements and referrals under indemnity insurance plans in 1994 with those administered by MBHOs in 1995.

In 1994, under the indemnity plan, 85 percent of the mental health referrals went to psychiatrists, and 5 percent went to social workers. In 1995, under managed care, the respective rates were 11 percent to psychiatrists and 56 percent to social workers.

Psychiatrists were reimbursed, on average, $150 per visit under the indemnity plan and $90 from MBHOs. The respective rates for social workers were $85 and $65.

That chart, created by E. Clarke Ross, appeared in the chapter “The Promise and Reality of Managed Behavioral Health Care,” in “Mental Health, United States, 2000,” published by CMHS in 2001.

In addition, the initiation of managed care has resulted in a decrease in the number of days of inpatient care. Mechanic presented data that showed, for example, a decline in the number of hospital days for mental health or substance abuse treatment per 1,000 employees of the Xerox Corporation from 327 in 1987 to 61 in 1994.

Managed care practices are also being implemented in the public sector, said Mechanic, adding that the trend poses special challenges. Those with serious mental illness most frequently receive treatment in the public sector.

He said that with the introduction of those practices, there are“ substantial cost reductions,” but evidence from studies in Minnesota, Utah, and Tennessee suggests that patients who have schizophrenia do “less well” over time under a public-sector managed care system.

Managed care models “inadequately differentiate among levels of severity [of illness] and need,” said Mechanic

He also noted that states have been implementing cost-containment strategies in their Medicaid programs over the last three years, as a response to budgetary constraints.

During their Fiscal 2002 to Fiscal 2004 periods, every state used some mechanism to control the costs of prescription drugs and either reduced or froze payments to those providing mental health services, according to the Kaiser Commission on Medicaid and the Uninsured.

Thirty-five states reduced benefits, 34 reduced or restricted eligibility to them, and 32 increased copayments.

He cautioned advocates to be particularly wary of the use of caps on the number of prescriptions that can be filled each month by Medicaid beneficiaries. According to a study published in the September 8, 1994, New England Journal of Medicine, costs exceeded savings by a factor of 17 when New Hampshire Medicaid officials established a three-prescription limit on antipsychotic medications.

Mechanic described the challenges to providing care for those with serious mental illness and outlined actions that state Medicaid agencies should take to ensure the adequacy of that care (Original article: see box).

“The Promise and Reality of Managed Behavioral Health Care” is posted online at<http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3537/chapter9.asp>.▪