Mental health advocates are cautiously optimistic that a final health care reform bill will retain an initiative to provide the first widespread use of coordinated medical care for people with mental illness.
A version of health care reform that was approved by the Senate Finance Committee in October (see Health
Reform Advances With MH Amendments on Board) includes an option for every state Medicaid plan to use so-called medical homes that reimburse physicians to coordinate the care of a patient with multiple health conditions. The legislation explicitly includes mental illnesses among the conditions for which the medical home would coordinate care.
The addition of people with mental illness as a Medicaid "target population" eligible to participate in the first nationwide medical-home program is seen as a victory by mental health advocates, because even people who do receive treatment for psychiatric disorders may not get treatment for other medical conditions.
"Mental health is essential to overall health, and we're very pleased with how mental health has been integrated into health care reform," said William Emmet, director of the Campaign for Mental Health Reform, during a Capitol Hill briefing in September on mental health and medical homes in health care reform.
The proposed program would be a significant change to Medicaid. Although that state and federal partnership is the single largest payer for mental health care in the nation, like other major health care payers, Medicaid does not fund coordinated care for people with psychiatric illness. The consequences of uncoordinated care include sicker patients who die earlier than they would have if they had not had mental illness, according to researchers.
"That's where we have seen a massive yawning gap and tragic consequences from the lack of access to effective primary care for people with serious mental illness," said Andrew Sperling, J.D., director of legislative affairs for the National Alliance on Mental Illness, in an interview with Psychiatric News.
One high-profile study found, for example, that people with mental illness treated in the public health system die 25 years younger than the national average, mainly due to a lack of appropriate primary care. The 2006 study by Colton and Mandersheid was published in the April 2006 Preventing Chronic Disease.
Research also has found that mental illness rates are significantly higher among patients with certain chronic conditions—such as diabetes, heart disease,
and asthma—than they are in the general population.
The potential for coordinated care to improve overall patient health is particularly great when mental health treatment is provided in primary care, the setting in which patients often first report psychiatric symptoms to a clinician.
"There is no way there is enough system capacity to see all of the people with mental illness within the behavioral health care sector," said Joseph Parks, M.D., director of the Division of Comprehensive Psychiatric Services in the Missouri Department of Mental Health. "It's a good thing that they are seen in primary care settings, because many of these people have other chronic health care problems."
Parks called the coordination of primary care and mental health treatment "a marriage made in heaven" because many primary care physicians want help with patients who have substance abuse disorders, for example, while many substance abuse clinicians lack primary care medical support.
"It's a common problem," said Ted Epperly, M.D., an Idaho family physician, about the inability to find mental health treatment for his primary care patients. "I can't tell you how often we see it."
Despite the research supporting a coordinated approach to care, such programs for people with psychiatric illness have been largely limited to pilot programs and local efforts of small groups of clinicians because major health care payers have balked at paying for it.
Currently, only 10 percent of U.S. patients are treated using evidence-based, integrated-care models, said John Bartlett, M.D., M.P.H., a senior project advisor at the Carter Center Mental Health Program in Atlanta.
Parks said such care coordination will become widespread only when the major private insurers, as well as public ones such as Medicare and Medicaid, pay clinicians to provide such care.
"We need to demand better performance from our payer system, both public and private," he said.
One incentive for congressional leaders to add care coordination to Medicaid is the potential for significant cost savings. Patients with nonpsychiatric chronic health conditions and mental illness incur significantly higher health care costs, on average, than chronically ill patients who do not have a mental illness, according to 2003 data from the federal Agency for Healthcare Research and Quality (AHRQ). The AHRQ study found that, on average, $1,913 is spent annually on care for adults with a chronic health condition and no mental illness, while $3,545 is spent on chronically ill adults with mental illness.
Coordinated care could help control such costs if it increases the use of evidence-based approaches in the treatment of psychiatric illnesses, said Bartlett. A growing body of evidence shows that the use of "effective approaches" to mental health care in primary care settings through care coordination can double the effectiveness of that care. Current widespread deviation from evidence-based mental health treatments leaves 70 percent of people treated for depression, for instance, without clinically significant improvement after two months, he noted.
"We don't have a lack of evidence [on effective treatments]," Bartlett said. "We have a lack of demand to implement that evidence."
Information on efforts to include coordinated care for mental illness in health reform legislation is posted at <www.mhreform.org>.