He opened his term of office in Philadelphia in 2002 by warning that reductions in mental health resources could lead to a "wholesale collapse of our mental health system," told attendees at the Institute on Psychiatric Services in Chicago to "sound the alarm" through a five-step action plan, and used his closing presidential address in San Francisco to urge advocacy for resources that would realize a vision of a "genuine system of care."
In an article in the September-October Health Affairs titled "The ‘Quiet’ Crisis in Mental Health Services," Appelbaum took those messages to health-policy researchers. He then was invited to testify in front of the Senate Subcommittee on Substance Abuse and Mental Health about the report of the New Freedom Commission on Mental Health, after a staff member in Sen. Edward Kennedy’s office read the article.
Appelbaum expanded on his thoughts in an interview with Psychiatric News.
Not surprisingly, when asked to name two important policy changes that should be made, he said, "First, reimbursement levels must be brought up to the point where they cover costs."
In his article, Appelbaum described how systematic defunding unfolded in Massachusetts. Practitioners and facilities accepted contracts at 30 percent to 50 percent below the prevailing rate of payment when managed care arrived in the 1990s. Rates edged up, but so did costs and the amount of time diverted to the administrative tasks required by managed care.
Outpatient clinics do not receive payment at rates that "come close" to covering the costs of care. Community mental health centers (CMHCs), such as one run by UMass Memorial Health Care, no longer receive funding for outpatient services from the state, he noted. CMHCs turn away uninsured patients because they have to limit their outpatient-treatment losses. Many of those patients end up in emergency rooms.
The second policy change? "Purchasers must pay more attention to what they are buying in terms of mental health services," Appelbaum said.
He said that employers are defrauded because they are "not getting the product they paid for." Their employees have limited or no access to psychiatrists because of "virtual networks" comprised of psychiatrists who participate in health plans in name only.
State governments, which increasingly are contracting with managed care companies for Medicaid mental health services, also must become more aggressive in monitoring the quality and extent of coverage.
In fact, lack of information about various aspects of mental health, according to Appelbaum, is an important factor preventing reform. "People who make decisions about mental health services are remarkably unaware of the issues and problems," he said.
He wrote that as he traveled around the country, he "found little awareness of the severity of the problem on the part of political leaders, public administrators, insurers, business leaders, and others who could actually bring about some of the needed changes."
One cause for this myopia, according to Appelbaum, is the "slowly progressive nature of the problem." Mental health services have undergone a steady attrition, which has not been acknowledged.
During his APA presidency, he spoke about a process in which members would gather data, meet with local media, prioritize targets, gather allies, and meet with state legislators and business leaders.
Data about the crisis and its impact are key to the effort. Appelbaum believes health services researchers have "let us down in terms of identifying the nature of the problem, in particular, the diminution of resources."
Their analyses frequently rely on data that are too old to capture the extent of the crisis or have been collected for purposes other than analysis of the mental health care crisis.
"I sometimes think it would be more cost-effective to blow up the current system and start over," he said. Unfortunately, however, persuading others about the extent of the irrationality and cost inefficiencies in the current system would require a series of studies and analyses, and the data are scattered and fragmentary.
Studies are being published based on aggregate data that reflect the situation five years ago, a time lag that may be inherent in research of this sort, but limits its utility for identifying current problems in the system.
Moreover, Appelbaum said, data collected for administrative purposes often focus on such easily measured variables as number of visits or payments, while slighting measures of quality, cost, and access that might be more revealing about the state of the mental health system.
Appelbaum thinks the report of the New Freedom Commission on Mental Health is "helpful as far as it goes."
"It states bluntly how bad the system is," he said. "Psychiatrists have been making similar critiques for years, but their views were often written off as only reflecting self-interest."
And returning to a familiar theme, he noted, "In order to make the reforms necessary, we will need more financial resources. The commission studiously stayed away from any item with a price tag."
But the report, Appelbaum said, provides "the nail to drive the point home" that the system is broken and must be fixed.
He wants policymakers to understand that a comprehensive approach to fixing the mental health system is needed. In his APA presidential address, Appelbaum pointed to greater integration of mental health care into the primary medical care system and revitalization of CMHCs as key elements of such a plan. Many of the necessary resources could come from dollars now used to pay for the consequences of an inadequate mental health system, such as the expanding jail and prison population of people with mental disorders.
During his presidency, Appelbaum appointed a task force to develop a vision of a mental health system for the United States. He chairs a follow-up group charged with identifying objectives and strategies that APA can pursue to make the vision a reality. The new task force plans to present its report to the APA Board of Trustees in March.
"The ‘Quiet’ Crisis in Mental Health Services" is posted on the Web at www.healthaffairs.org free to journal subscribers or for a fee to nonsubscribers. ▪