State and federal Medicaid officials expressed growing alarm at the high
rates of comorbidity and early death among beneficiaries with mental illness,
as they outlined new efforts to address mental disorders among the general
Ann Kohler, director of the Division of Medical Assistance and Health
Services in the New Jersey Department of Human Services, said her office is"
becoming increasingly concerned" about the increasing evidence of
high rates of early mortality in people with mental illness. An August 1999
study found that people served by her department lost 8.8 more years of
potential life than did the general population.
Those concerns led Kohler and others to convince the Centers for Disease
Control and Prevention to begin nationwide monitoring of mortality rates among
those with certain mental illnesses and other chronic health conditions.
Kohler and other health officials discussed the impact of mental illness on
the Medicaid population and treatment approaches to it in primary care
settings at the meeting of the National Association of State Medicaid
Directors last month in Washington, D.C.
Renata Henry, director of the Division of Substance Abuse and Mental Health
in the Delaware Department of Health and Social Services, described efforts to
improve treatment by ensuring that referrals between psychiatrists and mental
health professionals and general medical personnel are more effective.
"Mental illness and substance abuse disorders are common. We need to
know and accept that and allow that to drive what we do," Henry
One example of her agency's integrated-care approach is the Delaware mental
health centers' use of contract care from internists who come to those centers
regularly to treat co-occurring conditions among patients with mental
In addition, the state encourages primary care providers to assess all
chronic-disease patients for depression, said Glyne Williams, program manager
in the Delaware Department of Health and Social Services' Medicaid and Medical
Henry encouraged managed care organizations to collect "encounter
data" on care provided for comorbid illnesses, which could provide more
evidence that significant savings may accrue from timely treatment and
preventive care for people with multiple chronic health conditions.
Delaware is developing a "co-location and enhanced-access
project," which places mental health and general health professionals in
the same facility to maximize care for beneficiaries with mental and physical
"It's a challenge to get patients to keep appointments, but that's
not an issue if you can refer them to professionals within the same
facility," Williams said.
Although such co-location offers promise, the earliest attempts have not
all been successful. The best outcomes were from facilities that fully
integrated both mental-health and non-mental-health leadership at each
facility, with all meetings and decisions made collaboratively. Primary care
providers want to help detect mental health and substance abuse problems,
Williams said, but they won't if they don't have the time or information
available to them.
Federal health officials at the conference said they were becoming"
increasingly concerned" about inadequate health care contributing
to the high mortality rate among Medicaid beneficiaries with mental illness.
They described use of community health centers as an effective way to reach
the greatest number of beneficiaries with co-occurring mental and other
Community health centers increasingly have taken on the role of caring for
Medicaid beneficiaries with mental illness, according to research published in
the October American Journal of Public Health. Benjamin Druss, M.D.,
and colleagues found that between 1998 and 2003 the number of patients
diagnosed with a mental health or substance abuse disorder in community
healthcenters increased nearly fourfold, from 210,000 to 800,000. Most
community health centers were found to have some on-site mental health and
substance abuse services, but centers without them were more likely to be
located in counties with fewer mentalhealth and substance abuse clinicians,
psychiatric emergency rooms, and inpatient hospitals.
Alexander Ross, senior health policy analyst in the Health Resources and
Services Administration of the Department of Health and Human Services, said
federal officials are working to remove administrative barriers to
reimbursement of nonphysician and nonpsychologist mental health workers in
rural areas in an effort to provide more care.
"Rural locations need to rely on other mental health professionals
not normally sanctioned by the state, because psychiatrists and psychologists
are not available in those locations," he said.
More than 100 health centers nationwide now use a collaborative-care model
for depression that relies on electronic health records and other tools to
ensure that patients with other chronic health conditions are preventively
screened. Such approaches and other mental illness prevention strategies are
frequently eligible for reimbursement, but because state or local officials
may be unaware of this, federal officials plan to focus on ensuring federal
reimbursement guidelines are better disseminated.
Another common area of misunderstanding that can affect the provision of
both mental and physical health care is the belief that federal rules usually
bar reimbursement for two or more services on the same day for the same
Peggy Clark, technical director of the Center for Medicaid and State
Operations at the Centers for Medicare and Medicaid Services, said that no
Medicaid statute or regulation forbids the provision of both a mental health
and physical health service to the same person on the same day, a
misconception on which some states may have acted.
The 2005 Deficit Reduction Act, a federal law that gave states more
flexibility in their Medicaid programs, also offers more federal support for
the "collaborative-care" model of treating comorbid disorders, but
federal regulations to implement that financial assistance are still under
development. Federal officials said they will disseminate that information to
the states once the regulations are complete. ▪