Public Psychiatry Responds to New World of Health Care Reform

As the Affordable Care Act (ACA) continues to roll across American medicine, its ongoing rumble may herald an opportunity for renewing public psychiatry, says Roderick Shaner, M.D., medical director of the Los Angeles County Department of Mental Health.

“What we’ve been saying in public psychiatry is now being made possible,” Shaner told Psychiatric News. “Health care reform changes the way of insuring the population, gives them access to good care, and alters the mechanism of delivering care through an integrated program with primary care at its center.”

In some ways, the ACA nudges along other positive trends in the field: the recovery movement, increased use of technology like telepsychiatry, and a so-far-incomplete destigmatization of mental illness.

Medicaid expansion is bringing in a broader range of patients in the system, and treating that influx has led to experimentation with at least three alternative models of care delivery, said Shaner.

Perhaps the most familiar model is integrating psychiatrists with primary care sites while taking steps to ensure that care is truly integrated and that collaboration is close.

Alternatively, behavioral health homes—“essentially community mental health centers augmented by on-site provision of primary care services”—remain “mostly unexplored,” he said. “They are especially useful for seriously mentally ill patients who are hard to integrate into usual primary care settings, but it’s a challenge to have the right resources to deliver the primary care.”

Shaner’s third paradigm is probably expanding the most quickly, he said. “Consultation hubs” using a mix of telepsychiatry and in-person services are gaining acceptance and may need fewer structural changes, at least once seamless referral processes and electronic health records are in place.

The ACA’s introduction—or rather, reintroduction—of payments other than fee for service recalls the days of the original Community Mental Health Act from 1964 to 1981. Then, and now again, funds can be allotted to uses other than direct patient care.

“Taking advantage of these new opportunities will require that community psychiatrists reeducate themselves to work as physicians in medical settings, to act as consultants and supervisors rather than simply direct care providers in mental health settings, and to work as administrators and leaders in organizations,” wrote Shaner and five colleagues in the September issue of Psychiatric Clinics of North America. “In addition, they will need to enhance their skills at negotiation, budgeting, and leadership and become passionate about achieving measurable improvement in outcomes and keeping within budget without losing their passion for recovery and social justice.”

Another opportunity lies in renewed partnerships with the research community through academic medical centers, with benefits for both sides.

“Federal funding is now available for translational research,” he said. “Locally, public mental health systems can ensure they have a solid research base while providing training opportunities for psychiatry and other departments. To the extent that we expand public psychiatry into curricula, we become more a part of mainstream psychiatry.”

Shaner noted the ongoing public debate surrounding involuntary outpatient treatment. Rights-based groups are adamantly against it, while families and advocates of treatment stand in favor. Such coercive community treatment may leave a patient freer than coercive care in jails or hospitals, but a more complex and nuanced approach is needed to apply it, he said.

At the same time, community anxieties at the thought of the presence of people with mental illness or drug addiction cannot be ignored, especially at a time when politicians and the media are linking mental illness and violence.

One opportunity presented by the ACA lies in reducing the amount of involuntary care in acute, locked, long-term facilities and shifting to more open settings using assisted outpatient treatment.

“But that calls for more psychiatrists and collaborative work with other medical and social services to help provide greater acceptance and integration into the community,” he said.

Beyond that lies the broader need for public psychiatrists to step forward and help shape the discussions on mental health policy as well as mental health care, he said. ■