APA Joins Advocates to Decry Deteriorating MH System

APA and other advocacy organizations identified a broad range of problems with public and private mental health systems in testimony before the New Freedom Commission on Mental Health in July.

President George W. Bush established the commission last April to recommend improvements that would enable adults with serious mental illness and children with serious emotional disturbances to live, work, learn, and participate fully in their communities (Psychiatric News, May 17).

Darrel Regier, M.D., M.P.H., executive director of the American Psychiatric Institute for Research and Education, told commission members that a “tragic consequence” of previous efforts to reform the system is that “those with the most severe mental disorders have often seen their services diluted as expansion has occurred for those with less disabling conditions.”

Jails and prisons have become the new institutions for many with severe mental disorders, he said, as psychiatric hospital beds decreased from 555,000 in 1955 to about 54,000 in 1997.

Regier noted that the situation in the private mental health system has also deteriorated. Mental health expenditures decreased by more than 50 percent from 1988 through 1997 in mid- to large-size companies, at the same time there was minimal change in expenditures for medical/surgical treatments.

Commissioner Henry Harbin, M.D., chair of the board of Magellan Health Services, asked the panel of representatives how their associations were responding to problems resulting from the scarcity of mental health professionals.

Regier described APA’s activities in three areas. The Association is working with other medical associations to enhance the capability of primary care and other physicians to diagnose and treat mental illnesses such as depression.

APA administers a federally funded fellowship and other programs designed to increase the number of psychiatrists and researchers who are members of minority groups.

The Association is also working with federal agencies and medical associations to evaluate psychiatry training programs with the hope that they can be streamlined and increase the number of psychiatrists in short supply, such as those who treat children.

Expanding Role of Consumers

Mental health organization representatives testified about the importance of involving consumers in the design and administration of mental health programs.

Michael Faenza, president and CEO of the National Mental Health Association, urged a “focus on consumer rights and recovery.” He said, “Consumers (and when appropriate, families or other consumer-supporters) must also be treated as equal partners in treatment decisions leading to recovery.”

Robert Bernstein, Ph.D., executive director of the Bazelon Center for Mental Health Law, testified, “Consumers must have a far greater role in defining services and supports, greater choice of voluntary services, and more control over how resources designed to help them are spent.”

James McNulty, president of the National Alliance for the Mentally Ill, spoke in support of empowering consumers and families “to drive treatment and recovery options.”

Commissioner Anil Godbole, M.D., noted that some consumers challenge the idea that mental disorders have a biological basis. He asked, “How do you reconcile the idea of transforming the mental health system with their insistence that it is beyond repair?”

Godbole is chair of the psychiatry department at Advocate Illinois Masonic Medical Center and president of the National Association of Psychiatric Health Systems (NAPHS).

McNulty described the indignities of his hospitalization for treatment of bipolar disorder. He said, “It’s not surprising if people come out of the mental health system thinking ‘I’m not the problem.’ ”

Bernstein commented that some consumers had rejected the idea that the mental health system could be helpful because it had performed so poorly for them.

Other testimony focused on specific legislation, policies, and procedures that inhibit the development of an effective mental health system.

Legislative and Policy Failures

Pope Simmons, vice president for government relations of the National Council for Community Behavioral Healthcare, cited an article by William Goldman, M.D., in the December 2001 Psychiatric Services to support his concern about the “growing crisis” in recruiting and retaining appropriate mental and behavioral health clinicians.

He also charged that Medicare “can be. . .viewed as a template used by private insurance plans on how to limit mental health services.”

In Medicare, patients are charged a 50 percent copay for outpatient mental health services. All other Medicare Part B services require only a 20 percent copay. In addition, Medicare legislation limits treatment in freestanding psychiatric hospitals to 190 days during the course of a person’s life.

Faenza said that although Medicaid is projected to cover 60 percent of state and local mental health funding by 2007, states are increasing efforts to cut Medicaid spending because of budget deficits.

He expressed concern about the administration’s new Health Insurance Flexibility and Accountability Demonstration Initiative, which gives states flexibility to reduce Medicaid coverage by using a streamlined waiver process.

Faenza said, “This combination of a budget-scare environment and increased flexibility is a prescription for reduced or eliminated services.”

Edward Irby, a member of the NAPHS Board of Trustees, noted the problem of funding streams that do not follow the patient. He cited the Institution for Mental Disease Exclusion, which prohibits Medicaid reimbursement for any person over age 21 and under age 65 who resides in an institution for mental diseases, even for treatment unrelated to mental illness. A patient who turned 22 while in a psychiatric hospital immediately would become ineligible for Medicaid reimbursement.

The presidential commission meets monthly in public session. It is scheduled to issue an interim report on November 1 that describes the extent of unmet needs and barriers to care within the mental health system and also provides examples of successful community-based models of mental health care.

The commission’s Web site is www.mentalhealthcommission.gov. In related news, on August 13 Health and Human Services Secretary Tommy Thompson sent the governors a letter announcing a Web site to help states share “promising practices” of innovative programs that states have adopted to strengthen long-term support systems in communities. The address is www.cms.gov/promisingpractices. ▪