Politics of Psychiatry and Mental Health Care

Winston Churchill said, “Politics is not a game; it is an earnest business,” and finally we are getting serious about the politics of mental health care. After decades if not centuries of neglect, the bona fide health care disparity is receiving an unprecedented amount of attention. In part, this is due to the efforts to reform our nation’s health care delivery and financing systems to improve quality and rein in costs. But it represents an attitudinal change in our society toward mental illness prompted by the egregious deficiencies in our mental health care policies, sensationally and shockingly, reflected by the rising number of people with mental illness involved in civilian massacres, imprisoned by the criminal justice system, and homeless on the street. However undesirable the factors that may have occasioned it, the increased public attention to mental health care is welcome.

Most recently, we saw this reflected in the November 2013 release of the final rule for the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA), the goal of which is to improve the quality of and access to care for people with mental illness. But this goal can be achieved only if accompanied by adequate oversight and enforcement of the law among insurance companies and providers.

We must be sure health insurance plans are explicitly required to show exactly how their general medical benefits line up with their mental health benefits. Government monitors must be able to determine whether insurance plans are adhering to parity standards in all settings—from primary care offices to specialized mental health and addiction settings.

For consumers to make informed decisions, they need to know what each plan covers. Therefore, we must have clarity on exactly what information insurance plans must disclose to potential customers before they make these decisions. And once they have chosen a plan, medical necessity criteria used for approval or denial of claims must be easily and readily available to subscribers in an understandable and specific manner.

But true parity goes beyond monitoring and enforcement. It extends to the fundamentals of how we practice medicine. Integrated medical and behavioral health models, in which psychiatric physicians and mental health specialists work closely with patients’ primary care providers, can expand access, leveraging limited resources for truly comprehensive care that ensures more people are receiving quality health care, including mental health care. Not only do these models help close the gap between physical and mental health, but a growing body of research, including a recent Cochrane review of 79 randomized, controlled trials, demonstrates their potential for lowering health care costs while improving patients’ health.

We expect accountable care organizations (ACOs) to incorporate mental health and addiction services into integrated models of care and to make sure these services are paid for—but how it happens and whether it works remains to be seen, as these organizations become more widespread. Our job is to make sure that ACOs meet the mental health needs of the people whose lives are entrusted to them by ensuring that the care they promise is delivered.

Expanded access to health insurance through the Affordable Care Act will increase the population that can avail themselves of quality health care. It is immensely important and gratifying that the ACA incorporates MHPAEA and its final rule.

Perhaps no piece of the puzzle is more complex than payment. Consequently, as this historic new legislation (ACA, MHPAEA) is implemented, we will need to continue to test delivery and payment models designed to improve care, lower costs, and, most of all, better serve individuals in need. We must recognize that all areas of practice have to adapt to a new set of realities if those with mental health and substance use disorders are to be adequately served.

We must continue to be vigilant of our patients’ privacy rights. If we are truly embracing the culture of parity, we must find a way to share information with our health care partners with electronic medical records and in the context of contributing to seamlessly accessible information such as through registries in the broader health care world.

In addition to these overarching issues of access and care delivery, our legislators are now considering mechanisms that would significantly impact the implementation of these policies. Rep. Tim Murphy’s Helping Families in Mental Health Crisis Act, introduced partly in response to the Sandy Hook shooting, is aimed at improving interagency coordination, government data collection on treatment outcomes, and creating a centralized effort to implement evidence-based care. We support the bill’s intentions, but are also pleased with the opportunity it offers to work with members of Congress to educate them about the changes needed in mental health care. We must stay vigilant to ensure that the rights of people with mental illness are not being jeopardized and the services they need and deserve are secure.

Yet another area requiring attention is the proposal by the Centers for Medicare and Medicaid Services to do away with several of the “protected classes” of prescription drugs under the Medicare Part D program in 2015 and 2016 (see page 4). APA’s concern about the effect of this rule is well placed, since it would limit patient choice and provider options for treatment. This is especially important in psychiatry, an area of practice in which we cannot predict which medications a patient will respond to and tolerate best, and in which individuals may uniquely respond to a specific drug.

While the political pendulum has swung in our direction (the result of great effort on the part of APA and many other stakeholder groups, it should be noted) and we have made great legislative strides, we must always bear in mind our end goal. We are working to create a society in which mental disorders and chronic addictions are recognized and understood to be what they are: illnesses that are real and treatable. To truly effect sustainable change, we must view these historic legislative initiatives as more than just laws, but as a means by which to shift the way we collectively think about mental health and integrate it into general health. We are working to ensure that people with mental illness receive the care they need when and where they need it and without bias in a true culture of parity. ■