Appelbaum Outlines Plan to Address Country’s Mental Health Crisis

Despite America’s proud heritage of 251 years of hospital care for people who are ill, including those suffering from mental illness, modern times have seen this country take a huge leap backward, said incoming APA President Paul Appelbaum, M.D., in his response to the presidential speech at the Opening Session of APA’s 2002 annual meeting last month in Philadelphia.

“The principle that inspired the founders of the Pennsylvania Hospital, the Friends Asylum, and APA—that a civilized society is obligated to care for those of its members who suffer from the consequences of mental illness—seems everywhere to be honored in the breach,” said Appelbaum. “Wishing that mental illness would not exist has led our policymakers to shape a health care system as if it did not exist. The result can be described only as incipient disaster.”

Appelbaum quoted a report from the Bazelon Center for Mental Health Law indicating that states now spend 30 percent less on mental health care, adjusted for inflation, than in 1955. Moreover, from 1990 to 1997, per capita state expenditures on mental health dropped 7 percent, with states now providing only 2 percent of the dollars spent on mental health services. He added that in his home state of Massachusetts, the government has created a convoluted, unfair system of payment in which essentially the state doesn’t pay anything at all for mental health services.

Access and payment problems, however, go beyond the public sector, said Appelbaum, chair of the psychiatry department at the University of Massachusetts Medical School and one of the country’s preeminent forensic psychiatrists. Approximately 170 million Americans have mental health benefits overseen by a for-profit managed care company. Since these companies have control over large groups of patients, they get away with negotiating below-cost rates for inpatient and outpatient care, forcing facilities and physicians to operate in the red. At the same time, these managed care companies also impose huge additional costs to obtain approvals to initiate and continue care—all this while managed care companies are cutting their overall spending on services.

“From 1988 to 1998,” Appelbaum pointed out, “managed care plans cut the amount of money they were spending on psychiatric care by 55 percent, compared with reductions of 12 percent in dollars spent on care for all other conditions.”

The federal government, too, is responsible for part of the turmoil in this country’s health care system, continued Appelbaum. Medicare payments have been cut, especially to teaching hospitals and physicians. If not reversed, physician payments will drop by 17 percent over the next four years.

All these reductions in mental health resources could lead to “a wholesale collapse of our mental health system—which is what I believe we are facing today,” Appelbaum said. The crisis, however, is not inevitable, and he shared his ideas on what needs to be done to avert it.

“First, those of us who are aware of the problem have to sound the alarm. We need to make sure that the public at large, the media, opinion makers, and political leaders become aware of the perilous state of financing for mental health care today. . . . [W]hen their family members need help, there may simply be no place to obtain it.”

Another part of the solution is legislative. Congress must be convinced to enact parity legislation this year. Moreover, the federal and state governments must pass legislation requiring that procedures for reviewing psychiatric care be comparable to those for other types of medical care. “The petty harassment that bleeds providers and hassles patients—such as requiring advance approvals for every few visits and delaying payment indefinitely—has to end.”

The federal government must also adjust Medicare and Medicaid payments to cover the actual costs of care and prevent states from abandoning their historic responsibilities of “providing a safety net for indigent patients,” he continued.

The business community has a role to play as well, Appelbaum said. This entails providing coverage with “adequate payments to cover the costs of the provision of care, a large enough network to meet the needs of the insured population, minimal hassles for patients and caregivers in getting authorization for treatment, independent appeals mechanisms when requests for care are denied by the insurer or managed care company, and defined performance measures to demonstrate that patients actually get the care they need.”

“It is up to us,” said Appelbaum as he addressed his colleagues in the Pennsylvania Convention Center, “to redeem the implicit promise of the physicians and lay people who created the Pennsylvania Hospital and Friends Asylum and founded this organization here in Philadelphia so many years ago: the promise to offer compassion and care to persons with mental illness, to relieve suffering and to restore function, to advance knowledge, to transmit it to a new generation, [and] to be the best physicians that we can be so that our patients can be everything that they are capable of being.” ▪