Mental Illness Mortality, Morbidity Get Medicaid Officials' Attention

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 Medicaid population.

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 said.

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 illness.

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 Assistance.

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 comorbidities.

“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 medical conditions.

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 beneficiary.

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. ▪