November 2010: This Month's Highlights

A three-article special section on health care reform and mental illness constitutes "a primer for mental health clinicians and policy makers," notes Thomas G. McGuire, Ph.D., guest editor of the special section. In his introduction to these articles ( page 1073 ), he also notes that the Patient Protection and Affordable Care Act (PPACA) "primarily reforms health insurance, not health care." Indeed, the first two articles focus on provisions of the law that will expand insurance coverage. Many Americans will purchase private insurance through newly created state-based "exchanges" that consolidate and regulate the marketplace for individual and small-group plans. In the first article, Dr. McGuire and Anna D. Sinaiko, Ph.D., discuss ways to structure an exchange to ensure that it will serve people with mental illness fairly and efficiently. They describe the experience of people with mental illness in insurance markets similar to exchanges, such as the Massachusetts Connector. The authors recommend approaches to regulating pricing, enrollment, and consumer choice and emphasize the important role of the exchange authority in each state ( page 1074 ). In the second article, Rachel L. Garfield, Ph.D., M.H.S., and colleagues highlight likely gaps in the insurance coverage that will be offered under health reform to people with mental illnesses or substance use disorders through private plans and public programs. They describe policy options to address these gaps and to ensure that a full range of services and supports is covered ( page 1081 ). In the third article, Benjamin G. Druss, M.D., M.P.H., and Barbara J. Mauer, M.S.W., C.M.C., describe opportunities afforded by reform for improving the delivery of care at the interface between behavioral health care and primary care, including patient-centered medical homes and colocation of services. They focus on key supports needed to ensure success of these initiatives: new financing mechanisms, quality assessment metrics, information technology infrastructure, and technical support ( page 1087 ). In a Taking Issue commentary Vidhya Alakeson, M.Sc., and Richard G. Frank, Ph.D., note that even though the PPACA places behavioral health squarely in the health care mainstream, policy makers must redouble their commitments to address the "sometimes exceptional circumstances presented by mental health care delivery" ( page 1063 ). In an Open Forum, Neil Krishan Aggarwal, M.D., M.B.A., and colleagues describe elements of the PPACA that posit seemingly contradictory views of health care: is it a commodity or a right, and what implications are inherent in these two views ( page 1144 )?

A population-based study in Philadelphia found that 2,703 persons who met federal criteria for chronic homelessness incurred costs of $20.1 million a year in psychiatric care, substance abuse treatment, and jail stays. In an analysis of data from multiple sources, Stephen R. Poulin, M.S.W., Ph.D., and colleagues showed that the 20% of persons who incurred the highest costs accounted for 60% of total costs ($12 million)—mostly for psychiatric care and jail stays—and that 81% of those in the highest cost quintile had a diagnosis of serious mental illness. Persons in the lowest cost quintile accounted for less than 2% of total costs, and 83% had a history of addictions treatment with no serious mental illness diagnosis. The authors note that cost offsets resulting from supported housing interventions are likely to be substantial for the former group, whereas cost neutrality for the latter group will require less service-intensive programs ( page 1093 ).

A number of interventions reduce suicidality and psychiatric hospitalizations among individuals with borderline personality disorder. However, clinicians at Harborview Mental Health Services (HMHS) in Seattle wanted to set the bar higher for stabilized patients who had successfully completed HMHS's year-long dialectical behavior therapy (DBT) program. They designed a second-year, follow-on program—DBT-ACES (Accepting the Challenges of Exiting the System), which reinforces progress toward recovery goals, such as paid work or school enrollment. Katherine Anne Comtois, Ph.D., M.P.H., and colleagues conducted a pre-post evaluation of outcomes for 30 DBT-ACES participants, which showed significant improvements in the odds of being employed or in school, as well as in other measures of community integration ( page 1106 ).

• Latino primary care patients with depression who participated in a collaborative care intervention were 21 times as likely as those receiving usual care to receive their preferred treatment ( page 1112 ).

• In Michigan a four-year partnership between two large state universities and the National Guard has provided needed help for returning soldiers and their families ( page 1069 ).