Presidential Address: Re-Envisioning a Mental Health System for the United States
Publication: American Journal of Psychiatry
Members of the American Psychiatric Association, it has been an honor to serve you this year as President. This has been a year of many accomplishments for APA:
We campaigned for parity in health insurance coverage for mental disorders. We fought to block destructive cuts in state and federal budgets for mental health treatment. And we reiterated our commitment to protecting the public from the absurd notion that psychologists who have not graduated from medical school can safely prescribe medications for the treatment of psychiatric disorders. So far this year, I am pleased to report, we have defeated psychologists’ efforts to practice medicine by legislative fiat in five states—and we will not desist until this threat to public health is put to rest once and for all.
We created an array of new services for our members, including FOCUS: The Journal of Lifelong Learning in Psychiatry, free online continuing medical education, and guidance on dealing with the new Health Insurance Portability and Accountability Act (HIPAA) medical privacy regulations—including extensive information available to members on the APA web site and an online bulletin board where HIPAA-related questions are answered by an APA attorney. And there will be more to come. No member will ever again need to wonder what benefits they receive from belonging to APA.
We made significant progress in placing APA back on firm financial footing. By generating a substantial surplus in revenues—while controlling expenditures—we were able to begin the crucial task of replenishing APA’s reserves.
We hired a new Medical Director, Jay Scully, M.D., whose energy and enthusiasm have already brought renewed vitality to our operations.
And in the interest of increasing efficiency and reducing costs, we moved our offices to beautiful new quarters across the Potomac River in Arlington, Va.
These and all of APA’s other achievements were made possible by the hard work of my colleagues on the APA Board of Trustees, of our members who serve in the Assembly and on our components, and of the wonderful people on the APA staff. My thanks to all of them, and as well to my family, especially my wife, Dede, whose support has been so important to me this year.
Mental Health Services in Crisis: The Defunding of a System
Last year in Philadelphia, I stood before you to describe the crisis in our mental health system (1). The genesis of that crisis lies in the uniformly inadequate resources allocated for the delivery of psychiatric care in America today. So poorly are psychiatrists, clinics, and hospitals compensated for the treatment they render that relying on insurance payments for patients’ care is often literally a losing proposition. As a result, hospitals are closing psychiatric inpatient units, clinics are cutting back on services, and psychiatrists and other mental health professionals are finding that insurance reimbursements can no longer sustain their practices. The situation is compounded by the extraordinary additional costs imposed by the managed care industry, whose utilization review and other procedures often seemed designed primarily to discourage patients from pursuing treatment and psychiatrists from providing it.
The inevitable result of this situation, as I demonstrated for you starkly 1 year ago, is a critical inability of patients to access needed psychiatric care. Hospital beds are routinely unavailable in many parts of the country, forcing severely ill patients to wait for days in emergency rooms or to travel hours from their homes to find a hospital that can accept them. When outpatient care is required, patients who must rely on insurance coverage for their treatment face waiting lists of weeks to months in many hospital or community clinics, and they often find that those private practitioners who are listed on their managed care companies’ panels are unable to accept any new patients at managed care rates. Simultaneously, they discover that what was once the safety net of the public mental health system, having been steadily drained of resources for decades, can no longer offer them even minimal treatment.
In the year since we spoke of these developments, which I characterized as the consequences of the “systematic defunding” of the American mental health system, things have become even worse. There has been no meaningful improvement in reimbursement for psychiatric treatment by the for-profit managed care companies that dominate the field. Indeed, the largest of these companies, Magellan, which covers in excess of 60 million Americans, has itself gone into bankruptcy (2). As most specialties saw their Medicare payments increase, psychiatry’s actually decreased, based on a badly flawed formula that continues to favor procedure-oriented specialties (3).
Medicaid, which pays for more than 20% of all psychiatric care in this country (4), has been hit particularly hard. Faced by unprecedented budget deficits, states are simply slashing what they will pay for psychiatric treatment across the board, imposing counterproductive restrictions on access to psychiatric medications and, in the worst cases, dropping tens or hundreds of thousands of indigent people from the Medicaid rolls (5). Oregon is this year’s poster child for discriminatory treatment of Medicaid enrollees with mental illness, depriving 100,000 persons of coverage for psychiatric treatment, while retaining coverage of every other kind of medical care (6). At the same time, funding is being reduced for state departments of mental health, with yet more state hospitals closing (7) and still more patients discharged to community services that are inadequately funded even to care for their current caseloads.
By now, you know what comes next. With the costs of providing care continuing to rise—take spiraling malpractice insurance rates as just one example—the availability of psychiatric services is steadily declining. Hospital inpatient units continue to close. Not long ago I received an anguished call from a psychiatrist in the Northeast whose hospital CEO had just told him that the excellent 20-bed psychiatric unit that he oversaw would be replaced by medical/surgical beds. The reason? The hospital needed the extra income that medical/surgical beds would provide. So long as psychiatry remains the poor sister of medicine, such stories will continue to proliferate (8). And an identical process is going on in community and hospital-based outpatient clinics (9). In a country in which only 20% of persons with a mental disorder receive any treatment in a given year, even more people are having trouble accessing care than was the case a year ago.
Re-Envisioning the Mental Health System
As important as it is to call attention to the crisis in access to and reimbursement for psychiatric care, merely sounding the alarm—as I urged you to join me in doing last year—is not enough. Psychiatrists work every day to overcome the obstacles placed before us and our patients by the current nonsystem of care. Hence, we are in the best position not merely to critique the ongoing muddle, but—even more important—to set out a vision for a genuine system of care. Toward this end, I appointed a special APA task force, chaired by our Vice-President Steve Sharfstein, M.D., to develop a vision statement for the mental health care system. The task force worked through the winter, producing an excellent document titled “A Vision for the Mental Health System” (10), which was endorsed by APA’s Board of Trustees at its March 2003 meeting. Members of the media and government decision makers have already told me how useful they have found this document, which creates a set of benchmarks against which progress toward meaningful mental health system reform can be measured. I encourage you to access and read this report on APA’s web site (10).
Today, I want to share parts of the “Vision” report with you, using it as a starting point to suggest some key directions in which we must begin to move, if we are to create a genuine system of mental health care.
I begin with what I consider to be the cornerstone of the task force’s vision:
Every American with significant psychiatric symptoms should have access to an expert evaluation leading to accurate and comprehensive diagnosis which results in an individualized treatment plan that is delivered at the right time and place, in the right amount, and with appropriate supports such as adequate housing, rehabilitation, and case management when needed. Care should be based on continuous healing relationships and engagement with the whole person rather than a narrow, symptom-focused perspective. Timely access to care and continuity of care remain today cornerstones for quality, even as a continuum of services is built that encourages maximum independence and quality of life for psychiatric patients. (10, pp. 1–2, italics in the original)
What would a system that could achieve these goals look like? Here I use the “Vision” report as a starting point but move beyond its specific recommendations.
For most people with mental disorders, I submit to you, care is best delivered in the context of the general health system. As many patients already receive treatment for mental disorders from their internists and family practitioners as they do from psychiatrists (11, 12). Primary care specialists write the majority of prescriptions for psychotropic medications (13). Rather than seeing this as a less-than-optimal situation, we ought to consider the involvement of primary care physicians in the treatment of mental disorders as a potential strength of a future, integrated system of care. Not only are patients likelier to have ready access to primary care physicians, but there are simply not enough psychiatrists to treat every person with a mental disorder. I remind you again of the National Comorbidity Study finding that 80% of persons with mental disorders receive no care in a given year, including more than 50% of persons with such major psychiatric disorders as schizophrenia and bipolar disorder (14). Meeting this demand requires more access to medical expertise than psychiatrists themselves can provide.
But this is not a task that all primary care physicians can fulfill right now. Many of them need additional training in the recognition and treatment of mental disorders as an important component of primary care. Nor can they do this on their own. Psychiatrists should be available to every primary care setting for consultation—preferably on-site—and treatment of the more challenging cases, of which there will be no shortage. Collaborative management of psychiatric disorders is the essential component of an effective primary-care-based system. Far from excluding psychiatrists from the treatment of most patients, it will tap their knowledge and skills to a much greater extent than is possible today. And no discipline without medical training can possibly substitute for the needed medical expertise.
Today, of course, there are multiple systemic obstacles in the way of widespread implementation of such an approach, although model programs organized along these lines have long existed (15, 16). When insurance coverage for psychiatric treatment is carved out from general health care—as is typical today—primary care physicians often cannot get reimbursed for dealing with psychiatric problems. Moreover, almost no insurer compensates psychiatrists (or other physicians) for consultation on patients whom they do not examine directly. This undercuts the most efficient model of psychiatric consultation in primary care and other general medical settings. Often described somewhat pejoratively as “curbside consults,” these brief contacts can be all that is needed to assist nonpsychiatric physicians in managing cases or appropriately referring patients for psychiatric evaluation. In addition, when nonpsychiatric physicians are precluded from making direct referrals to psychiatrists—as they frequently are today—the relationships on which a consultative model depends can never develop. All of these self-defeating aspects of the current system need to be changed, a process that will be facilitated immensely by “carving” mental health coverage back into general health insurance plans.
It goes without saying that no primary-care-based system can succeed without every person having health insurance coverage. APA has long supported universal health insurance, a reform that is more crucial today than ever. Whatever universal insurance plan is adopted should cover treatment of psychiatric disorders on a nondiscriminatory basis compared with other forms of medical care. Nondiscrimination must go beyond benefits on paper to encompass the mechanisms of review for authorizing care. And, of course, the rates paid for treatment of psychiatric disorders must take into account the real costs of delivering such care. That is not the case today but is essential for both primary care and psychiatric physicians to be able to deliver effective treatment in this model.
As the task force recognized, for people with severe and persistent mental illness, special considerations come into play. Many of these patients can best be treated in the specialty psychiatric sector, where additional expertise and adjunctive services are available. They may require case management, social reintegration, employment training, assistance with housing, and other services that cannot be supplied in the primary care setting. For this extremely vulnerable group of patients, the most logical locus of care is a revitalized community mental health center (CMHC) network.
The Community Mental Health Centers Act of 1963 was the closest this country has ever come to acknowledging its responsibility to provide quality care for all persons with mental disorders (17). We can all point to problems in the implementation of the CMHC act. But its conceptual foundation was rock-solid: proactive efforts to provide mental health care are facilitated by assigning responsibility for a defined population in a circumscribed catchment area. No part of the country should be without such a facility. Refocused on the severely and persistently ill population, supported by ongoing allocations of state and federal funding (especially important for services that are not easily funded on a fee-for-service basis—e.g., case finding), given the flexibility to manage funding streams across the usual human services boundaries, emphasizing continuity of care, and evaluated by measurable outcome criteria, CMHCs would become the linchpin for serving people with long-term and severe psychiatric disorders. As a complement to this outpatient-oriented system, adequate numbers of beds should be available for acute and longer-term hospitalization when needed.
Funding a New System of Care
It is one thing, of course, to sketch the outline of a genuine system of psychiatric care—and it is only the barest outline that I have been able to present here today—and quite another to persuade the public and our political leaders to provide the necessary funding to make this vision a reality. Here, once more, the report of the “Vision” task force points the way. As the task force suggests, a methodology now exists for quantifying the impact of mental illness in our society, relying on the concept of the “burden of disease.” A common metric—disability-adjusted life years—allows comparisons to be made across all medical disorders, in terms of both years of life lost and years lived with disabilities. When mental illness is looked at in this way, it becomes clear that psychiatric care is grossly underfunded. Mental disorders account for 20% of the total burden of disease in the United States, while only 5.7% of all health expenditures go to their treatment (18). Enlightened self-interest alone would suggest that this country should be investing a much greater proportion of its health care dollars in psychiatric care.
Beyond this, we need to make it perfectly obvious to decision makers at the federal and state levels that mental illness ignored does not simply disappear. The costs of untreated mental illness are shifted elsewhere in our society: to the correctional system, which may now house and treat more people with mental illness than our public mental health facilities; to the health care system, which covers the costs of emergency, inpatient, and often outpatient care for those without insurance coverage; to our social welfare system, which provides welfare and disability payments to persons who, with adequate treatment, might be self-supporting; and to patients’ families, who often substitute for an ineffective mental health system and bear the staggering costs. Were the financial resources now being consumed to compensate for the deficiencies of the current mental health nonsystem utilized to provide quality psychiatric care, we could afford to implement the vision of a genuine system of care.
The value of a vision is that it creates a “big picture” into which each of our incremental efforts can fit. Once we know what we need to do, it remains to muster the courage to do it. When the task seems too difficult, the outcome uncertain, our efforts unappreciated or ignored, we can draw inspiration in this quest from our patients, who often struggle to overcome precisely these feelings as they make their way through life. So I leave you with the words of the early 19-century Chassidic master Rav Nachman of Bratzlav, who himself suffered from recurrent, intense depressive episodes. Rav Nachman would say to his followers, “Kol ha’olom kulo, gesher tsar m’od” (“The world in its entirety is a very narrow bridge”); “v’haikar lo lefacheid klal” (“and the most important thing is to have no fear”).
Footnote
Presented at the 156th annual meeting of the American Psychiatric Association, San Francisco, May 17–22, 2003. Dr. Appelbaum, 129th President of the American Psychiatric Association, is A.F. Zeleznik Distinguished Professor and Chair, Department of Psychiatry, University of Massachusetts Medical School. Address reprint requests to Dr. Appelbaum, Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA 01655; [email protected] (e-mail).
References
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