News & Notes

The amount of money U.S. employers spent for behavioral health care benefits for their employees dropped by 54 percent over the past ten years, according to a study conducted by the Hay Group, an actuarial and benefits consulting firm in Washington, D.C. The study found expenditures of only $69.61 per employee per year in 1997, compared with $151.54 in 1988.

Although an overall decrease in expenditures for health care benefits during the past decade was expected as a result of the rise of managed care, the study found that the decrease in expenditures for behavioral health care benefits was much greater than that for general health care benefits, which decreased by 7.4 percent from 1988 through 1997. Total health care benefits decreased by 10.2 percent over the same period. Dollars spent for behavioral health care benefits constituted only 3.1 percent of the total value of health care benefits in 1997, compared with 6.1 percent in 1988.

The study was based on data from a broad industry and geographic mix of U.S. employers. The findings are sum marized in a report entitled Health Care Plan Design and Cost Trends: 1988 Through 1997, which was released in May at a press conference in Washington, D.C., called by the three mental health provider and advocacy groups that commissioned the study: the National Association of Psychiatric Health Systems (NAPHS), the Association of Behavioral Group Practices, and the National Alliance for the Mentally Ill. The NAPHS Education and Research Foundation funded the study.

At the press conference, representatives of the three organizations cautioned that the report's findings suggest a loss of funding for and access to behavioral health care that could seriously reduce patients' likelihood of receiving effective treatment for mental illnesses. They plan a national educational campaign to bring the report's findings to the attention of employers, health care leaders, and legislators.

According to the report, health plan limits on behavioral health care benefits have become increasingly common over the past ten years. The percentage of health plans imposing various types of limits on inpatient psychiatric care-such as limits on length of stay and annual or lifetime dollar limits-increased to 86 percent in 1997 from 63 percent in 1990. Fifty-seven percent of health plans imposed limits on the number of days a patient could remain in inpatient psychiatric care in 1997, compared with 38 percent of plans in 1988. However, limits on length of stay have remained stable-59 percent of plans limited inpatient care to 30 days in 1988; 57 percent did so in 1997.

The percentage of health care plans that provide the same maximum coverage for inpatient psychiatric care as for other confinements decreased to 14 percent in 1997 from 37 percent in 1990, although the percentage of plans that cover 100 percent of the reasonable and customary costs of inpatient psychiatric care remained relatively stable over the years.

As for outpatient psychiatric care, 48 percent of plans imposed an annual visit limit in 1997, compared with 26 percent of plans in 1988. In addition, the number of visits allowed each year has decreased. In 1997, the most prevalent annual limit on visits allowed a maximum of 20 visits, and only 17 percent of plans allowed 50 visits a year. In 1988, 46 percent of plans with an annual limit on visits allowed a maximum of 50 visits. Although fewer plans imposed per-visit dollar limits in 1997 than in 1988, the amount of the average limit was more restrictive in 1997 than in 1988.

Over the past ten years, an increasing percentage of plans have required a separate per-visit copayment for outpatient psychiatric care rather than providing these benefits under the general medical plan deductible. Thirty-five percent of plans required a separate copayment in 1997, compared with 6 percent in 1988. Although plans were more likely to pay 100 percent of reasonable and customary charges for outpatient psychiatric care in 1997 than in 1990, the increased use of other limits, such as per-visit or annual dollar limits or limits on the number of visits, toward the end of the study period decreased the actual amount of charges plans cover.

The data in the report were collected before implementation of the Mental Health Parity Act of 1996, which became effective January 1, 1998. The act requires parity with physical health coverage with respect to aggregate lifetime expense limits and annual dollar limits on mental health benefits. It does not require a health plan to provide mental health benefits, and plans are allowed to adopt higher copayments and deductibles and to impose limits on the number of visits or days of treatment.

For more information about the findings reported in Health Care Plan Design and Cost Trends: 1988 Through 1997, contact the National Association of Psychiatric Health Systems, 1317 F Street, N.W., Suite 301, Washington, D.C. 20004-1105; telephone, 202-393-6700; fax, 202-783-6041.

Older mental health consumer-activists from 27 states met at a conference in Washington, D.C., in late May to begin organizing a new national mental health advocacy movement to meet their special needs. The conference, which was convened by the Bazelon Center for Mental Health Law, was underwritten by the Center for Mental Health Services, the Retirement Research Foundation, and the Nathan Cummings Foundation.

Robert Bernstein, Ph.D., executive director of the Bazelon Center, said older people with mental illnesses have been left behind by the consumer movement. A primary concern of conference participants was the large number of people with mental disorders languishing in nursing and boarding homes for lack of support to help them live at home. They pointed out that mental health providers often refuse to serve older people with mental illnesses, falsely assuming they can't be helped.

Representatives of several national organizations attending the conference expressed support for the advocacy movement. Groups represented included the American Association of Retired Persons, the Alzheimer's Disease and Related Disorders Association, the National Alliance for the Mentally Ill, the National Mental Health Association, and the National Association of State Mental Health Program Directors.

Imformation about the the group will be posted on the Bazelon Center's Web site (www.bazelon.org/older.html) or can be obtained by writing the Older Adult Program, Bazelon Center for Mental Health Law, 1101 15th Street, N.W., Suite 1212, Washington, D.C. 20005; fax, 202-223-0409; e-mail, [email protected].

Abuse of alcohol and abuse and misuse of prescription drugs-an "invisible epidemic"-affect up to 17 percent of adults age 60 and older, according to a report released in May by the Center for Substance Abuse Treatment. Alcohol-related problems account for more emergency room visits among older adults than heart attacks. Because the older segment of the population is the fastest growing, underdiagnosis and undertreatment of substance abuse threaten to rob an increasing number of older Americans of their health and independence, the report warns.

Substance Abuse Among Older Adults is a best-practice guideline developed by a consensus panel of 15 experts in geriatric psychiatry and addiction treatment. The panel attributed the invisibility of the epidemic to several factors. Health care providers tend to overlook substance abuse among older people, mistaking the symptoms for those of dementia, depression, or other problems common to this population. Older adults are more likely than younger people to hide their substance abuse, the panel noted, and are less likely to seek help. The relatives of older adults, particularly their adult children, are often ashamed of the problem and choose not to address it. The panel pointed out that "ageism" also contributes to the invisibility of the epidemic and to the silence: there is an unspoken but pervasive assumption that it is not worth treating older adults for substance use disorders.

One of the panel's intentions was to correct long-standing misperceptions about alcohol use among older adults that impede identification and treatment. For example, the typical older adult with a drinking problem has long been considered to be a man with an extensive drinking history. DSM-III-R stated, "In males, symptoms of alcohol dependence or abuse rarely occur for the first time after age 45." However, the panel cited studies in the last decade indicating that nearly 30 percent of male alcoholics report that their first symptoms of alcoholism occurred after age 60-15 percent between the ages of 60 and 69 and 14 percent between the ages of 70 and 79. For women, these figures are 24 percent and 28 percent, respectively.

The report describes problems clinicians may encounter in diagnosing an alcohol use disorder in an older adult. DSM-IV criteria may not apply to many older adults who have reduced role obligations at work, school, or home and who may not experience the legal, social, or psychological consequences specified by the criteria. Nor does the criterion "continued use of the substance despite persistent or recurrent problems" always apply. Many older alcoholics do not realize that their persistent or recurrent problems are related to their drinking, a view likely to be reinforced by health care providers who may attribute these problems to the aging process or age-related comorbidities. Furthermore, the panel pointed out that although tolerance is a criterion for a diagnosis for substance dependence, the thresholds of alcohol consumption often considered by clinicians as indicative of tolerance may be set too high for older adults because of their altered sensitivity to alcohol.

A separate chapter of the report describes the problem of misuse and abuse of psychoactive medications and over-the-counter drugs in this population. Largely due to safer drugs and better prescribing practices, misuse and abuse of psychoactive drugs have actually diminished in recent years. However, the problem is still prevalent among older adults not only because more drugs are prescribed for them-a third of people over age 65 take eight or more prescription medications daily-but also because aging makes the body more vulnerable to the effects of drugs. The report cites studies showing that long-term administration of psychoactive drugs to older adults, even at therapeutic doses, has been associated with a variety of adverse central nervous system effects, including diminished psychomotor performance, loss of coordination, falls, confusion, rage, and amnesia. Any use of alcohol in combination with these drugs increases the risk of adverse effects.

The panel's report and recommendations are aimed at raising awareness of the problem among substance abuse treatment providers, primary care clinicians, social workers, senior center staff, and others who have regular contact with older adults. A chapter on screening and assessment, which recommends routine screening of older adults in primary care settings, highlights the need for rescreening as older patients undergo key life transitions, times when late-onset alcoholics typically report that their abuse began. In addition to reviewing several screening tools that clinicians have found useful with this population-some of which are reproduced in an appendix-the chapter lists examples of indirect and direct questions that nonclinicians such as senior center staff or Meals-On-Wheels volunteers may ask to elicit information about alcohol use.

Another chapter on referral and treatment approaches reviews specific interventions from least to most intensive, as well as general approaches, such as cognitive-behavioral and group-based approaches. Problems that may be encountered by older adults in various treatment settings are highlighted, and the report describes basic principles that should be incorporated if programs are to be effective with this population. A separate chapter describes outcomes measures appropriate for older adults and addresses cost and reimbursement issues.

The consensus panel makes several recommendations in the report. The panel strongly endorsed the recommendation for low-risk drinking set in 1995 by the National Institute on Alcohol Abuse and Alcoholism for individuals over age 65: for men, no more than one drink per day, and a maximum of two drinks on any drinking occasion such as on New Year's or at a wedding. For women, somewhat lower limits are recommended. The panel also suggested the use of a two-stage model to differentiate older drinkers- "at-risk" and "problem" drinkers-rather than a three-stage model incorporating "heavy" drink ers. Special considerations in applying DSM-IV criteria to older adults with alcohol problems were also recommended by the panel.

Substance Abuse Among Older Adults is the 26th publication in the Center for Substance Abuse Treatment's (CSAT) Treatment Improvement Protocol (TIP) series. All TIPs are available in full-text versions on the CSAT Web page at www.samhsa.gov, or they can be ordered free of charge by contacting the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.

Green Spring of Maryland wins NCQA accreditation: Green Spring of Maryland, an operating unit of Magellan Health Services, is the first organization in the nation to be accredited under the new standards for managed behavioral health care organizations developed by the National Committee for Quality Assurance (NCQA). Green Spring was awarded one-year accreditation through May 10, 1999. NCQA is an independent, not-for-profit organization that has been evaluating managed care organizations since 1991. Its accreditation survey is a voluntary review process that includes evaluation of how well a managed behavioral health care organization manages all parts of its delivery system in order to continuously improve health care for its members. Beginning in 1999, all health plans in the nation seeking NCQA accreditation will be required to meet the new standards for their behavioral health services whether they are managed by the health plan itself or by a managed behavioral health care organization.

Certification in administrative psychiatry: Five psychiatrists were certified as having met the requirements for certification in psychiatric administration and management on May 30 during the American Psychiatric Association annual meeting in Toronto. They are Douglas R. Budde, M.D., of Winter Park, Florida; Kenneth J. Miller, M.D., of San Clem ente, California; Lindsay B. Paden, M.D., of Escondido, California; Shir ish V. Patel, M.D., of Rochester, New York; and Syed Atezaz Saeed, M.D., of Edelstein, Ill inois. The certification is awarded by APAcommittee on psychiatric administration and management to candidates who successfully complete a written examination, given each December, and an oral examination, given the following May. William H. Reid, M.D., of Horseshoe Bay, Texas, is chairman of the committee. The deadline for receipt of applications for 1999 certification is August 1. Information and application forms are available from Donna Stuckey Bostick in APA's office of education; phone, 202-682-6109.