Men­tal health rises to top of agenda, but has a tough course ahead

Modern Healthcare - - NEWS - By Har­ris Meyer

Af­ter decades of tak­ing a back seat to other so­cial is­sues, fix­ing the na­tion’s bro­ken sys­tem of care for mil­lions of Amer­i­cans suf­fer­ing from men­tal ill­ness and drug ad­dic­tion has risen to the top of Congress’ agenda.

Law­mak­ers are poised to pass a sweep­ing pack­age of men­tal health­care re­forms dur­ing the lame-duck ses­sion next month, fol­low­ing en­act­ment in July of leg­is­la­tion to ad­dress the epi­demic of opi­oid ad­dic­tion. They and ad­vo­cacy groups are op­ti­mistic the Se­nate will fol­low the House in ap­prov­ing bi­par­ti­san leg­is­la­tion to re­vamp the govern­ment’s men­tal health­care ef­forts and in­crease fund­ing for preven­tion and treat­ment.

“There are 959 deaths ev­ery day re­lated to men­tal ill­ness— sui­cides, over­doses, homi­cides, men­tally ill home­less peo­ple dy­ing pre­ma­turely,” said Rep. Tim Mur­phy (R-Pa.), a psy­chol­o­gist who is the chief spon­sor of the House bill. “Un­der any other cir­cum­stance, we would con­sider that an epi­demic that would panic us. We have to do some­thing.”

The big ques­tion is whether Congress will have enough time dur­ing the 20 days of the lame-duck ses­sion fol­low­ing the Novem­ber elec­tion to pass the leg­is­la­tion, given the need to ap­prove a con­tin­u­ing bud­get res­o­lu­tion and po­ten­tially ad­dress tough is­sues such as the Trans-Pa­cific Part­ner­ship trade agree­ment and a re­vamp in the fed­eral ap­proval process for pre­scrip­tion drugs and med­i­cal de­vices. There’s also the chance that par­ti­san ran­cor af­ter the elec­tion could de­rail across-the-aisle co­op­er­a­tion. “I re­main op­ti­mistic be­cause we’ve talked to the lead­er­ship in both par­ties in the House and Se­nate, and they want to make this a pri­or­ity,” said Paul Gion­friddo, CEO of Men­tal Health Amer­ica, a coali­tion of men­tal health ad­vo­cacy groups. “Even if it doesn’t pass this time, we’ve laid good ground­work for next year.”

Law­mak­ers such as Sen. Bill Cas­sidy (R-La.) say broad con­sen­sus has de­vel­oped af­ter hear­ing con­stituents’ heart-wrench­ing sto­ries about peo­ple strug­gling with men­tally ill or ad­dicted rel­a­tives who are un­able to get ad­e­quate treat­ment. “When­ever Sen. Cas­sidy asks peo-

“There are 959 deaths ev­ery day re­lated to men­tal ill­ness. ... Un­der any other cir­cum­stance, we would con­sider that an epi­demic that would panic us.” REP. TIM MUR­PHY (R-PA.)

ple, ‘Who has been touched by men­tal ill­ness?’ hands shoot up around the room,” a Cas­sidy aide said.

Leg­is­la­tors are also in­creas­ingly aware of the costs of hous­ing thou­sands of se­verely men­tally ill peo­ple in prisons and jails, of the stresses on hos­pi­tal emer­gency de­part­ments of hold­ing pa­tients for lack of psy­chi­atric beds, and of grow­ing num­bers of men­tally ill and ad­dicted home­less peo­ple wan­der­ing the streets and oc­ca­sion­ally hav­ing tense en­coun­ters with po­lice. Also grab­bing their at­ten­tion are the painfully reg­u­lar cases of men­tally ill peo­ple en­gag­ing in in­ci­dents of mass vi­o­lence, though only a small per­cent­age of men­tally ill peo­ple com­mit vi­o­lent acts. Men­tal dis­or­ders top the list of the most costly con­di­tions in the U.S., ac­count­ing for $201 bil­lion in health­care spend­ing in 2013, far more than was spent on heart dis­ease or cancer, ac­cord­ing to fed­eral data.

An es­ti­mated 8.1 mil­lion adults have schizophre­nia or bipo­lar dis­or­der, and 3.9 mil­lion go un­treated in any given year, ac­cord­ing to data from the Na­tional In­sti­tute for Men­tal Health. Fifty-seven per­cent of adults with a men­tal ill­ness re­ceived no treat­ment in 2012-13, while 64% of youth with ma­jor de­pres­sion were un­treated, ac­cord­ing to the Sub­stance Abuse and Men­tal Health Ser­vices Ad­min­is­tra­tion.

The pend­ing leg­is­la­tion would build on a num­ber of other

mea­sures taken dur­ing the Obama ad­min­is­tra­tion to im­prove fund­ing for and ac­cess to men­tal health­care. Those ac­tions in­clude Med­i­caid ex­pan­sion un­der the Af­ford­able Care Act; the ACA’s re­quire­ment that health plans cover men­tal health­care as an es­sen­tial ben­e­fit; a sep­a­rate law man­dat­ing equal cov­er­age for be­hav­ioral and phys­i­cal care; and a law fund­ing cre­ation of in­no­va­tive be­hav­ioral health cen­ters in eight states.

These pol­icy changes come as a grow­ing body of re­search shows that early in­ter­ven­tion and treat­ment can sig­nif­i­cantly im­prove the long-term prog­no­sis for peo­ple with se­ri­ous men­tal ill­ness.

“There’s been more done for men­tal health in the last eight years than there has been since 1972,” said Richard Frank, a pro­fes­sor of health eco­nom­ics at Har­vard Univer­sity who served in a top HHS post in the Obama ad­min­is­tra­tion. “The new leg­is­la­tion will con­tinue the mo­men­tum.”

The Help­ing Fam­i­lies in Men­tal Health Cri­sis Act, which passed the House 422-2 in July, would cre­ate a new HHS as­sis­tant sec­re­tary in charge of men­tal health and sub­stance use dis­or­ders; au­tho­rizes grants for com­mu­nity treat­ment teams and as­sisted out­pa­tient treat­ment for non­co­op­er­a­tive pa­tients; and al­lows state Med­i­caid man­aged-care pro­grams to pay for short-term in­pa­tient stays.

In ad­di­tion, the bill re­quires HHS to clar­ify when providers may share in­for­ma­tion. It would also step up en­force­ment of rules for in­sur­ers to cover men­tal health­care on par­ity with phys­i­cal health; boost sup­port for training more men­tal health pro­fes­sion­als; help providers more eas­ily track avail­able in­pa­tient beds; sup­port a wide range of pro­grams to com­bat sui­cide and im­prove screen­ing, early di­ag­no­sis and early in­ter­ven­tion for men­tal ill­ness in chil­dren; and push to re­duce in­car­cer­a­tion of non­vi­o­lent, men­tally ill offenders over the next decade.

In the Se­nate, the Men­tal Health Re­form Act con­tains some sim­i­lar pro­vi­sions but is not as com­pre­hen­sive. Still, sup­port­ers see broad con­sen­sus be­tween the House and Se­nate bills and ex­press con­fi­dence the cham­bers can reach agree­ment if con­gres­sional lead­ers make this a pri­or­ity. A com­pro­mise is in the works to strip out a Se­nate GOP pro­vi­sion mak­ing it eas­ier for men­tal pa­tients to re­gain gun-own­er­ship rights, which had threat­ened to tor­pedo the leg­is­la­tion.

Still, men­tal health­care providers and ad­vo­cacy groups say the leg­is­la­tion would be just a first step to­ward over­haul­ing the na­tion’s bro­ken be­hav­ioral health sys­tem and that much more money needs to be in­vested in ex­pand­ing ser­vices and training more men­tal health pro­fes­sion­als. The pend­ing leg­is­la­tion would au­tho­rize only mod­est in­creases in grant fund­ing.

“We won’t have enough treat­ment sup­port for all the peo­ple who need it,” said Heather O’Don­nell, vice pres­i­dent for public pol­icy at Thresh­olds, a large com­mu­nity-based agency serv­ing se­ri­ously men­tally ill peo­ple in the Chicago area.

What’s re­ally needed, she said, is a sig­nif­i­cant in­crease in Med­i­caid pay­ment rates to providers and broader in­sur­ance cov­er­age for men­tal health ser­vices.

Mur­phy ac­knowl­edged the need for greater in­vest­ment, urg­ing the Se­nate to au­tho­rize more spend­ing. “Ab­so­lutely,” he said. “Over half the coun­ties in Amer­ica don’t have a psy­chi­a­trist or psy­chol­o­gist or other men­tal health pro­fes­sional. You can’t get ser­vices even if you want them.”

Bernard Tyson, CEO of Kaiser Per­ma­nente, agreed that health plans and providers need to re­think how they cover and treat men­tal ill­ness and ad­dic­tion. Kaiser launched a broad ini­tia­tive to im­prove cov­er­age and care, fol­low­ing sanc­tions against Kaiser dur­ing the past two years for al­leged de­fi­cien­cies in be­hav­ioral-care ser­vices.

Kaiser has hired more men­tal health providers and added tele­health ses­sions, and it is ex­per­i­ment­ing with de­ploy­ing be­hav­ioral providers in pri­mary-care clin­ics. On the in­sur­ance side, the sys­tem is re­struc­tur­ing its ben­e­fits to ease ac­cess to care. It’s also run­ning public-ser­vice an­nounce­ments to in­crease aware­ness of men­tal health is­sues in chil­dren and re­duce the stigma of seek­ing treat­ment for peo­ple of all ages.

“This is one of the few ar­eas where there is uni­ver­sal agree­ment that we need to do some­thing in this coun­try,” Tyson said.

That’s not to say there aren’t con­tin­u­ing dif­fer­ences over many is­sues, in­clud­ing the most ef­fec­tive treat­ment ap­proaches and how to share sen­si­tive pa­tient in­for­ma­tion with fam­i­lies and among providers. There also are sharp par­ti­san dif­fer­ences in Congress over ex­pand­ing Med­i­caid un­der the ACA or turn­ing the pro­gram into capped state block grants. Ad­vo­cacy groups fear the lat­ter ap­proach would roll back cru­cial cov­er­age gains for peo­ple with be­hav­ioral dis­or­ders.

But ex­perts say the leg­is­la­tion would cre­ate a badly needed frame­work for try­ing out dif­fer­ent in­no­va­tive ap­proaches and set­ting the U.S. on a more ef­fec­tive course of pre­vent­ing and treat­ing the ter­ri­ble scourge of se­ri­ous men­tal ill­ness.

“It would lay a nice foun­da­tion for build­ing a bet­ter sys­tem of care that we all ex­pected to hap­pen decades ago,” Men­tal Health Amer­ica’s Gion­friddo said. “I’d love it if things moved quicker; but we didn’t get here overnight and we’re not go­ing to get out of here overnight.”


Source: Health Af­fairs

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