Healing the Broken Places

PROBLEMS OF ACCESS
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”

The allure of other specialties also keeps people from mental health fields. “There are a lot of jobs and openings for PAs in psychiatry,” St. John says, “but there are a lot of jobs in orthopedics or surgery, too—and that’s what tends to draw them.”

The shortage of mental health care providers and subsequent lack of access to services means a larger role for primary care providers. High-profile expert panels have highlighted the need for integration of mental health into primary care settings—which St. John says is already largely the case.

“Most mental illness is treated in primary care, not in mental health settings,” he points out. “Mental health settings should really be reserved for the more challenging patients, the more difficult diagnoses and problems, and co-occurring illnesses.”

“Most primary care clinicians have some education in relationship to diagnosing and treating mild to moderate mental health issues, and then they refer on when needed,” Clement says. “The problem is, referring on is more and more difficult if there aren’t any people to refer to, or if waiting lists are as long as they currently are.”

Time is just as much of a problem in primary care as it is in specialty care, and when it comes to psychiatric and behavioral disorders, you can’t just order a lab test or an x-ray. “In psychiatry, you have to talk with the person and try to figure out what’s going on in their head and how that’s affecting their function,” St. John says. “It takes more time, and in primary care, that’s the problem they have. They’ve got appointments that may only have 10 minutes uled, and that’s not adequate to obtain a decent psychiatric history.”

The importance of both primary care providers and mental health specialists cannot be downplayed, because mental illnesses are among the most disabling and deadly. “If you look at disabling conditions, depression is right up there at the top,” St. John says. “Actually, it’s predicted that in the next three or four years, worldwide, depression will be the number one disabling illness.”

Anorexia is associated with a 15% death rate, and the completed suicide rate for persons with severe depression is also 15%. “If you were to look at one issue alone that we’re missing the boat on, it’s suicide,” Stuart says. “There are more suicides globally than there are deaths from war and violence combined—and the incidence of suicide is rising. So if, for example, a primary care provider sees someone who’s depressed, they have to go the next step and also ask about potential suicidal thought.”

Clement says it is equally important to integrate primary care services into mental health settings, since many patients with mental illnesses “are not going to show up in a private office in a primary care setting. And people with mental illness die 25 years earlier than the general population, from treatable medical illnesses.”

This is why, for example, the APNA is partnering with the Smoking Cessation Leadership Center. “Persons with mental illness are purchasing approximately half of the cigarettes that are being bought in the US,” Clement says. “And many of the treatable medical illnesses that people are dying from are related to smoking. It’s a whole person you’re working with, not just a brain or a body.”

REIMBURSEMENT ISSUE
Reimbursement is one of the major deterrents to the pursuit of a career in mental health care. “The whole reimbursement issue makes it difficult to attract people to work in mental health, particularly in community-based clinics, state hospitals, prisons, and jails,” which Judd says results in a lack of services for the seriously mentally ill and decreased access for people of low income.

The biggest problem is parity—or rather, the lack of it. What services are covered and at what rate tends to vary by state, and mental health is often not covered at the same rate as physical health. “There are a number of states that now have parity in mental health,” Clement observes. “If insurance is offered for physical health and [includes] mental health coverage, it has to be at exactly the same level as physical health, in terms of copays and lifetime limits.” But even so, there is not always parity in parity.

Furthermore, many people who need mental health services fall under the Medicaid program, which is state-based and just as variable. “Definitions of ‘medical necessity’ differ, and providers don’t get paid unless they can document according to medical necessity,” Clement says. “Even though what people—particularly those in the Medicaid and public mental health systems—need, along with their treatment, is a community-based program that helps people find jobs and housing. But that’s not ‘medical necessity.’”

Another problem is the sheer expense of some of the medications for mental disorders. “A lot of the drugs that we use to treat serious mental illnesses are horrendously expensive,” St. John notes. “They’ll almost bankrupt some states.…We just don’t have those budgets.”

Achieving parity and improving reimbursement is a slow process. Clement has been involved at the federal level with a parity bill, but as she notes, “that has not been resolved in terms of the differences between the House and the Senate.” Since so many of the programs are administered at a state level anyway, some suggest that might be a good place to begin working on reform.

In October 2007, the Annapolis Coalition, of which Stuart is President of the Board of Directors, released an action plan for reforming the mental health system—particularly for addressing workforce needs. The report (available at www.annapoliscoalition.org) includes the most specific recommendations possible in an overarching “framework” document, and Stuart says the coalition is currently working with some states—including North Carolina, Connecticut, New Mexico, and California—to identify and prioritize their needs and determine how best to tailor the plan to them.

“We’re really approaching it not at a federal level but seeing that the true change would come about at a state level,” Stuart says. “The need is derived differently by each state. If I can use the analogy, it’s a little bit like having a general way of approaching hypertension, but then you tailor it to the individual.”

Whether at the state or federal level, St. John thinks major changes to reimbursement for mental health care will require a cultural shift. “We reimburse for activity, we reimburse for procedures; we don’t reimburse for time spent or for decision making or thinking,” he points out. When a clinician is being reimbursed 50% (compared to 90% for other medical care), or $12 to $15 per visit for providing medication management, “You have to see large volumes of people in order to get reimbursed enough to pay for yourself and your staff.”

In the current economic climate, finding the money is going to take some shuffling. “It would be unrealistic to say that there are new dollars out there, because clearly there are not,” Stuart says. “So I think the issue is to reallocate the current resources that are out there and evaluate, Are we getting the best return on our investment of these dollars?”

The irony is that the people with the greatest needs for treatment, monitoring, and support services are the ones who face the biggest barriers to accessing care. “Services are more readily available to people who have jobs, have insurance—which would tell you in and of itself they’re probably higher functioning to start with,” Judd says. “I mean, if you’re having stress holding down a job, you’re probably higher functioning at your baseline than the homeless person who is living in the streets and under bridges and doesn’t go to shelters because they’re too paranoid to be around other people.”

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