Health Care Administration, Week 11 notes
Health Care Administration, Week 11 notes HCA 340 -002
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Date Created: 04/14/16
Week 11 notes Tuesday, April 12, 2016 9:35 AM Chapter 10 Mental Health Tuesday Current background Mental health terminology changes: "mental health care" often now called "behavioral health care" with psychiatric care, a medical subspecialty, one aspect of integrated services "patient" replaced by "consumer" or "person/people" with a psychiatric or substance abuse disorder or "mental health issue" "problem-based" diagnosis model replaced with "strength-based" model in "recovery Movement" Historical Overview Colonial era to 1800s: mentally ill confined to almshouses, jails, hospitals with no treatment, decrepit conditions 1800s: Quakers advocated "moral treatment" established 1814 Philadelphia "asylum" WW1: "shell-shock" in returning military focused new attention on mental illness Came back with PTSD or "shell shock" 1930s: First effective biological treatments: insulin coma, drug-induced convulsions, electroconvulsive therapy Post WWII, National Mental Health Act of 1946 National Institute of Mental Health (NIMH) Dept. of Veterans' Affairs psychiatric hospitals and clinics By 1950s, still primarily inpatient- 1/2 M+ in state, county mental hospitals New drugs for schizophrenia, other psychotic disorder allowed ambulatory treatment Partial hospitalization After-care programs Transitional residencies 1955: Joint Commission on Mental Illness and Health established by Congress, the first time a federal body considered resources for the mentally ill Attacked poor quality in county and state psychiatric hospitals 1960s Mental health care reforms supported by president Kennedy Additional, new pharmaceutical treatments Federal Mental Retardation Facilities, Community Mental Health Centers Construction Acts Medicare, Medicaid, Supplemental Security Income (SSI). Social Security Disability and housing subsidies accessible for mentally ill Until 1980s, payments on basic of units of service; no incentive for limiting treatments that went on for years. 1955-1980: treatment episodes quadrupled Insurers balked with payment limits, discounted fee-for-service payments different from other medical care, "carve-out" outsourcing coverage to specialty managers, and capitation; "non-parity" for mental health services was established to plaque the mental health industry for decades. Deinstitutionalization (1970s-1980s) Medicaid incentives to move patients from psychiatric hospitals to community boarding and nursing homes; community mental health centers inadequately staffed for severely mentally ill Large numbers incarcerated, homeless 1950: 77% inpatient, 23% outpatient; 1990: 21% inpatient, 7% partial hospitalization, 67% outpatient Breakthrough developments- 1980s NAMI (National Alliance on Mental Illness), HIMH clinical researchers' for advocacy re- defined mental illness from quantitative continuum to discontinuous in development; mental illness as biologically based, disorders more clearly defined requiring target treatments, not unfocused "talk therapies" Carter's Presidential Commission on Mental Health sought applications of new research findings to benefit patients and reduce costs Recommendations taken by Health and Human Services to expand psychosocial rehabilitation programs under Medicaid; Medicaid payment for outpatient services expanded; severely ill eligible for Supplemental Security Income Expanded services severely curtailed in 1980s under Ronald Regan 1990-Present Focus on sever mental illness with grants, federal support for research, training, not erroneous prevention strategies Medicare Act of 2003 expanded drug coverage; CHIP (Child Health Insurance Program) increased coverage for low-income children; Wellstone-Domenici Parity Act of 2008 advanced equitable coverage for mentally ill ACA of 2010 reinforced insurance parity Recipients of Psychiatric and Behavioral Health Services Epidemiological Catchment Area and Co-morbidity Studies report 26.2% of Americans will have a mental disorder during any one year period, 57.7 M people 6%, subgroup classified as having "serious mental illness" with symptoms (excluding substance abuse) for at least 12 months Neuropsychiatric disorders: the leading cause of disability in the US and Canada measured in units encompassing the total burden of disease as "disability-adjusted life years" (DALYs); contribute 2x DALYs of cardiovascular disease and cancers DALYs- total number of years lost to illness, disability, or premature death in a given population Diagnosis and Treatments As effective as physical health treatments; criteria provide predictability of natural history of illness and treatment Classified in 17 categories; diagnostic criteria for over 450 conditions Co-morbidity: the co-existence of two diagnoses; -1/2 of mentally ill have an additional disorder. Ex: substance abuse, 23- 80% with other disorders Mental Illness Costs In addition to unquantifiable personal and family suffering, $300 B annually for disability payments, health care expenditures and lost earnings Treatment Services Who does and does not get treatment? 45.6 M people over 18 years met criteria for one psychiatric disorder in the past 12 months… 19.6% of adult population; only 38.2% able to access treatment Access to treatment worst among underserved groups: minorities, low income, uninsured, rural Barrier to Care Barriers: provider availability; financial, lack of health insurance; stigma; misunderstanding about treatability; personal and provider attitudes; cultural issues; poorly organized system of care Substance abuse and adductions: providers view as "moral," not chronic disease issues; removal from treatment often follows relapse Children and Adolescents Service use date available first in 1999 from NIMH survey: only 9% able to access some services: half of those with diagnosed mental illness; school system is largest provider 2009 study: prevalence in 4-17 year olds increased 40% through diagnosis by primary doctors Clinical research for children and adolescents lags far behind adults, inadequate number of trained professions for size of population at risk Older adults- 25% with significant psychiatric disorders Diagnosis and treatment difficult due to other conditions Complications from drugs to treat medical conditions Fear of stigma Stereotypes about aging The Organization of Psychiatric and behavioral Health Services Four major delivery system sectors 1. Psychiatric and behavioral health 2. Primary care 3. Human services 4. Voluntary support network Psychiatric and Behavioral Health Sector 1. Behavioral health professionals, e.g. psychiatrists, psychologists, psychiatric nurses, psychiatric social workers, behavior health clinicians; also "peer specialists" Provide majority of outpatient care in private or public clinics; acute care in designated in-patient hospital beds in community and public hospitals; residential treatment centers for children and adolescents 2. Multi-service facility provide or coordinate a range of outpatient, intensive case management, partial hospitalization, or inpatient services 3. Increased focus on independent living accommodations in apartments with case managers to assist with daily living skills Primary Care Sector 1. Health care professionals, e.g. private practice internal medicine, family practice doctors, nurse practitioners, pediatricians, clinics, hospitals, nursing homes Often the initial and only point of contact for mental health services Rates of mental illness diagnosis in primary care in past decade: double for children and increased almost 30% for adults Human Services Sector 1. Staff of social services agencies, school-based counseling services, residential rehab services, vocational rehab services, criminal justice/prison-based services, religious professional counselors 2008 recession reduced state funding and increased barriers to care from this sector with loss of support for housing, medical care and medications 2. Increased homelessness; lost medication support led to recurrence of symptoms among those previously stable 3. Increased petty crimes and incarcerations in prison system ill-equipped for treatment, with very high costs Volunteer Support Network Sector 1. Self-help groups, family advocacy groups Powerful In shifting public attention to people with persistent and severe mental illness Major impacts on Congress and funding appropriations for research on mental illness and substance abuse through NIMH (national institution for mental health) State3 legislature lobbying against cuts in service programs and general assistance for mentally ill Paradigm Shifts Since 2008, shifts toward turning the mental health system into a more integrate effective care system Recovery oriented systems of Care (ROSC) Initiated by Bush's "Freedom Commission on Mental Health." 2004 National Consensus Conference cited "recovery" as most important goal for transforming mental illness in America Focus on choice, consumer strength-based empowerment, establishing hope for a better life to guide treatment planning; goal to empower with choices and vision for hopeful future; link consumers; strengths with family, community resources Patient Protection and Affordable Care Act Provide psychiatric benefits with parity ACO's care continuum will benefit mental health service recipients with coordination of services through primary care and with multiple providers Integration of Primary Care and Behavioral Health Services ACA provisions on parity support service integration, diffusing prior issues with behavioral health professional reimbursement for primary care services PCMH puts behavioral health practitioners on the "team" of providers eligible for reimbursement Financing Psychiatric and Behavioral Health Services Funding sources: private health insurance, Medicaid, Medicare, state and county funding, contracts and grants "Non-parity" existed for many years, denying the chronic nature of mental illness compared with medical conditions, dates to 1950s Parity: requirements that insurers cover mental health at the same levels as general medical care Mental Health Parity Act., 1996: Equated aggregate lifetime limits, annual limits with general medical care Allowed cost-shifting loopholes: e.g. limits on psychiatric inpatient days, prescription drugs, raising co-insurance and deductibles; did not require employers to offer mental health coverage or coverage for substance abuse disorders Mental Health Parity and Addiction Equity act, 2008: End health insurance benefit inequity between mental health/substance abuse plans and medical/surgical plans Equal coverage applicable to all deductibles, copayments, coinsurance and out-of-pocket expenses an all treatment limitations Parity for annual and lifetime dollar limits Broad definition of mental health and substance abuse benefits MH coverage not mandated to employers, but if offered must be equal with medical coverage Out-of-network coverage must be equal Preserves existing state parity laws Public Funding of Mental Health Care Recession effects on State budgets: unemployment, financial markets impact Kaiser 50-state study Sharp Medicaid outlay increases due to recession, decline in employment American Recovery and Reinvestment Act assistance insufficient to stem state crisis The ACA is a "game-changer" $100 b appropriation over 10 years and $100 B discretionary funds will extend insured health services to millions of mentally ill persons ACA health insurance exchanges and Medicaid expansion will open care access to many mentally ill adult, child and adolescent persons Use of "non-quantitative treatment limitations" by insurers to curtail benefits must be monitored and addressed Cost Containment Mechanisms Managed care systems (public and private) tightly control and monitor services for mentally ill; use subcontractors, "managed behavioral healthcare organizations" (MBHOs) to manage behavioral health patients through carve outs; research indicated that MBHOs successfully facilitate service access and coordinate care for patients in need The future of Psychiatric and Behavioral Health Services Shift to a "recovery Model" provides for strength based system with client-directed goals paramount Move toward psychiatric care more integrated with primary care ACA will assure Americans of access to services and bring disenfranchised mentally ill persons into the "system