Panel Discusses ACA's Effect on Mental Health Delivery, Care for Those With Comorbidities
Mary K. Caffrey
Care for those with mental illness has come a long way recently, with the Affordable Care Act (ACA) ensuring that services are covered and a federal parity law requiring that coverage limits for mental health be no less generous than medical benets. Those who work with the mentally ill or advocate on their behalf know that better laws are just the beginning of improving care, according to a panel of experts convened recently by The American Journal of Managed Care.
The panel discussion, moderated by Surabhi Dangi-Garimella, PhD, managing editor of AJMC’s Evidence-Based series, included Stuart L. Lustig, MD, MPH, lead medical director, child & adolescent care, Cigna Behavioral Health; Paul Gionfriddo, president and CEO, Mental Health America; and Wayne J. Katon, MD, director of the Division of Health Services and Epidemiology and professor and vice chair of the Department of Psychiatry and Behavioral Sciences, University of Washington Medical School.
ACA implementation will be only a first step toward treating mental illness with the same urgency as other chronic conditions, although the healthcare world is awakening to the fact that delaying mental health care only increases costs elsewhere, with most of the economic impact of mental illness occurring “on the medical side,” as Katon explained. The panel discussed the connections between mental illness and chronic conditions such as diabetes and hypertension, which Katon and his colleagues have researched for decades. Thanks in part to the ACA, Katon said, their pioneering approach to collaborative care, known as TEAMcare, has drawn more interest in the past 5 years than in previous 25 that Katon and his colleagues have been researching these approaches.
“I think we have to move away from the idea that we’re going to train enough psychiatrists or child psychiatrists to treat all people with mental illnesses,” Katon said. “We do need team-based approaches.”
EARLY IDENTIFICATION OF PROBLEMS
Better and earlier identication of persons with mental health problems is essential, starting with teenagers who are still in school, said Gionfriddo. This way, treatment can start before the illness becomes hard to treat and other comorbidities set in. “It’s critically important that we move people’s thinking upstream,” he said. Mental illnesses are “the only chronic conditions that as a matter of public policy, we wait until Stage 4 to treat, and then often only through incarceration.”
“Half of mental illness manifests itself by the age of 14, which makes this very much a disease of childhood,” Gionfriddo said. Mental Health America’s experience with online screening has been that many who screen positively for early stages of mental health disorders have never been diagnosed with a problem; the group encourages participants to use the results to open a dialogue with their local provider. The trouble is, Gionfriddo said, the parity law cannot x disparities in the availability of mental health providers, especially in the South.
Katon and Lustig discussed the difficulties of access to care despite changes in laws to require insurance coverage. Most care for anxiety or depression starts with the primary care physician (PCP), Katon said, and referral rates forgetting patients to see mental health providers are abysmal. Even when patients do seek a specialist, they average about 2 visits, which is not enough for adequate treatment.
MENTAL HEALTH AND COMORBIDITIES
Depression and anxiety are risk factors for developing diabetes or hypertension, Katon explained; at the same time, suffering a chronic condition or a heart attack puts one at risk for depression. “There is a bidirectionality,” he said. What’s challenging is that the more complex the disease—and diabetes is very complex—the more difcult it can be for a patient who also has a mental health condition to maintain good adherence with medications.
This is why, Katon said, that so much of the cost of mental illness actually comes from treating medical conditions. Patients with mental illness die younger than their counterparts, and while suicide and accident rates are higher, the more typical outcome is an early death from a poorly treated disease.
He offered the example of a person with depression who is newly diagnosed with type 2 diabetes mellitus (T2DM). “On the date of your diagnosis, you start 4 disease-controlling medications,” he said adding that it doesn’t help that some atypical antipsychotics can actually trigger the onset of T2DM by contributing to obesity.
Giofriddo emphasized that the relationship between mental health and comorbidities further points to the need to address conditions “upstream,” before diseases worsen and become harder and more expensive to treat. “By waiting until later for anything, it complicates everything,” he said. Lustig noted that payers and accountable care organizations are starting to realize the need for what he called “intensive case management,” to make sure that doctors are talking to one another, that patients have proper transportation between appointments, and that there is a central point of contact and access to medication.
“It’s resource-intensive,” Lustig said, “But it’s less resource-intensive than having patients get sicker and sicker.” Katon’s TEAMcare approach goes beyond the coordination of services. The collaborative care model places the mental health professional alongside PCPs or in a consulting capacity to help the primary practice manage multiple patients and to ensure better diagnoses. Collaborative care improves patient education, allows for more frequent updates of medications, and ensures the ability to provide evidence-based psychotherapy in the primary care clinic.
“We have to think through what we will do with these people with comorbid illnesses,” he said. Too often, opportunities are lost to provide better care that would lead to better outcomes—and save money.
Lustig said better community support and prevention services will help get patients who need help into the system; he agreed with the need to get patients with serious illnesses into the pipeline of care earlier. He and Katon also discussed the need for better education and close follow-up to get patients on the right medication at the right dose to improve adherence; the initial brief visit in which PCPs make a diagnosis, prescribe an antidepressant, and instruct the patient return in 4 to 6 weeks is often a recipe for failure, asserted Katon.
“Any time any clinician picks up a prescription pad, they are making a number of very specic assumptions about that patient that may or may not be accurate,” Lustig said. Can the patient afford the medication? Is there access to follow-up care? Is the patient comfortable being on a psychotropic drug? Are there concerns about side effects? Psychotherapy and other treatments aside from drugs are time intensive, and that can interfere with adherence, Lustig added.
All 3 experts, however, were optimistic that the landscape for mental health care is improving despite the challenges. Just getting behavioral health included among the ACA’s essential health benets is a huge step forward, they agreed.