The Relevance of the Affordable Care Act for Improving Mental Health Care.

Provisions of the Affordable Care Act provide unprecedented opportunities for expanded access to behavioral health care and for redesigning the provision of services. Key to these reforms is establishing mental and substance abuse care as essential coverage, extending Medicaid eligibility and insurance parity, and protecting insurance coverage for persons with preexisting conditions and disabilities. Many provisions, including Accountable Care Organizations, health homes, and other structures, provide incentives for integrating primary care and behavioral health services and coordinating the range of services often required by persons with severe and persistent mental health conditions. Careful research and experience are required to establish the services most appropriate for primary care and effective linkage to specialty mental health services. Research providing guidance on present evidence and uncertainties is reviewed. Success in redesign will follow progress building on collaborative care and other evidence-based practices, reshaping professional incentives and practices, and reinvigorating the behavioral health workforce.

Sociology of health care reform: building on research and analysis to improve health care.

Health reform efforts in the United States have focused on resolving some of the fundamental irrationalities of the system whereby costs and services utilization are often not linked to improved patient outcomes. Sociologists have contributed to these efforts by documenting the extent of problems and by confronting central questions around issues of accountability, reimbursement, and rationing that must be addressed in order to achieve meaningful reform that controls costs, expands access, and improves quality. Major reform rarely occurs without "paying off" powerful interests, a particularly difficult challenge in the context of a large and growing deficit. Central to achieving increased coverage and access, high quality, and cost control is change in reimbursement arrangements, increased accountability for both costs and outcomes, and criteria for rationing based on the evidence and accepted as legitimate by all stakeholders. Consensus about health reform requires trust. The traditional trust patients have in physicians provides an important base on which to build.

Toward a 21st-century health care system: recommendations for health care reform.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

Facilitators and barriers to employment among individuals with psychiatric disabilities: a job coach perspective.

Unemployment rates remain high among individuals with psychiatric disabilities despite growing evidence that supported employment programs (SEPs) can help such individuals to obtain and retain competitive employment. A complete understanding of factors that may facilitate or hinder the success of such supported employment efforts is urgently needed to increase the efficacy of SEPs and move more individuals with psychiatric disabilities from welfare to work. This exploratory study provides insight into potential facilitators and barriers to employment among individuals with psychiatric disabilities from the perspective of job coaches. Twenty-eight job coaches from 14 SEPs in a Northeastern state reported on their experience with four recent clients, two who were successful in obtaining employment and two who failed, through a semi-structured mail survey. Findings suggest that job coaches use similar strategies to assist clients, but in each case try to tailor specific strategies to client's needs and characteristics. Factors that influence successful job placement and research and policy implications are discussed.

Policy challenges in addressing racial disparities and improving population health.

Socioeconomic status fundamentally affects most health and disease outcomes, but black Americans are doubly disadvantaged by low status, discrimination, and residential segregation. Improving health and removing disparities are essential goals, but some efforts that improve the health of blacks in important ways also increase black-white disparity ratios. People with more information, influence, resources, and social networks may be better able to take advantage of new technologies and scientific developments, initially increasing disparities. Better health and reduced mortality should be the key policy criteria, but these criteria should be linked with consideration of careful targeting to level the playing field and close disparities.

Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders.

BACKGROUND: A majority of adults with common mental disorders do not seek professional help. To better understand why not, we examined the correlates of various stages of help-seeking, including perceived need for professional help, seeking such help, and from which professionals participants sought help. METHODS: The sample for this study comprised 1792 participants in the National Comorbidity Survey, conducted from 1990-1992, who were diagnosed with a 12-month DSM-III-R mood, anxiety, or substance disorder. In this sample, we assessed correlates of perceived need for professional help, seeking professional help among those with a need, and, among those who did seek professional help, seeking help from mental health professionals. RESULTS: Mood disorders, comorbid mood and anxiety disorders, and mental disorders associated with impairment in role functioning or suicidality were strong predictors of perceived need. Psychopathology was also associated with the decision to seek help from mental health professionals, but not with the decision to seek professional help overall. After controlling for the nature and severity of psychopathology, various sociodemographic and attitudinal factors appeared to be associated with perception of need, help-seeking, and participants' choices of professionals. CONCLUSIONS: Unmet need for mental health care is a serious public health problem. Meeting this need requires expanding our attention beyond psychopathology to various evaluations and decisions that affect help-seeking. Our results suggest the importance of attitude and behavior change strategies in reducing the gap between need and care.

Interventions to improve medication adherence in schizophrenia.

OBJECTIVE: Although nonadherence with the antipsychotic medication regimen is a common barrier to the effective treatment for schizophrenia, knowledge is limited about how to improve medication adherence. This systematic literature review examined psychosocial interventions for improving medication adherence, focusing on promising initiatives, reasonable standards for conducting research in this area, and implications for clinical practice. METHOD: Studies were identified by computerized searches of MEDLINE and PsychLIT for the years between 1980 and 2000 and by manual searches of relevant bibliographies and conference proceedings. Key articles were summarized. RESULTS: Thirteen (33%) of 39 identified studies reported significant intervention effects. Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective. Concrete problem solving or motivational techniques were common features of successful programs. Interventions targeted specifically to problems of nonadherence were more likely to be effective (55%) than were more broadly based treatment interventions (26%). One-half (four of eight) of the successful interventions not specifically focused on nonadherence involved an array of supportive and rehabilitative community-based services. CONCLUSIONS: Psychoeducational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains.

Removing barriers to care among persons with psychiatric symptoms.

Many persons with serious psychiatric conditions who could benefit from available treatments do not receive care, and the barriers are generally understood to be limited knowledge, inadequacies in insurance coverage, and stigma. Sophisticated approaches are needed to realistically eliminate these and other barriers. Public policy should focus on criteria for need for care and encourage interventions that facilitate treatment when it can be helpful. Appropriate insurance coverage is indispensable, and achieving mental health parity will require careful management of care. Policymakers must help to create a trustworthy management structure that is inclusive, that develops and disseminates models of best practice, that encourages evidence-based decision processes, and that ensures continuing dialogue and procedural fairness in managed care decision making.

Disadvantage, inequality, and social policy.

Eliminating disparities in health is a primary goal of the federal government and many states. Our overarching objective should be to improve population health for all groups to the maximum extent. Ironically, enhancing population health and even the health of the disadvantaged can conflict with efforts to reduce disparities. This paper presents data showing that interventions that offer some of the largest possible gains for the disadvantaged may also increase disparities, and it examines policies that offer the potential to decrease disparities while improving population health. Enhancement of educational attainment and access to health services and income support for those in greatest need appear to be particularly important pathways to improved population health.

Is the prevalence of mental disorders a good measure of the need for services?

Mental disorders are highly prevalent, but prevalence is different from need for treatment. Some mental disorders are a major source of distress, disability, and social burden, and many people who could benefit from treatment do not receive it. Need is typically self-defined or defined by clinicians who are motivated to bring treatment to those who could benefit. Defining need appropriately requires consideration of the duration and reoccurrence of disorder, associated distress and disability, and the likelihood that treatment will be beneficial. Demand may be promoted inappropriately by clinicians and drug manufacturers who profit from expansion of demand. Future assessments of need must be based on evidence and take into account priorities for care and cost-effectiveness.

Treatment of people with mental illness: a decade-long perspective.

Many believe that managed behavioral health care has been associated with reduced access to care. Data from a variety of sources suggest that access has increased, although patterns of care and locations of treatment have changed. Data from Healthcare for Communities, a nationally representative community survey, show that access to care has not decreased for people with the most serious conditions who were more likely to receive specialty mental health care after 2000. Further, once people enter specialty care, the number of visits appears unrelated to need. The data highlight the urgent need for a greater focus on the quality of care and patient outcomes.

Employing persons with serious mental illness.

Data from various national surveys find that approximately half the population with mental disorders is gainfully employed across the entire range of occupations; such persons have an employment rate of about two-thirds that of the general population. More than a third of persons with serious mental illness also work, and many hold high-status positions. Among those with schizophrenia, a diagnosis associated with high impairment, only slightly more than a fifth are at work, and 12 percent are working full time. Approximately two-thirds are enrolled in federal disability insurance programs. Our analyses indicate considerable diversity of jobs among persons with various mental disorders. Most persons with mental illness want to work, and some with even the most serious mental disorders hold jobs requiring high levels of functioning. Educational attainment is the strongest predictor of employment in high-ranking occupations among both the general population and persons with mental disorders.

Socio-cultural implications of changing organizational technologies in the provision of care.

Technology refers to inputs (machines, bureaucratic procedures, management strategies) organized to achieve specified outcomes. Such inputs and how they are used arise from socio-cultural conditions and in turn influence social behavior and values. Advances in medical technology are due to the high value populations place on health, emerging developments in science (also a cultural product). and from the opportunities and incentives the society gives to varying stakeholders. In the United States for example, the development and uses of medical technology are shaped by faith in marketplace competition, technological progress, activism, choice and consumerism. This constellation of values has resulted in very rapid growth and dissemination of hardware and related procedures whose costs pose significant financial dilemmas. In response, a range of management technologies have been developed to restrain the excesses of intervention but, because they are counter to many prevailing values and interests, they have led to much tension and a social backlash. Resolving these rationing tensions--which are rarely acknowledged as such--is a major challenge in American medical care and in much of the world. In the context of American social values, once new preventive or treatment technologies are introduced, they take patients on treatment trajectories that are difficult to control and which result in many being labeled with diagnoses they do not have and receiving interventions they do not need. Major efforts are under way to increase the sophistication of consumers of health care in a manner consistent with evidence-based medicine but these face significant barriers. Underlying what at first appears as simply technical barriers are the particular social and cultural influences on how people acquire and use information, the sources they trust and distrust, and the types of information they find credible and relevant to their situations. In short, the competition between new preventive and treatment technologies and managed care technologies is at its heart a culture war.

The rise and fall of managed care.

The managed care backlash is analyzed as a collective behavioral response led by attacks from threatened professional, provider, and special interest communities. Central to the backlash was the middle class's repudiation of explicit rationing at the point of service adopted by Health Maintenance Organizations (HMOs) and other managed care plans. Americans are accustomed to choice and autonomy in their health care utilization and reacted negatively to restrictions. Assisted by negative anecdotes in the media and allegations of the denial of needed services, opponents built a negative picture of managed care often inconsistent with the empirical evidence. They succeeded in arousing public anxiety that appropriate health care might not be available when people most needed it. The private centralization of large health plans made them an easy target for the media, politicians, and provider groups in opposition. These attacks and regulatory initiatives succeeded in diluting strong utilization management controls contributing to current difficulties of containing large health cost increases.

Improving the quality of health care in the United States of America: the need for a multi-level approach.

Serious efforts to address quality require coordinated, multi-faceted, multi-level strategies that address the organisational environments and cultures that affect how care is provided. Most efforts over the past 50 years to improve the care provided by physicians and other clinicians have been individually rather than system based. Such individual interventions to modify physician behaviour typically have only modest effects whether considering the recognition and treatment of depression in primary care, following established practice guidelines, carrying out preventive interventions, monitoring and managing chronic illness appropriately, or managing pain and end-of-life care. It is increasingly recognised that quality of care is a property of health systems. Internal efforts to shape clinical routines, such as performance incentives and disease-management approaches, and external inducements and constraints that shape how clinical contexts are organised and function are equally relevant. Internal factors include the skills training of clinical personnel, organisational procedures and mechanisms to coordinate care and prevent errors, implementation of best practices, effective use of informational technologies and appropriate incentives. External factors include broader financial and reimbursement mechanisms, regulatory arrangements that protect access and patient rights in situations of vulnerability and performance-based contracts. The mobilisation of effective advocacy, independent and non-profit statutory watchdog organisations, and good consumer information can facilitate and reinforce quality efforts. System integration is admittedly difficult, and always incomplete, but movement toward this goal is an essential strategic objective.

Physician discontent: challenges and opportunities.

Most physicians continue to report overall career satisfaction, but increased public and patient expectations and administrative and regulatory controls contribute to perceptions of increased time pressures and erosion of autonomy. Increasingly, knowledgeable patients armed with information from the media, as well as guidelines developed by health plans, government, specialty societies, professional organizations, and advocacy groups, confront physicians with a bewildering array of new expectations and demands. Although physicians are spending more time with patients than in earlier periods they feel themselves on a treadmill. Strategies to ease pressures include increased use and enhanced scope of nonphysician clinicians, adoption of information technology and disease management programs to reduce errors and to increase efficiency and quality, and thoughtful practice design. Use of such strategies, combined with leadership and a clear sense of direction, can empower physicians, provide them with expanded knowledge and expert systems, and relieve some practice burdens and frustrations.