Problems With 'Serious Mental Illness' As A Policy Construct.

Increasingly, mental health policies focus on "serious mental illness" (SMI). This trend is mostly unquestioned, but SMI policies have serious flaws that raise concerns about their effectiveness and desirability. One such flaw is the lack of consensus on how to define the population with SMI. This problem means that under various policies, groups identified as having SMI may be as much different as alike and may vary greatly in size. Another serious limitation is the lack of essential and accurate data on the SMI population. SMI policies are further complicated by unexamined conceptual issues-for example, why it is necessary to have policies in mental health services that discriminate on the basis of severity. Finally, the potential negative consequences of SMI policies, such as stigma effects, are rarely considered in their development. In this article I describe these problems and discuss the issues and challenges that they pose for effective mental health policies. I conclude that the desirability of many policies focused on serious mental illness are questionable, and I suggest types of questions that should be asked when such policies are considered.

Current and future funding sources for specialty mental health and substance abuse treatment providers.

OBJECTIVES: Goals were to describe funding for specialty behavioral health providers in 1986 and 2005 and examine how the recession, parity law, and Affordable Care Act (ACA) may affect future funding. METHODS: Numerous public data sets and actuarial methods were used to estimate spending for services from specialty behavioral health providers (general hospital specialty units; specialty hospitals; psychiatrists; other behavioral health professionals; and specialty mental health and substance abuse treatment centers). RESULTS: Between 1986 and 2005, hospitals-which had received the largest share of behavioral health spending-declined in importance, and spending shares trended away from specialty hospitals that were largely funded by state and local governments. Hospitals' share of funding from private insurance decreased from 25% in 1986 to 12% in 2005, and the Medicaid share increased from 11% to 23%. Office-based specialty providers continued to be largely dependent on private insurance and out-of-pocket payments, with psychiatrists receiving increased Medicaid funding. Specialty centers received increased funding shares from Medicaid (from 11% to 29%), and shares from other state and local government sources fell (from 64% to 46%). CONCLUSIONS: With ACA's full implementation, spending on behavioral health will likely increase under private insurance and Medicaid. Parity in private plans will also push a larger share of payments for office-based professionals from out-of-pocket payments to private insurance. As ACA provides insurance for formerly uninsured individuals, funding by state behavioral health authorities of center-based treatment will likely refocus on recovery and support services. Federal Medicaid rules will increase in importance as more people needing behavioral health treatment become covered.

The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act.

Public substance abuse treatment services have largely operated as an independent part of the overall health care system, with unique methods of administration, funding, and service delivery. The Affordable Care Act of 2010 and other recent health care reforms, coupled with declines in state general revenue spending, will change this. Overall funding for these substance abuse services should increase, and they should be better integrated into the mainstream of general health care. Reform provisions are also likely to expand the variety of substance abuse treatment providers and shift services away from residential and stand-alone programs toward outpatient programs and more integrated programs or care systems. As a result, patients should have better access to care that is more medically based and person-centered.

Changes In US spending on Mental Health And Substance Abuse Treatment, 1986-2005, and implications for policy.

The United States invests a sizable amount of money on treatments for mental health and substance abuse: $135 billion in 2005, or 1.07 percent of the gross domestic product. We provide treatment spending estimates from the period 1986-2005 to build understanding of past trends and consider future possibilities. We find that the growth rate in spending on mental health medications-a major driver of mental health expenditures in prior years-declined dramatically. As a result, mental health and substance abuse spending grew at a slightly slower rate than gross domestic product in 2004 and 2005, and it continued to shrink as a share of all health spending. Of note, we also find that Medicaid's share of total spending on mental health grew from 17 percent in 1986 to 27 percent in 2002 to 28 percent in 2005. The recent recession, the full implementation of federal parity law, and such health reform-related actions as the planned expansion of Medicaid all have the potential to improve access to mental health and substance abuse treatment and to alter spending patterns further. Our spending estimates provide an important context for evaluating the effect of those policies.

Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states, 2003.

OBJECTIVE: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. METHODS: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. RESULTS: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and .7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. CONCLUSIONS: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.

Psychiatric discharges in community hospitals with and without psychiatric units: how many and for whom?

OBJECTIVE: This study sought to describe the extent to which community hospitals, in a sample of states, are caring for patients with psychiatric disorders in medical-surgical beds (scatter beds) and to compare the characteristics of patients treated in scatter beds with those of patients treated in psychiatric units in community hospitals. METHODS: Information on hospital discharges in 12 states for patients with a principal psychiatric diagnosis was gathered from the Healthcare Cost and Utilization Project State Inpatient Databases. Discharges of patients who were treated in community hospital psychiatric units (N=370,984) were compared with those of patients who were treated in scatter beds (N=26,969). RESULTS: Overall, only 6.8% of discharges were from scatter beds. The rate of total psychiatric discharges per 10,000 total state population ranged from a high of 62.3 in one study state to a low of 9.6 in another. The average rate of scatter bed discharges per 10,000 state population ranged from 1.6 to 5.8, whereas the average rate of psychiatric unit discharges ranged from 7.4 to 58.9. A comparison of discharges of patients treated in scatter beds with discharges of patients treated in psychiatric units indicated that patients in scatter beds were more likely to have somatic conditions and were half as likely to have an accompanying substance use disorder. Discharge codes indicated that almost 40% of patients from scatter beds had a diagnosis of schizophrenia, episodic mood disorder, or depression; about two-thirds were admitted from emergency rooms; and about one-fifth were transferred to another facility. CONCLUSIONS: More research is needed to determine the optimal supply of psychiatric unit beds across regions and whether and how scatter beds should be used to address the lack of psychiatric beds.

Implementation of mental health parity: lessons from california.

OBJECTIVE: This article reports the experiences of health plans, providers, and consumers with California's mental health parity law and discusses implications for implementation of the 2008 federal parity law. METHODS: This study used a multimodal data collection approach to assess the first five years of California's parity implementation (from 2000 to 2005). Telephone interviews were conducted with 68 state-level stakeholders, and in-person interviews were conducted with 77 community-based stakeholders. Six focus groups included 52 providers, and six included 32 consumers. A semistructured interview protocol was used. Interview notes and transcripts were coded to facilitate analysis. RESULTS: Health plans eliminated differential benefit limits and cost-sharing requirements for certain mental disorders to comply with the law, and they used managed care to control costs. In response to concerns about access to and quality of care, the state expanded oversight of health plans, issuing access-to-care regulations and conducting focused studies. California's parity law applied to a limited list of psychiatric diagnoses. Health plan executives said they spent considerable resources clarifying which diagnoses were covered at parity levels and concluded that the limited diagnosis list was unnecessary with managed care. Providers indicated that the diagnosis list had unintended consequences, including incentives to assign a more severe diagnosis that would be covered at parity levels, rather than a less severe diagnosis that would not be covered at such levels. The lack of consumer knowledge about parity was widely acknowledged, and consumers in the focus groups requested additional information about parity. CONCLUSIONS: Experiences in California suggest that implementation of the 2008 federal parity law should include monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs; examining the breadth of diagnoses covered by health plans; and mounting a campaign to educate consumers about their insurance benefits.

Recent changes in Medicaid policy and their possible effects on mental health services.

As Medicaid has emerged as the primary funder of public mental health services, its character has affected the organization and delivery of such services. Recent changes to the program, however, promise to further affect the direction of changes in states' mental health service systems. One group of changes will further limit the flexibility of Medicaid mental health funding, while increasing provider accountability and the authority of state Medicaid agencies. Others will increase incentives for deinstitutionalization and community-based care and promote person-centered treatment principles. These changes will likely affect state mental health systems, mental health providers, and the nature of service delivery.

Transforming mental health and substance abuse data systems in the United States.

State efforts to improve mental health and substance abuse service systems cannot overlook the fragmented data systems that reinforce the historical separateness of systems of care. These separate systems have discrete approaches to treatment, and there are distinct funding streams for state mental health, substance abuse, and Medicaid agencies. Transforming mental health and substance abuse services in the United States depends on resolving issues that underlie separate treatment systems--access barriers, uneven quality, disjointed coordination, and information silos across agencies and providers. This article discusses one aspect of transformation--the need for interoperable information systems. It describes current federal and state initiatives for improving data interoperability and the special issue of confidentiality associated with mental health and substance abuse treatment data. Some achievable steps for states to consider in reforming their behavioral health data systems are outlined. The steps include collecting encounter-level data; using coding that is compliant with the Health Insurance Portability and Accountability Act, including national provider identifiers; forging linkages with other state data systems and developing unique client identifiers among systems; investing in flexible and adaptable data systems and business processes; and finding innovative solutions to the difficult confidentiality restrictions on use of behavioral health data. Changing data systems will not in itself transform the delivery of care; however, it will enable agencies to exchange information about shared clients, to understand coordination problems better, and to track successes and failures of policy decisions.

Future funding for mental health and substance abuse: increasing burdens for the public sector.

Spending on mental health (MH) and substance abuse (SA) treatment is expected to double between 2003 and 2014, to $239 billion, and is anticipated to continue falling as a share of all health spending. By 2014, our projections of SA spending show increasing responsibility for state and local governments (45 percent); deteriorating shares financed by private insurance (7 percent); and 42 percent of SA spending going to specialty SA centers. For MH, Medicaid is forecasted to fund an increasingly larger share of treatment costs (27 percent), and prescription medications are expected to capture 30 percent of MH spending by 2014.

Mental health and substance abuse spending by age, 2003.

This article presents national estimates of mental health and substance abuse (MHSA) spending in 2003 by age groups. Overall, $121 billion was spent on MHSA treatment across all age groups in 2003. Of the total $100 billion spent on MH treatment, about 17% was spent on children and adolescents, 68% on young and mid-age adults, and 15% on older adults. MH spending per capita by age was $232 per youth, $376 per young and mid-age adult, and $419 per older adult. Of the total $21 billion spent on SA treatment, about 9% was spent on children and adolescents, 86% on adults ages 18 through 64, and 5% on older adults age 65 and older. SA spending per capita by age was $26 per youth, $98 per mid-age adult, and $28 per older adult.

Mental health treatment expenditure trends, 1986-2003.

OBJECTIVE: This study determined spending on mental health treatment in the United States over time by provider and payer relative to all health spending. METHODS: Estimates were developed to be consistent with the National Health Expenditure Accounts. Numerous public data sources were used. RESULTS: Mental health treatment expenditures grew from $33 billion in 1986 to $100 billion in 2003. In real 2003 dollars, spending per capita on mental health treatment rose from $205 to $345. The average annual nominal total mental health growth rate was 6.7%. In comparison, total health care expenditures increased by 8.0%. As a result of the slower growth rate of mental health expenditures compared with all health spending, mental health fell from 8% of all health expenditures in 1986 to 6% in 2003. Total national health spending increased by approximately $1.175 trillion from 1986 to 2003; of this, 6% is attributed to an increase in mental health spending. The mix of services has changed, with more care being provided through prescription drugs and in outpatient settings and less in inpatient settings. Payer mix has also shifted, with Medicaid taking a more prominent role. CONCLUSIONS: Spending on mental health treatment has increased over the past decade, reflecting increases in the number of individuals receiving mental health treatment, particularly prescription drugs and outpatient treatment. Changes in payer and provider mix raise new challenges for ensuring quality and access.

Trends in spending for substance abuse treatment, 1986-2003.

Since 1987, public and private investment in substance abuse (SA) treatment has not kept pace with other health spending. SA treatment spending in the United States grew from $9.3 billion in 1986 to $20.7 billion in 2003. The average annual total growth rate was 4.8 percent. In comparison, total U.S. health care spending grew by 8.0 percent. As a result of the slower growth of SA spending compared to that for all health care, SA spending fell as a share of all health spending from 2.1 percent in 1986 to 1.3 percent in 2003.

Mental health benefits in Employer-sponsored Health Plans, 1997-2003.

Data drawn from the Mercer National Survey of Employer-sponsored Health Plans in 1997 and 2003 indicate that a large majority of employers continue to provide some level of coverage for mental health (MH) services in their primary plans. However, a majority of plans continue to impose different benefit limitations for MH than for other medical treatment. Among plans with limitations on MH coverage, there was a sharp increase in the use of limits on inpatient days and outpatient visits between 1997 and 2003. The proportion of employers providing coverage for some MH services decreased; e.g., among small employers, 88% provided coverage for inpatient MH care in 2003, compared with 94% in 1997. These results suggest that parity legislation has had a noticeable but limited effect, but that, at least in the short-term, it is unlikely that universal parity in employer-based plans will be achieved through a legislative strategy.

National estimates of mental health insurance benefits.

This article presents estimates of the proportion of the U.S. population that had mental health benefits in 1999, of the extent of their coverage, and of the proportion that were enrolled in health plans subject to the Mental Health Parity Act of 1996 (MHPA). Findings indicate that over three-quarters (76%) of the U.S. population had mental health benefits as part of their health insurance. Approximately 18% of the population had no mental health benefits, and for the remaining 6%, mental health benefits could not be determined. Of the 18% with no mental health benefits, most (84%) had no health insurance whatsoever, while the remainder (16%) had health insurance that did not cover mental health benefits. Estimates of the generosity of coverage indicate that 44% of the population had benefits that included prescription drugs, and that provided at least 30 inpatient days and 20 outpatient visits for psychiatric care. For 12% of the population, benefit generosity could not be determined. Finally, study results suggest that the MHPA affected only 42% of the U.S. population.

Characteristics of U.S. youths with serious emotional disturbance: data from the National Health Interview Survey.

OBJECTIVE: Although it is estimated that serious emotional disturbance affects 9 to 13 percent of children and adolescents in the United States, there are few national data on the characteristics of this group. METHODS: This study used data for 13,579 youths from the 2001 National Health Interview Survey (NHIS) to describe the sociodemographic features and insurance coverage of youths with serious emotional disturbance living in the United States. Youths with serious emotional disturbance were identified through their scores on the Strengths and Difficulties Questionnaire, which was added to the NHIS in 2001. RESULTS: A large majority of youths with serious emotional disturbance were white and had income at 200 percent of the poverty level or higher. About 40 percent of youths with serious emotional disturbance had private insurance coverage, whereas Medicaid and the State Children's Health Insurance Program provided coverage for about a third of youths with serious emotional disturbance. CONCLUSIONS: Although Medicaid is an important payer of mental health services for youths with serious emotional disturbance, private insurance is still the primary source of health coverage for youths with serious emotional disturbance and for the overall population of youths.