AJMC Panelists Agree ACA, Parity Law Bring Progress in Mental Health Care, But There’s Still a Long Way to Go

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The Affordable Care Act and a federal parity law have already helped persons with mental health challenges get access to proper care. But a leading advocate, a medical director for Cigna, and a psychiatrist who has studied innovative care delivery models say more can be done to improve screening, to ensure the correct diagnosis, and to provide better access to services.

The American Journal of Managed Care recently hosted a panel discussion on how mental health care has changed under the Affordable Care Act.

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. We do need team-based approaches.

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 are not less generous than medical benefits. But 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. To hear the full discussion, click here.

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
  •     Wayne 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 only be a first step in 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 Dr. Katon explained.

Better and earlier identification 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 found 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 fix disparities in the availability of mental health providers, especially in the South.

Drs. 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), Dr. Katon said, and referral rates for getting 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.

These days, finding a specialist who isn’t booked can be difficult, especially for pediatric patients. Collaborative care, which Dr. Katon has studied and promoted for decades, 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 more frequent updates of medications, and ensures the ability to provide evidence-based psychotherapy in the primary care clinic.

“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,” he said. “We do need team-based approaches.”

Dr. 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 Dr. 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 four to six weeks is often a recipe for failure, Dr. Katon said.

“Any time any clinician picks up a prescription pad, they are making a number of very specific assumptions about that patient that may or may not be accurate,” Dr. 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, Dr. Lustig said.

All three experts, however, were optimistic that the landscape for mental healthcare is improving despite the challenges. Just getting behavioral health included in the ACA’s essential health benefits is a huge step forward, they agreed.

About the Journals

The American Journal of Managed Care, now in its 20th year of publication, is the leading peer-reviewed journal dedicated to issues in managed care. The American Journal of Pharmacy Benefits, provides pharmacy and formulary decision-makers with information to improve the efficiency and health outcomes in managing pharmaceutical care. In December 2013, AJMC introduced The American Journal of Accountable Care, which publishes research and commentary devoted to understanding changes to the healthcare system due to the 2010 Affordable Care Act. AJMC’s news publications, the Evidence-Based series, bring together stakeholder views from payers, providers, policymakers and pharmaceutical leaders in oncology and diabetes management. To order reprints of articles appearing in AJMC publications, please call (609) 716-7777, x 131.

CONTACT:Mary Caffrey (609) 716-7777 x 144
        mcaffrey(at)ajmc(dot)com
        http://www.ajmc.com

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