Published: Feb 7, 2014Demand -- for both facilities and providers -- has long outpaced supply in the field of mental health, but recent moves to increase funding for mental health services combined with innovative delivery systems may reverse that trend.
In December, to mark the 1-year anniversary of the Sandy Hook Elementary School tragedy, Vice President Joe Biden announced the executive branch would invest $100 million in the nation's mental health system. Biden said the funds would be used to expand mental health services at community health centers and in rural America.
Biden's announcement was welcome news since the American Psychiatric Association estimates that in 2015 the nation will face a shortage of 22,000 child psychiatrists and 2,900 geriatric psychiatrists, and many of them are aging out of the profession according to theNational Institute of Mental Health website, which notes that 55% of all psychiatrists are older than 55.
Since there are currently 1,360 psychiatric residency spots in the U.S., increasing psychiatric residency spots is not the answer to this problem, explained Richard Summers, MD, co-director of the psychiatric residency program at the University of Pennsylvania's Perelman School of Medicine.
The Primary Solution
Summers thinks primary care providers (PCPs) are a big part of the answer because they are often the first, sometimes only, physicians to diagnose and treat a patient's mental illness.
But the American Academy of Family Physicians said that while PCPs prescribe the majority of the nation's antidepressants, they are not getting rich providing those services:
- "Although primary care physicians are major providers of psychiatric care, they are discriminated against by payment mechanisms that create a disincentive to thorough and comprehensive mental health screening. The issue of appropriate payment is critical when national surveys reveal that the majority of both diagnosed and undiagnosed patients of a mental health disorder sought their care from general medical providers."
Under the Affordable Care Act (ACA), all insurers must provide mental health and substance abuse coverage, which is one of the 10 "essential benefits."
Last November, the federal government issued its final rules for the Mental Health Parity and Addiction Equity Act, passed in 2008 and enhanced in the ACA. The act requires parity for mental health coverage with the coverage offered for medical and surgical claims.
But, as Summers pointed out, we won't know for a while how the reimbursement will play out: "There is an attitude of cautious optimism that this may be helpful, but what's going to be interesting is to see how this rule will be interpreted and implemented."
A major obstacles are grandfathered and other ACA-exempt plans that don't have to provide mental health or substance abuse coverage at all. If they do provide coverage, they can limit inpatient and outpatient services. Those plans can retain "grandfathered status" as long asthey continue to meet certain requirements.
But money is not the only issue: many PCPs lack the needed psychiatric training, according toJaseu Han, MD, residency director of the combined family medicine/psychiatry program at the University of California Davis Health System.
"There has to be a behavioral component to all residencies. There is a ton of talk about the value of patient-physician interactions, but the residents are not receiving psychiatric training. If you look at internal medicine, Ob/Gyn, pediatrics, and family medicine, they don't get anything. There is no requirement during residency to get any mental health experience."
A few programs have emerged to address this issue. The Resource for Advancing Children's Health, which began in 2006, teaches medical professionals to care for childhood depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, and aggression. As of December 2012, 1,000 clinicians had completed the program.
Another program, Project Extension for Community Healthcare Outcomes, funded in part by a grant from the Robert Wood Johnson Foundation, began this past June at the University of New Mexico School of Medicine. The program helps PCPs "develop the capacity to safely and effectively treat chronic, common, and complex diseases in rural and underserved areas, and to monitor outcomes of this treatment."
Even with adequate training, Han still thinks PCPs should only treat patients with mild to moderate anxiety disorders and depression and refer patients with more severe psychiatric problems -- schizophrenia, bipolar disorder, debilitating anxiety, major depression, and others -- to psychiatrists.
Integrated Models
To help patients gain access to proper care, integrated behavioral health models, which integrate psychiatrists into primary care practices, are being formed.
Katherine Nordal, PhD, executive director for professional practice of the American Psychological Association, supports this integrated approach, noting that 70% to 75% of patients first bring up their mental health issues with their PCP. Many patients are averse to seeing a psychiatrist due to the stigma attached to it, but feel comfortable discussing their mental health problems with their PCP.
An example of an integrated program is the IMPACT care model, which was designed to treat older adults with depression and dysthymia. According to the IMPACT website, in their model the patient's PCP works with a care manager to develop and implement a treatment plan, consisting of medications and/or brief, evidence-based psychotherapy. The care manager and PCP work with a consultant psychiatrist to change treatment plans if the patient does not improve. The care manager is a social worker, nurse, or psychologist.
A 2-year, randomized control study was done in which 1,801 depressed or dysthymic adults enrolled. The enrollees were randomly placed into the IMPACT care model or the normal primary care clinic model, which included referrals to specialty mental health care providers.
Eighteen clinics, in five different states, participated in the program. The clinics varied in style and reimbursement requirements. Some accepted HMO plans, others were traditional fee-for-service clinics; there was also an inner-city public health clinic and two Veterans Affairs clinics.
The IMPACT website states that its model of depression care "more than doubles the effectiveness of depression treatment for older adults in primary care settings. At 12 months, about half of the patients receiving IMPACT care reported at least a 50 percent reduction in depressive symptoms, compared with only 19 percent of those in usual care ... When healthcare costs were examined over a four year period, IMPACT patients had lower average costs for all their medical care -- about $3,300 less -- than patients receiving usual care."
The Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND), an integrated model similar to the IMPACT model, has a unique reimbursement structure: nine medical clinics pay a monthly fee to DIAMOND clinics, which then offer a suite of mental health services. The monthly fees are based on patient outcomes not services billed.
According to Mark Vogel, PhD, director of behavioral science and psychiatry within Genesys Regional Medical Center, the outcome-based reimbursement model will emerge as the preferred structure: "It's still in its infancy as to how are we going to pay for it. In the future, it's probably going to be in the form of bundled payment ... the future is going to be fee for value, not fee-for service."
Vogel pointed out that already the integrated approach has become the "standard" within the VA. "Likewise, in the Department of Defense , they've made a requirement that all clinics above a certain size have at least one behavioral health clinician."
The Rural Challenge
America's rural areas have few, if any, mental health providers, so integrated behavioral care is not an option. In those communities, primary care physicians still treat moderate anxiety and depression, but often rely on telemedicine or, more precisely, telepsychiatry to treat patients.
In South Carolina, telepsychiatry is used by a majority of the state's emergency departments, said Mark Binkley, general counsel at the South Carolina Department of Mental Health (SCDMH).
"The continuing objective of the program is to make psychiatric consultation available in all South Carolina ERs at any hour. The consultations have increased the quality and timeliness of triage, assessment, and initial treatment of patients; reduced the number of individuals and length of stay in ERs; and allowed hospitals to direct critical personnel and financial resources to other needs; thus, realizing financial savings for hospitals," according to the SCDMH website.
Binkley said psychiatrists and patients have strongly endorsed the effectiveness of using telepsychiatry as a treatment modality.
According to the American Academy of Child and Adolescent Psychiatry (AACAP), "Research with adults shows that telepsychiatry is just as effective as treatment provided in person. Research with youth and families is just beginning. It shows that children, families, and referring doctors are very satisfied with the care received through telepsychiatry. Treatment recommendations, prescriptions, and laboratory tests can be coordinated by the telepsychiatrist or the referring doctor's office."
Telepsychiatry is also used throughout the state of Michigan to treat children and adolescents.Jed Magen, DO, MS, chairman of the department of psychiatry at Michigan State University (MSU), said his system provides telepsychiatry to many community mental health centers, one long-term hospital, and one juvenile detention center.
"It's gained wide acceptance; it's not quite like being there, but it's pretty close. You can provide quite effective services ... the only real patients that are problematic are those with severe suicidal ideation and real aggressive behavior. You can't really deal with those by video."
The downside is the telepsychiatry price tag for the technology -- computers, monitors, cameras -- is expensive, and Binkley said reimbursement is inconsistent, although Medicare added telepsychiatry coverage in 1999 and some Medicaid and private insurance plans also cover it. If they do cover it, they typically only cover treatment by a psychiatrist, not a social worker or psychologist.
At this time, it's unclear how the ACA and the mental health parity law will affect telepsychiatry reimbursement.
Another issue is state licensing. Almost all states require psychiatric treatment to be provided by psychiatrists licensed in their state. Because of this, a psychiatrist in Virginia couldn't treat a patient 10 miles away in Maryland through telepsychiatry.
Finally, there is no specific training or certification in telepsychiatry, so the physicians tend to learn telepsychiatry from colleagues or from the equipment vendors. Magen said that MSU's medical students and psychiatry residents all receive basic telepsychiatry training, and they've found it to be a good training modality.
In addition, the American Psychiatric Association, the AACAP, and the American Telemedicine Association all offer telepsychiatry practice guidelines on their websites.
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