Crossing state lines of chronic mental illness

A federal law passed in 1986 required states to develop service plans incorporating each state's own definition of chronic mental illness. This study considered whether the state definitions can be used to identify comparable populations of chronic mentally ill patients and to obtain a meaningful national estimate of the number of such patients. The study applied definitions of chronic mental illness used in ten states to a representative sample of patients receiving public mental health services in West Philadelphia over a two-year period. The prevalence estimates of patients defined as chronically mentally ill ranged from 38 percent using the Hawaii definition to 72 percent using the Ohio definition. The National Institute of Mental Health definition, used as a reference point, produced a prevalence estimate of 55 percent. The authors conclude that the considerable variance among the states in prevalence estimates renders the sum of state counts of chronic mentally ill patients of limited use.     

Capitation financing of public mental health services for the chronically mentally ill

In the 30 years since deinstitutionalization began the public mental health system has experimented with a variety of financing and management models in the delivery of care to the chronically mentally ill. Currently, capitation methods of payment for public mental health services to the chronically mentally ill are being tested as an alternative to fee-for-service reimbursement. Proponents suggest that capitation will increase service flexibility and produce a variety of better coordinated, more cost efficient services. Opponents believe that capitation will result in reduced care given the absence of treatment protocols and the financial incentives for cost containment. This paper discussed the impact of financing mechanisms and organizational structure on the delivery of mental health care for the chronically mentally ill, provides a review of the pertinent literature, and describes demonstration projects currently underway. Questions are raised as to the potential impact of capitation on the mental health system.This research was supported by a grant from the Pew Charitable Trusts to the University of Pennsylvania and The Community Council for Mental Health and Mental Retardation Inc., and was carried out jointly by the Policy Modeling Workshop of the Wharton School and the Section on Public Psychiatry and Mental Health Services Research of the School of Medicine.     

Cycles of reform in the care of the chronically mentally ill

Three major cycles of reform in public mental health care--the moral treatment, mental hygiene, and community mental health movements--are described as a basis for assessing current fiscal policies in the mental health field. The authors argue that the incipient effort to create community support programs for the chronically mentally ill constitutes a fourth distinctive cycle of reform. They discuss legislative and administrative threats to the viability of this initiative, along with the necessity for developing financing mechanisms commensurate with the needs of the chronically mentally ill for long-term care.     

Opportunities and risks in Philadelphia's capitation financing of public psychiatric services

The city of Philadelphia was one of nine sites selected by the Robert Wood Johnson (RWJ) Foundation and the U.S. Department of Housing and Urban Development (HUD) to receive five-year funding to improve the delivery, quality and cost efficiency of public mental health services to its chronically mentally ill population. As part of the RWJ project, the city plans to restructure its delivery and reimbursement system, creating a not-for-profit central authority which will function as a health insurance organization (HIO) responsible for coordinating and managing psychiatric care to Medicaid clients. Operating under a model of capitation, the central authority will employ diverse funding mechanisms to finance and manage service delivery. This paper examines the benefits and risks inherent in the reorganization of Philadelphia's mental health service system under a capitation financing model. Issues considered include cost and utilization patterns, treatment outcomes, providers and their staffing patterns, service mix and the overall impact of capitation on clients.     

Form and function of mental health authorities at Robert Wood Johnson Foundation Program sites: preliminary observations

The Robert Wood Johnson Foundation Program on Chronic Mental Illness provides support for broad change in the organization, financing, and delivery of services in public systems of care for chronic mentally ill persons. To address the lack of an organizational locus of responsibility in these systems, the foundation proposed that each of the nine cities participating in the program create a mental health authority that would centralize administrative, clinical, and fiscal oversight. The authors present site-by-site observations of the developing mental health authorities at the end of the program's two-and-a-half-year planning phase. They conclude that although the Robert Wood Johnson Foundation grant represented a significant incentive for innovation, at this relatively early stage in the demonstration authorities at only a few sites had achieved direct clinical responsibility for chronic mentally ill persons. Although services had expanded, no site had yet developed a comprehensive system of care that included inpatient services as well as a full range of ambulatory, housing, and social welfare services.     

Psychiatry's future: Facing reality

U.S. public and private health care costs, including mental health treatment costs, continue to rise at unacceptably high annual rates of increase. "Basic" health insurance plans presently being developed by both public and private payers, in response to this crisis, will include: (1) severely limited coverage for psychiatric care; and (2) coverage for specific categories of serious mental illness. Psychiatrists must develop cost-effective goals and treatment standards that achieve satisfactory outcomes for these high-priority conditions. Treatment standards must be compatible with economic reality. Psychiatry as a profession (i.e., all psychiatrists) must accept cost-effective treatment responsibility for society's most seriously mentally ill individuals. We need to train psychiatrists who are biologically-, crisis-, and rehabilitation-oriented and who can practice effectively and comfortably within society's treatment expectations and funding constraints.     

Underinsurance for severe mental illness

Mental health care for the severely mentally ill in the United States is financed by a combination of public and private funds. Both public and private health insurance programs handle mental illness differently than they do other illnesses. This article documents uninsurance and underinsurance for severe mental illness in the United States based on studies conducted during the last decade. The relationship between private insurance and public assistance is analyzed, and major arguments around equality in insurance coverage for severe mental illness are examined. Alternatives for reducing uninsurance and underinsurance for severe mental illness in order to avoid undertreatment are discussed.     

Changing a state mental health system through litigation: the Arizona experiment

Litigation may be a viable means to change mental health systems for the chronically mentally ill. Court orders achieved in the 1970s have been ignored or proven inefficient over the years. However, in Arizona, a strategy was designed by a team of lawyers and psychiatrists to deal with failures seen elsewhere in court actions seeking adequate services for chronically mentally ill patients. This novel approach produced a favorable court outcome and triggered a chain reaction at the executive and legislative levels to reform radically the system of care for the chronically mentally ill in Arizona.     

Rural mental health coverage under health care reform

Efforts to integrate services and financing under health care reform hold benefits for provision of services to rural mentally ill persons. Remote areas pose a particular challenge as the unique characteristics of rural America are even more evident. The model for managed care in remote rural areas will differ from those used in urban and their adjacent rural areas. Universal coverage would remove the barriers to accessing care for this population, but does not assure availability of adequate mental health services or providers in rural areas. Characteristics of currently available rural mental health services are presented and obstacles to expanded delivery under health care reform are outlined.This work was supported by NIMH Grant #MH 49173-02.     

The fate of the public psychiatric system

Psychiatry faces a vast array of problems today, including its inability to implement programs for the chronic mentally ill and to apply principles of differential therapeutics, the lack of funds for community services, and the continuing severe fragmentation of the psychiatric delivery nonsystem. Old solutions will not suffice. If the public mental health system is to survive, it must first be defined as comprising all settings, services, and funding for the severely and chronically mentally ill. And it must shift the balance of resources and services from institutional to community-based care. A range of financial and administrative mechanisms, such as various kinds of aggregate funding and a division of responsibility among levels of government, are available to accomplish that shift.     

Health care utilization by persons with severe and persistent mental illness

Claims for physical health care among 220 Medicaid enrollees with severe mental illness and 166 Medicaid enrollees who were not enrolled in the public mental health system were compared. Claims for the mentally ill group were 18 percent less than for the group without severe mental illness. Twenty-eight percent of claims for mentally ill patients were for treatment in emergency rooms and ambulances, compared with 11 percent for patients without mental illness; 26 percent of claims for patients without mental illness were for care in outpatient surgical and outpatient hospital settings, compared with 14 percent for mentally ill patients. Results suggest inefficient use of the health care system by mentally ill patients and highlight the need for coordination of care.     

Health maintenance organizations and their implications for psychiatry

Rapidly rising health care costs, a growing surplus of physicians, and recent federal legislation have created a more competitive health care market and have led to rapid growth in the number of health maintenance organizations, or HMOs. HMOs may place psychiatrists and their patients at a disadvantage because they generally restrict coverage of mental illness, use mental health practitioners other than psychiatrists, and lack provision for treating chronic and indigent mentally ill patients. In this review article, the authors describe the characteristics of HMOs, review the historical, legislative, and economic forces that have contributed and will contribute to their explosive growth, and outline measures that psychiatrists must take to ensure that mental health care is not compromised in HMOs and other price-competitive health care delivery systems.     

Public health care for the chronically mentally ill: Financing operating costs issues and options for local leadership

Revenue sources for mental health care for the chronically mentally ill are fragmented, and services limited. What services are provided are frequently underfunded, and gaps in the “safety net” undermine a continuum of care. Given this situation, what can local units of government do to leverage multiple funding streams in a way that makes optimal use of scarce resources? The authors describe different types of reimbursement, noting that every method of health care reimbursement carries different response incentives and disincentives for providers and patients. They frame an analysis of long term care financing models that may have heuristic value for systems of public care for this special population.     

Primary health care in the CMHC: a role for the nurse practitioner.

Although persons with chronic mental illness have a high incidence of physical health problems, they are often ill equipped to seek care within complex health care systems and tend to depend on community mental health centers as their only source of regular health care. The authors describe a role for the nurse practitioner in assessing the medical needs of chronic mentally ill outpatients at a community mental health center and in devising strategies to meet those needs. The nurse practitioner's activities include direct physical health screening and treatment, referral for specialized medical services, consultation, research, and staff and patient education.     

Philadelphia's capitation plan for mental health services

Dr. Sharfstein's Introduction: Prospective payment is the major economic change that is reshaping the delivery of medical care. Capitation financing for the chronic mentally ill is an innovative and promising alternative to underfunded and bureaucratically rigid public programs on the one hand and underfunded retrospective cost-based Medicaid programs on the other. This month's column describes one such capitation plan. Its impact on the target population as well as on the use of resources by persons with long-term and severe mental illnesses will require close evaluation.     

Evaluating mental health care reform: including the clinician, client, and family perspective

This article suggests one direction that theory building might take to develop a stronger conceptual foundation needed to test the effect on clients of reforms in the financing and organization of mental health care delivery systems. The authors recommend that health status outcomes be measured from three perspectives: the client, who can best report his or her own subjective experience of illness; the clinician, who is the best source of information about the client's disease; and the family, which is the best source of information about the effects on members' health status of caring for a mentally ill family member. The authors also recommend that measurement of health status should be multidimensional.     

Recent developments in the care, treatment, and rehabilitation of the chronic mentally ill in Greece

The chronic mentally ill in Greece are primarily cared for in large public mental hospitals or by their families because of the absence of community-based alternatives and the centralization of existing services in Athens and Thessaloniki. However, in the last decade new legislation to improve the lives of the chronically ill has been passed, additional day care facilities have been opened, and the development of decentralized mental health services has been scheduled by the National Health System. A case report illustrates the care provided at Greece's first community mental health center, established in 1979 in Athens.     

Financing changes and their impact on the organization of the public mental health system

This article describes the changes in the financing of the public mental health system over the past 40 years. These changes have had profound effect on the organization and delivery of care. The paper documents the tremendous fragmentation of funding and services and details the effects that these changes have had on continuity of care, access to care, organizational and financial management complexity, services to the seriously mentally ill and future of the system.     

The chronic psychiatric patient: problems, promises and perspectives, past, present and future

OBJECTIVE: To present an overview of the issues involving the severely and chronically mentally ill over the past 50 years and summarize new research that may aid them. METHOD: To present the problems that have faced and will face this population, the promises that have been made about and to them, and assess how well we fulfilled our promises and handled the problems. RESULTS: We have made some but not enough progress in solving the problems facing the severely and chronic mentally ill in the past and at present, but the future holds more hope if recent solid, practical, economically feasible mental health services research is translated through policy and practice into better patient care. CONCLUSION: As pessimistic as we often are about the plight of the chronic mentally ill, their future can be better if recent research is implemented.     

Build a better state hospital: deinstitutionalization has failed

The author cites increasing numbers of chronic, homeless, and neglected mentally ill people as evidence of the failure of deinstitutionalization and community care to live up to their promise to reduce chronicity, the need for long-term hospitalization, and even mental illness itself. He believes the state hospital system, despite having been maligned and nearly destroyed, has great therapeutic potential. It could provide extended care to acutely ill patients before they become chronically ill; restore the ability to pinpoint responsibility for patient care, which has been lost under community care; and provide a stimulating academic environment conducive to research into treatment of the mentally ill.