“America's mental health service delivery system is in shambles … [and] needs dramatic reform.”
Did that get your attention? It sure got mine, especially since it came from a 2002 presidential commission on mental healthcare. It's not that anyone wants it this way. Mental health providers work hard to treat those who seek care, consumers want to get better, and third-party payers hope their funded services will lead to healing. But somehow, despite these efforts, the outcome of mental healthcare in America is too often disappointing. Consumers continue to experience the vicious cycle of clinical crisis, hospitalization/stabilization, and discharge to less-than-optimal community services, where the cycle may well start over again.
As a former state commissioner for Virginia's Department of Mental Health, Mental Retardation, and Substance Abuse Services, I saw too many examples of a system in shambles. I worked hard to promote system reform, and since then have been speaking and writing about the need for overdue reforms and means of accomplishing them. Our neighbors with serious mental illness desperately need help. They need innovative and effective care that is home- and community-based, outcome-oriented, and leads to recovery. Recovery does not mean perfect healing, but improvement to the point that the consumer can have a real home, a fulfilling job, and deep relationships. Recovery means that these people can come home.
Timothy A. Kelly, PhD To achieve comprehensive and lasting change, a five-fold transformation is needed. A transformed system must be characterized by:
Outcome based measurement. Less than half of all mental healthcare is supported by good evidence. The way forward is to measure actual clinical outcomes in the lives of those receiving treatment. Scientifically sound and easy-to-use clinical outcome measures are readily available for just about any mental health service setting. An increasing number of policymakers and public/private insurers are expecting that treatments or services offered for a person with mental illness will first be subjected to scientific outcome-oriented testing and found to be effective. All mental health treatments will thus eventually be evidence-based with an expected outcome of recovery. Once outcome data are made available, policymakers, providers, consumers, and insurers alike will be able to tell which community-based services are operating as intended, for whom, and in what settings.
Innovation. There is no inconsistency between vigorous competition and delivery of high quality healthcare. In fact, when vigorous competition prevails, consumer welfare is maximized. Yet a state mental health agency is, by definition, a monopolistic enterprise. The inherent monopoly of state mental health agencies must be broken if transformation is to proceed and significantly improve the lives of those receiving care. A transformed, truly competitive mental health system would:
Facilitate well-informed and price-sensitive consumers
Facilitate well-informed providers
Assure easy market entry and exit
Develop multiple providers and a thriving market
Link comparative data and funding (with caution)
For the sake of all Americans with serious mental illness, it is time to do away with state-run mental healthcare monopolies.
Parity and universal coverage. Transformation will not get far if those with serious mental illness lack the coverage necessary to get needed care. Individuals and families that already struggle with the effects of serious mental illness should not have to struggle financially as well. The Mental Health Parity and Addiction Act of 2008 requires public and private insurers to offer comparable physical and mental health coverage. Implementation rules for this legislation are expected soon.
While parity legislation now requires the benefits for mental health diagnoses to match those for medical/surgical diagnoses, both of these benefits are subject to meeting “medical necessity” criteria. But these preclude the preventive and follow-up care that are essential for mental health services to be effective. So, criteria for “clinical necessity” should be used instead. Clinical necessity criteria can determine when a patient with serious mental illness is in need of services and when these services would qualify for payment. Qualifying mental health services would have to be:
For the treatment of mental illness and substance use disorders, or symptoms of these disorders, and the remediation of impairments in day-to-day functioning related to them, or
For the purpose of preventing the need for a more intensive level of mental health and substance abuse care, or
For the purpose of preventing relapse of persons with mental illness and substance use disorders, and
Consistent with evidence-based, generally accepted clinical practice for mental and substance use disorders, and
Efficient, in the sense that a less expensive treatment works as well as a more expensive treatment, and
Not for the patient's or provider's convenience.
The primary difference between medical necessity and clinical necessity is that the first three bullets are “or” phrases, which would deem treatment clinically necessary for treating symptoms, OR preventing more serious mental illness, OR preventing relapse.
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