SAN ANTONIO – Questions about how health care reform will affect the practice of medicine are nothing new, but there is particular uncertainty for the field of psychiatry, according to the president-elect of the American Psychiatric Association.
One reason for the uncertainty is that payment streams for psychiatric and substance use care are distinctive and poorly understood, and the scope of the relative sectors – including public, commercial, state, and self-pay – are unique in the field of psychiatry, Dr. Paul Summergrad explained at the annual meeting of the American College of Psychiatrists.
Dr. Paul Summergrad
According to a 2011 article in the New England Journal of Medicine, the greatest percentages of U.S. medical spending overall were from "private insurance" and "Medicare, out-of-pocket, and other private spending" (37% and 35%, respectively), but for mental health, Medicaid spending exceeded both of these (28% vs. 27% and 22%, respectively), and "other state and local spending" was also higher (18% vs. 6% for medicine overall).
For substance abuse, other state and local spending dominated at 36%, followed by Medicaid spending at 21% (N. Engl. J. Med. 2011;365:973-5).
"If you look at the total dollars that come into our world, they look different from the outset than they do for anyone else in medicine," Dr. Summergrad said, noting that patients with substance abuse, for example, fall mainly outside of the commercial insurance system.
Also, within Medicaid – the largest payer, the percentage spent on mental health services is about three times higher than for commercial insurance.
The impact of the Affordable Care Act through mandated parity rules for coverage of mental health and substance abuse services could provide for tremendous expansion of services within the insurance realm, he said.
Another reason for the uncertainty is a lack of understanding about the substantial extent and effects of medical and psychiatric comorbidities on the total cost of medical care, and the fact that most ambulatory psychiatric care is provided by physicians other than psychiatrists, said Dr. Summergrad, Dr. Frances S. Arkin Professor and chairman of psychiatry at Tufts Medical Center in Boston.
"This is both a challenge and an opportunity; it’s an opportunity to really improve the care of the patients, and not just individuals who have severe psychiatric illness," he said, noting that those improvements could come not only in terms of the quality of care, but in terms of the cost effectiveness of care – a factor that could benefit both patients and the care system, including psychiatrists.
"The care of our patients is deeply embedded in the general health care system, so for us, the payer environment is problematic, and we know that payment differentials have been deeply discriminatory. It’s part of the reason why, along with intrusive utilization review, many psychiatrists don’t take insurance," he said.
The impact of fourth-party carve-out models on both payment and models of care have had a very problematic impact on both the public and commercial sector – in particular because they don’t take into account the extent of medical-psychiatric comorbidity, he added, noting that "the impact of this commoditization really depends in large measure on stigma associated with mental health and substance abuse care."
Many patients in need can’t get adequate care, and the stigma associated with mental illness keeps them from addressing the problems with insurers or benefits managers.
"The insurance industry has relied, in my view, on that stigma to allow [psychiatric] care to be marginalized," he said.
However, studies consistently show that patients with mental illness and substance abuse issues have higher rates of medical comorbidities, and that patients with chronic medical conditions have higher rates of mental health issues. These interactions result in poorer outcomes and higher costs.
In many studies, the costs associated with treating patients with a psychiatric and/or substance use disorder are two to three times greater when accounting for a patient’s total medical costs, compared with the costs for patients without a behavioral condition, Dr. Summergrad said.
One way that health care reform can benefit patients and potentially psychiatry is through medical and psychiatric care integration. One collaborative team approach involves a behavioral health or chronic disease care manager in a primary care office working with a consulting psychiatrist. In a multisite randomized trial (the Improving Mood: Promoting Access to Collaborative Treatment, or IMPACT study) involving more than 1,800 patients, this collaborative care approach was associated with a 50% or greater reduction in depressive symptoms in 45% of intervention patients, compared with only 19% of usual care patients (Am. J. Manag. Care 2008;14:95-100).