The New York State Psychiatric Association (NYSPA), the state affiliate of the American Psychiatric Association, applauds and congratulates the Board of Mental Health News Education, Inc. for its decision to broaden their publication’s mission to address issues related to alcohol and substance abuse as well as mental illness. The publication’s new name, Behavioral Health News, serves to announce that broadened horizon.
The decision to advance the publication’s content areas comes at a time when the clinical need to address the challenge of the co-occurring disorders of mental illness and alcoholism/substance abuse is being recognized by psychiatric physicians and other clinicians as well as New York State’s Office of Mental Health (OMH) and Office of Alcoholism and Substance Abuse Services (OASAS) and federal agencies such as SAHMSA (The Substance Abuse and Mental Health Agency). The American Psychiatric Association (APA) and its state affiliates, such as NYSPA, have long advocated for integrated services and for the recognition of the need for Parity insurance benefits covering the full spectrum of mental illness and addiction diagnoses. The national coalition of advocacy organizations, among which the APA assumed a proud leadership role, saw its long-time goal realized with the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) in October, 2008. Psychiatrists viewed the federal Parity Act as the culmination of a long fight for equitable treatment for those with mental illness and addiction disorders in the mold of other civil rights struggles in our country’s history. With the passage of MHPAEA, the challenge now is to realize its goal by achieving full implementation despite resistance from the behavioral health insurance industry.
The APA recognizes, as do state and federal agencies, that these disorders are biologically based and socially influenced. As a consequence, they cannot be treated in isolation, one from the other. The epidemiologic data describing the prevalence rates of mental illness and substance use disorders and the frequency with which they co-occur are compelling. SAMHSA reports the following statistical findings. Forty-five million Americans suffer with mental illness of which 11 million are found to have serious and persistent mental illness (SPMI) and 8.9 million have co-occurring mental illness and substance use disorders. Almost 21 million persons are believed to have substance abuse disorders. While 44% receive care focusing on one or the other disorder, only 7.4% receive care addressing both problems and a whopping 55.8% are receiving no treatment at all. It also has been found, based on an analysis of Medicaid data, that those with co-occurring disorders are disproportionately costly and demonstrate higher levels of socially unacceptable behavior such as violence. Furthermore, much of the higher medical cost is attributable to increased rates of medical illness including diabetes mellitus, hypertension, and cardiac illness, among others.
With the attention of responsible federal and state governmental agencies and of professional societies, such as APA and NYSPA, focused on the important matter of mental illness, substance abuse, and medical disease co morbidities, the treatment landscape is rapidly evolving. These transformations are occurring at the same time that the requirements of the Accountable Care Act (ACA) are taking effect. The greatest change is poised to occur in 2014 when millions of Americans will gain access to affordable health care. Building on existing health insurance vehicles such as commercial insurance, Medicare, and Medicaid the ACA will extend benefits through the newly created healthcare exchanges and an extension of Medicaid to a newly defined low-income group in states such as New York which have chosen to participate. It is noteworthy that the Parity protections conferred on persons requiring care for mental illness and substance use disorders by MHPAEA is to be categorically preserved in the benefit design of these new health insurance products. Along with enrollee expansion will come an increased reliance on an ever more “managed” system with the goal of containing costs. Given the checkered history of enrollees’ experience with managed care and especially in the face of the resistance of behavioral managed care companies to full compliance with MHPAEA, consumers and professionals will need to remain vigilant and push in a variety of ways to assert the rights embodied in the law.
What are the steps being taken? In NYS Governor Cuomo initiated a Medicaid Redesign Taskforce to address the issues of the need for better integrated care and control of costs, among others. Several of its work products include the formation of Health Homes, initially funded largely through federal funds, to improve the environment for the delivery of integrated care. Collaborative efforts between the OMH and OASAS, such as the “no wrong door” approach have the goal of making access to mental health and addiction services easier. Going forward it is anticipated that the system is likely to transition from the current model of parallel, stove piped care to truly integrated care. Such a step forward would be presaged by regulatory change establishing unified service licensure of providers.
Aware of research findings on prevalence rates of substance use disorders and on the need for improved treatment of those with addictions, The American Academy of Addiction Psychiatry was founded in 1986, making it a new psychiatric subspecialty. Fellowships in addiction psychiatry began to emerge, the American Board of Psychiatry and Neurology took note and in 1997 established a subspecialty “Certification in Addiction Psychiatry,” a testament to the increasing recognition of the importance of that field. Today there are more than 45 such programs with many of them in the NYC metropolitan region. Psychiatric trainees, recognizing the need for more holistic treatment approaches to the care of those with dual diagnoses of mental illness, especially SPMI, and addiction are increasingly enrolling in addiction fellowships after their general psychiatric training to broaden their base of expertise.
Recognizing the complexity of mental health, addiction and medical illness care, the need for practitioners well versed in providing such treatment within integrated systems is evident. At national and state levels the healthcare system is in a state of unimaginable flux. How it will play out hangs in the balance. What is clear is that the decision to transform Mental Health News into Behavioral Health News is right on the mark. The community needs a publication which will report on these changes and their impact on consumers, their families, and the professionals who serve them – and I believe Behavioral Health News will be there to meet the challenge!
Barry B. Perlman, MD is the Director, Department of Psychiatry, Saint Joseph’s Medical Center with campuses in Yonkers and Harrison, New York, and is a past president of the New York State Psychiatric Association.