System transformation is underway in New York State and throughout the United States through the development of elaborate financial structures such as accountable care organizations and health homes. No doubt these new structures will change the way business is done in the mental health system. But will they result in the kind of transformation called for early in this century by the President’s New Freedom Commission on Mental Health? Will they result in real and fundamental improvements in mental health care and in the mental health of the American population? Here are 20 questions that need answers before we celebrate the remaking of how care is financed and managed.
- Currently only about 40% people with
mental disorders get treatment. Will this number increase substantially?
- In most parts of the U.S. and in many counties in NYS, the capacity to treat people with mental illness is simply inadequate. Will service capacity increase significantly, especially in remote and high poverty areas?
- Access to available care is often limited by cost, distance, inconvenient office hours and the like. Will mental health services become affordable? Will services be offered in places and at times that work for people who have real lives?
- Many people do not seek or reject mental health services because of a sense of shame created by the still widespread stigma that surrounds mental illness and/or because they do not know that treatment could help them or where to find it. Will these problems be addressed effectively?
- Of those who get treatment, at most 1/3 get even minimally adequate treatment. Will the quality of mental health services improve appreciably?
- One of the reasons for inadequate treatment is that so much of it is provided by primary care physicians who are not prepared to identify or treat mental disorders. Will primary care practices develop the capacity to provide effective care for people with mental disorders?
- Most people with co-occurring mental and substance use disorders do not get treatment, and of those who do get treatment very few get treatment for both disorders and even fewer get integrated “dual-diagnosis” treatment. Will there be an appreciable increase in the use of integrated treatment approaches?
- The mental health service system is fragmented, with inadequate coordination among mental health providers, between mental health and substance abuse providers, between behavioral and physical health providers, and with other human service providers. New managed care structures are specifically designed to reduce fragmentation. Will they succeed, not just from the standpoint of administrative and financial relationships but in the experience of people getting care?
- Creating a mental health system that is “recovery oriented” and “person-centered” was the major goal of the New Freedom Commission’s call for transformation. Will significantly more people with serious mental illness have lives that they find satisfying and meaningful? Will significantly more experience the mental health system as manageable and responsive to their needs and desires?
- Many people who do not or cannot come to mental health programs are responsive to outreach efforts such as ACT teams and will use services in their homes or in local settings such as community centers and houses of worship. Will mental health services become less characterized by professionals waiting for patients/clients/consumers in offices and more characterized by active efforts to engage people in need where they are?
- People in crisis often do not get an adequate response. Emergency rooms, especially in large urban areas, are often a horrible experience. Mobile crisis teams, few as there are, often are not available at times when they are needed. People who seek help for themselves or their families do so when they feel they are in crisis, but they often experience long waits to get mental health services in overloaded clinics and cannot get intensive services when they need them. Will these problems be adequately addressed?
- People with serious mental illness die 10-25 years younger than the general population. Will the mortality gap be reduced?
- Too many people with serious, long-term mental disorders do not have stable housing or are homeless. Will homelessness be reduced and stable, safe housing increased?
- Too many people with serious mental illness are in jails or prisons. Will the number of people with serious mental illness in jails because they cannot make bail be reduced? Will incarceration for minor crimes be replaced by humane alternatives? Will the criminalization of substance abuse be replaced by intelligent “harm reduction” interventions?
- Suicide is on the rise—up 20% since the turn of the century. Will more effective suicide prevention interventions be developed and put in place? Will the mental health system face up to the fact that guns are the major instrument of suicide?
- Overdose deaths are increasing despite some effective efforts to reduce the prescription and over-use of opioid painkillers. Will treatment for substance abuse become more readily available? Will harm-reduction measures be put in place to reduce deaths from overdoses?
- It does not appear that the incidence and prevalence of mental and substance use disorders have declined as the behavioral health system has grown and more effective treatments have been developed. Will more broad-based preventive interventions be put in place?
- The behavioral health system is unprepared for the major demographic changes taking place in America—the elder boom and the shift from a white majority to a non-white majority. Will the needs of older adults become a major concern of the mental health system? Will the needs of non-white populations, especially those for whom English is not a primary language, be addressed?
- At the heart of many of the inadequacies of the mental health system are vast workforce shortages. We need more, and more competent, mental health professionals including psychiatrists—especially child and geriatric psychiatrists, psychologists, clinical social workers, nurses, etc. We also need more and better trained paraprofessionals doing some of the most important but underappreciated and underpaid jobs in the system of care. Will these very difficult issues be addressed?
- Finally, inadequate funding for a broad range of mental health services is one of the reasons that America’s mental health system has improved only gradually over the past half century. New financial structures are explicitly designed to reduce future costs by reducing the need for intensive, high-cost services such as emergency rooms and inpatient treatment. Better care at lower cost is the promise. This is a promise that has been made many times before. Dorothea Dix promised that asylums would reduce the costs of poor houses. The Community Mental Health Centers Act promised that the dollars would follow the patients. Neither proved to be true. Will the new promise be fulfilled?
I am personally both hopeful and skeptical about the new financing structures. Their brilliance is undeniable; their effectiveness is yet to be proved. And even if they work, it is not clear that they will bring about broad transformation of the mental health system. We’ll see.
Michael B. Friedman is Adjunct Associate Professor at Columbia University School of Social Work and the volunteer Chair of the Geriatric Mental Health Alliance of New York. He can be reached at mf395@columbia.edu.
