How Do We Get From Here To There?
Even looking back at life from the age of 90, those of us fortunate enough to get that far are often surprised by how quickly the years pass. Between getting through school and the stress of building a career and a family, by the time we’re worrying about how to afford retirement, many of us are realizing life is all too short.
So why is it that so many people seem to spend so little of that precious time being happy?
Where Are We Now?
According to the CDC, in any given year, 25 percent of the U.S. population will need mental health services, and 50 percent will need some form of treatment during their lifetime. Far fewer actually receive it. One of the largest untreated public health problems in the U.S., only 38 percent of Americans get mental health services when they need it.
Financial concerns are the most common reason cited for not seeking treatment, but other factors are also involved.
“People talk with their neighbors about back surgery, but they are usually less inclined to talk about seeing a therapist,” Richard Akins, MD, MBA, of Alabama Psychiatric Services, said. “Although the stigma associated with being treated for a mental illness is less than it once was, people sometimes have concerns about confidentiality and the possible effect on their career if others become aware that they have been treated for a mental disorder.”
Even if everyone who needed treatment had the means and felt comfortable calling for an appointment tomorrow, they would have trouble getting one. Alabama, like many other states, already has a shortage of psychiatrists relative to the population. This shortage is likely to get more severe as regulations requiring all health plans to offer mental health coverage take effect next year
However, with the lingering impact of the recession on family and government finances, the greatest barrier to access is financial.
“In Alabama, we have both public and private sectors in mental health, and both are affected by the economy, but with some differences,” Akins said. “People who don’t qualify for Medicaid or Medicare may have insurance coverage if they haven’t lost it during disruptions in employment. Even with insurance coverage, co-pays for medications and office visits can add up, especially since the nature of mental illnesses may require frequent office visits and medications with a high co-payment.”
According to census data, median household income in Alabama is less than $43,000 per year, and in Birmingham it is less than $32,000 per year. In order to be eligible for Medicaid, income for a family of four cannot exceed $194 a week after deductions, which leaves a large number of families in-between. They are struggling to find enough money to pay for treatment while still managing to earn a paycheck.
“The stress of worry about finances and job security during the downturn, and the effect on families has actually increased our case load with private patients,” Akins said.
Nurses at a private mental health facility also report seeing another trend affecting patients whose incomes fall in the twilight zone—too high for Medicaid, but too low to cover costs. A disturbing number of discharged patients are being readmitted a month later when their symptoms return because they can’t afford to refill medications that cost $700 to $900 a month.
“Pharmaceutical companies offer assistance programs, but it can be difficult for private patients to qualify. If they have had disruptions in employment or other drains on their reserves, finding money for medications may not be easy,” Akins said.
Discussing a patient’s ability to afford a prescription may not be the most comfortable conversation, but it is one doctor and patient need to have.
“Even the best new drugs won’t work if patients don’t have access to them,” Akins said. “If you know cost is a problem, you may be able to substitute older, cheaper medications. Even if they aren’t your first choice, they may be better than no medication at all.”
What Is Happening In The Public Sector?
For public mental health programs, the effects of a lagging economy have taken a different form. State budgets across the country have been struggling with significant losses in revenue. Over the past few years, $40 million from the state general fund have been cut from Alabama’s mental health budget.
Jim Reddoch, JD, Commissioner of the Alabama Department of Mental Health, said that the department’s diverse funding stream has helped to cushion the impact of those cuts.
“Fortunately, the department receives funding from other sources, including the Educational Trust Fund,” Reddoch said. “We had to close facilities to balance the budget, but it came at a time when we were already moving toward community-based treatment, so there is much less demand for beds in a state hospital that may be far from a patient’s home.”
The Alabama Department of Mental Health provides services for patients with serious mental conditions, addictions, developmental disabilities and other disorders. In addition to treatment for those who qualify for Medicaid and Medicare, it provides in-patient psychiatric care for state residents who have been committed by the court.
The department is responsible for the operation of state hospitals which care primarily for patients with more severe illnesses that might require more specialized or longer term treatment, and it contracts with community-based facilities that treat most state patients.
“We’ve been pleased with the quality of care patients are receiving in community-based facilities, and having treatment available closer to home is also easier for families,” Reddoch said.
Another timely financial advantage for Alabama’s public mental health sector was having proceeds from the sale of the old Bryce’s Hospital available to reinvest in building a new, smaller, better-equipped Bryce’s Hospital on the grounds of the old Partlow facility, which is nearing completion and expected to open before the first of the year. (See companion article.)
Public sector patients are more likely to qualify for assistance programs offered by pharmaceutical companies, or to have their drugs covered through Medicaid or Medicaid.
“There had been some talk about Medicaid requiring generics and no longer covering brand name prescription drugs, but after review and community input, we’ve been assured that brand name medications will continue to be covered as before,” Reddoch said. “The good outcomes we’re seeing from the new antipsychotic drugs are one reason we’re able to treat more people as outpatients and in the community.
“As with patients taking antibiotics, our primary challenge with medications is compliance. When people start feeling better, they think they don’t need the medicine any longer and they stop taking it. Then their symptoms return and we have to start again.”
Moving the Paradigm from Mental Illness to Mental Health
State programs are geared toward providing treatment for those with serious mental health problems and focusing on recovery. In a time of budget austerity, there is little funding for preventive measures.
Insurance coverage in the private sector is also aimed at treatment, after the domino effect of mental illness has taken its toll on other family members, coworkers and the community. There aren’t many resources aimed toward a proactive model of keeping people mentally healthy in the way wellness programs are aimed at keeping the body healthy.
As the economy recovers and provisions of the Affordable Care Act make mental health coverage more widely available, more people should have the means to get treatment.
However, the inflow of new patients will also make the shortage of psychiatrists more challenging.
Akins said, “In mental health, a perfect storm of uncertainty is brewing.
Increased demand from the stress of the recession, parity laws, the Affordable Care Act and internal changes in care structure are likely to increase case loads beyond what the number of psychiatrists in Alabama can manage.
“UAB and the University of South Alabama are recruiting more residents for their psychiatric program, but we still need to consider how we can make access available when people need it.”
Moving beyond the traditional one-to-one treatment model of psychiatrist and patient, Akins sees a growing role for primary physicians, psychologists, masters-prepared therapists and counselors, nurse practitioners and both peer support groups and classroom style learning groups led by nurses on specific topics such as stress and anger management and medications.
“Physicians are already playing a greater role in recognizing the early symptoms of mental illness,” Akins said. “Getting patients into treatment sooner, combined with new antipsychotic drugs, seems to be improving outcomes particularly in some of the more serious disorders. We’re seeing fewer cases of catatonic schizophrenia, possibly because earlier intervention modifies the course of the disease.
“We also need to make mental health services more accessible in rural areas. Videoconferencing is an excellent way for therapists to reach out to patients in small towns. It isn’t reimbursed yet, but it is an existing technology that could quickly make a difference.”
Patients are also using technology to improve the wellness of their mind, and its impact on their physical health. In addition to online forums, there are cognitive therapy smart phone aps to record thoughts so they can be evaluated, and reminders to do deep breathing and relaxation exercises to manage stress.
With studies showing that happy employees are also healthier and more productive, some businesses are also taking a proactive position, making mental health services, stress reduction, substance abuse programs and emotional “first aid” programs available.
Researchers are still working to understand how genetics, environment and experiences figure into the root causes of more serious mental illnesses. As we learn more about causes, we can work toward prevention.
In the meantime, early identification of symptoms, early treatment and a proactive wellness approach to our own mental health can achieve a great deal. Like wellness of body, wellness of mind, so we can enjoy life, is a health goal well worth the effort.