Hospital & community psychiatry最新文献

State mental health systems have undergone dramatic changes in the last 40 years, including decreases in state hospital capacity and increases in the proportion of mental health care provided in ambulatory settings and in general hospital units and private psychiatric hospitals. Health care reform is likely to accelerate these changes. The authors consider whether state mental health agencies have a future, given that they were created to operate state hospitals, a role that has been greatly diminished. The authors suggest that state mental health agencies will continue to exist, but that their role will change significantly.

The creation of an effective coalition of mental health organizations was integral to the mental health community's early success in furthering coverage for mental health services in national health care reform. A unified coalition was able to establish political credibility and clarify substantive choices while the Task Force on National Health Care Reform was formulating the Clinton Administration's proposal, leading to initial indications that parity for mental health benefits and flexible coverage of a wide range of services would be included. As concerns about the cost of the benefit package increased, the Administration stepped back from including comprehensive coverage, and some organizations in the coalition became divided over specific provisions. However, as of June 1994, the mental health community's consistent consensus about the need for comprehensive coverage and parity enabled the field to gain inclusion for mental health services and, in fact, wider coverage in some of the proposals emerging from Congressional subcommittees.

Current health care reform proposals will expand coverage and alter the delivery of mental health services. Much of the debate has focused on the cost of coverage rather than on the question "Who will pay?" This paper analyzes the consequences of redistribution of the financial burden of care. The analysis reveals two concerns. First, current employer-based proposals are somewhat regressive because premium costs fall disproportionately on lower-income workers. Second, the increase in federal government subsidies may lead to a significant decline in state and local government financing for mental health services. Both of these concerns have been partly addressed in reform proposals, but there are political barriers to more progressive, non-employer-based approaches and to strategies to retain state and local dollars for mental health services. These distributional issues are critical for a mental health system serving the poor and depending so heavily on state and local resources.

Health care reform proposals based on a single-payer system of health care insurance were introduced in the U.S. Congress in 1992 and 1993 but were superseded by the Clinton Administration's health care reform proposal, which was based on managed competition. In a single-payer system, the government collects all health care funding and pays private- and public-sector providers; similar providers are paid the same rate. Other features include consumer choice of providers, distribution of risk of high utilization over the entire nation, and control of health care expenses via an annual national health care budget. Such proposals cover outpatient, inpatient, and long-term care and case management services for mental illness and substance abuse disorders, call for periodic utilization review of continuing mental health care, and eliminate the distinction between public and private services based on limits of coverage. The last provision particularly affects severely or chronically mentally ill persons who are likely to exhaust their private insurance coverage.

To implement the proposed Clinton mental health benefit for the year 2001 requires a capacity to manage a flexible, comprehensive benefit. If fragmentation of services and discontinuity of care are to be reduced, mechanisms must be developed to coordinate services among domains--between acute and chronic care, and among public and private providers. Evidence exists that basic mental health services generally can be managed in health maintenance organizations (HMOs) with considerable cost savings and without detrimental effects on health, but it is less clear whether this is true of services for persons with severe and persistent mental illness. Effective services for persons with severe disorders require a capacity to organize and manage services across broad medical and social areas, but anticipated costs encourage providers to narrow the scope of care they offer and to select low-risk patients. Much will depend on developing methodologies that allow providers to be reimbursed accurately in relation to risk and that protect small providers from the potential cost of acquiring too many high-risk patients.

Lack of adequate insurance coverage is one reason that the percentage of children who currently utilize mental health services is significantly lower than the estimated percentage of children with serious mental disorders. Principles of a reformed health care system with particular relevance for children's mental health services include coverage of a broad array of home- and community-based services, provision of organized systems of care for children with serious and persistent mental illness, mechanisms to ensure appropriate utilization of services, and provision of mental health services on the same terms and conditions as other health services. The Clinton Administration's proposed Health Security Act embodied many of these principles. In addition, its call for universal coverage and for elimination of insurance exclusions for preexisting conditions would extend mental health coverage to children who are currently uninsured or underinsured; the plan would also expand the range of services covered to include state-of-the-art approaches such as intensive nonresidential services and other alternatives to hospitalization. Implementation of the proposed plan would require developing the service and workforce capacity to provide a full continuum of services, ensuring availability of existing services, integrating existing and new systems of care, guarding against underserving children with serious mental illness, and planning for the role of Medicaid funding in the reformed health care system.