Healing the Broken Mind: Transforming America's Failed Mental Health System: ideas from a new book about transformation in the mental health system.
Article Type: Report
Subject: Health care reform (Laws, regulations and rules)
Psychiatric services (Management)
Author: Kelly, Timothy A.
Pub Date: 11/01/2009
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2009 Vendome Group LLC ISSN: 1931-7093
Issue: Date: Nov-Dec, 2009 Source Volume: 29 Source Issue: 10
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 200 Management dynamics; 970 Government domestic functions Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation; Company business management
Product: Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: United States Geographic Name: United States Geographic Code: 1USA United States
Accession Number: 230438302
Full Text: "America's mental health service delivery system is in shambles ... [and] needs dramatic reform."

Did that get your attention? It sure got mine, especially since it came from a 2002 presidential commission on mental healthcare. It's not that anyone wants it this way. Mental health providers work hard to treat those who seek care, consumers want to get better, and third-party payers hope their funded services will lead to healing. But somehow, despite these efforts, the outcome of mental healthcare in America is too often disappointing. Consumers continue to experience the vicious cycle of clinical crisis, hospitalization/stabilization, and discharge to less-than-optimal community services, where the cycle may well start over again.

As a former state commissioner for Virginia's Department of Mental Health, Mental Retardation, and Substance Abuse Services, I saw too many examples of a system in shambles. I worked hard to promote system reform, and since then have been speaking and writing about the need for overdue reforms and means of accomplishing them. Our neighbors with serious mental illness desperately need help. They need innovative and effective care that is home-and community-based, outcome-oriented, and leads to recovery. Recovery does not mean perfect healing, but improvement to the point that the consumer can have a real home, a fulfilling job, and deep relationships. Recovery means that these people can come home.

To achieve comprehensive and lasting change, a five-fold transformation is needed. A transformed system must be characterized by:

Outcome based measurement. Less than half of all mental healthcare is supported by good evidence. The way forward is to measure actual clinical outcomes in the lives of those receiving treatment. Scientifically sound and easy-to-use clinical outcome measures are readily available for just about any mental health service setting. An increasing number of policymakers and public/private insurers are expecting that treatments or services offered for a person with mental illness will first be subjected to scientific outcome-oriented testing and found to be effective. All mental health treatments will thus eventually be evidence-based with an expected outcome of recovery. Once outcome data are made available, policymakers, providers, consumers, and insurers alike will be able to tell which community-based services are operating as intended, for whom, and in what settings.


Innovation. There is no inconsistency between vigorous competition and delivery of high quality healthcare. In fact, when vigorous competition prevails, consumer welfare is maximized. Yet a state mental health agency is, by definition, a monopolistic enterprise. The inherent monopoly of state mental health agencies must be broken if transformation is to proceed and significantly improve the lives of those receiving care. A transformed, truly competitive mental health system would:

* Facilitate well-informed and price-sensitive consumers

* Facilitate well-informed providers

* Assure easy market entry and exit

* Develop multiple providers and a thriving market

* Link comparative data and funding (with caution)

For the sake of all Americans with serious mental illness, it is time to do away with state-run mental healthcare monopolies.

Parity and universal coverage. Transformation will not get far if those with serious mental illness lack the coverage necessary to get needed care. Individuals and families that already struggle with the effects of serious mental illness should not have to struggle financially as well. The Mental Health Parity and Addiction Act of 2008 requires public and private insurers to offer comparable physical and mental health coverage. Implementation rules for this legislation are expected soon.

While parity legislation now requires the benefits for mental health diagnoses to match those for medical/surgical diagnoses, both of these benefits are subject to meeting "medical necessity" criteria. But these preclude the preventive and follow-up care that are essential for mental health services to be effective. So, criteria for "clinical necessity" should be used instead. Clinical necessity criteria can determine when a patient with serious mental illness is in need of services and when these services would qualify for payment. Qualifying mental health services would have to be:

* For the treatment of mental illness and substance use disorders, or symptoms of these disorders, and the remediation of impairments in day-to-day functioning related to them, or

* For the purpose of preventing the need for a more intensive level of mental health and substance abuse care, or

* For the purpose of preventing relapse of persons with mental illness and substance use disorders, and

Consistent with evidence-based, generally accepted clinical practice for mental and substance use disorders, and

* Efficient, in the sense that a less expensive treatment works as well as a more expensive treatment, and

* Not for the patient's or provider's convenience.

The primary difference between medical necessity and clinical necessity is that the first three bullets are "or" phrases, which would deem treatment clinically necessary for treating symptoms, OR preventing more serious mental illness, OR preventing relapse.

Universal coverage would ensure the full success of reform by enabling all with serious mental illness to receive needed treatment and avoid ending up at the emergency room, on the street, or in prison. Without universal coverage, many will remain untreated regardless of parity or other reforms.

Successful reform will also create new streams of funding that help to cover the costs of universal care. For instance, many hospitals currently receive significant yearly funding called "disproportionate share" that is intended to reimburse the cost of care for uninsured patients. Such funds could of course be reduced if there were no uninsured patients.

Empowered Consumers. The mental health advocacy movement is growing throughout the world and is starting to change perceptions about mental illness. Consumers are beginning to articulate their own vision for the services they need and are making better informed treatment decisions. And yet, we have a long way to go. Too many persons with mental illness--and their families--still feel disenfranchised, shuffled from one provider to another, told what to do, and excluded from decision making. Too often, they are not at the table when policies are being drafted or when treatments are being evaluated for effectiveness.

The top priority should be to empower and equip patients and their families to take a more proactive role. This means inviting persons with serious mental illness and their families to speak out about new treatments and payments structures, how to select a provider, how treatment decisions are made, and in how they asses their own clinical outcomes. "Experts" created the previous mental health system, which is still trying to overcome the devastating consequences of deinstitutionalization without effective community-based care. Perhaps if we pay more attention to consumers and advocates this time around, we will come closer to getting it right.

Commitment to Change. There are many providers and third party payers who are content with the mental health system as it is--the status quo. So why change anything? Because there are too many people whose needs are not met--too many who suffer from serious mental illness and cannot find a way to come home. Unfortunately, there is strong inertia within the mental health system that makes change difficult. To drive real transformation, we need a "perfect storm" of visionary leadership, economic necessity, and public outcry. It is only a matter of time until these three converge, and at that point genuine national mental health reform will begin in earnest.


Timothy A. Kelly, PhD, is author of the new book, Healing the Broken Mind: Transforming America's Failed Mental Health System, published by New York University Press. Dr. Kelly served as Virginia's Commissioner for the Department of Mental Health, Mental Retardation, and Substance Abuse Services from 1994 to 1997. Currently, he is director of the DePree Center Public Policy institute and an associate professor at the Fuller Graduate School of Psychology in Pasadena, CA.
Criteria for Transformation

Outcome-based measurement      Use results-oriented outcome measures
                               and "evidence-based practice" to
                               improve quality of care and system

Innovation                     Open monopolistic state mental health
                               systems to competition and innovation
                               to improve effectiveness and increase
                               treatment choices.

Parity and universal coverage  Implement "parity" so that mental
                               health treatment coverage matches
                               medical/surgical coverage and provides
                               adequate funding.

Consumer empowerment serious   Empowering persons with mental illness
                               gives them and their families a real
                               voice in policy development and
                               service evaluation.

Commitment to change           Continually overcome resistance
                               to change from forces wed to
                               the status quo.

Source: Healing the Broken Mind: Transforming America's Failed
Mental Health System.
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.