The state of the Mental Health Care System in the US
In: Psychology
25 Dec 2009
The crisis has spread to everywhere and even when signs of recovery are spotted here and there we are not out of the storm yet. Actually, we may have to wait for one or two more years to be back to “normal”.
The Mental Health Care System is no exception to this and is being hit really hard from many fronts.
Many states are recalling their off-state clients in Residential Treatment Facilities (RTF) to compensate for the lack of referrals. The problem isn’t that there aren’t enough people with mental issues to be referred, it’s that the Agencies are not funding as many people as before and are also pushing for shorter treatments. There’s one caveat: the human mind just doesn’t work the way they (would like to) think and it’s also completely independent from the economy (no rocket science here).
I reckon that the referring agencies are going through tough times too, but these policies are extremely detrimental to clients. Treatments should not be “canned” and RTFs are no factories either. Each case has individual requirements (i.e.: time, resources, approach). If you want to regard treatments as an assembly line, well, it’s not going to work.
Consider a kid with AD/HD, mild MR, Autism or Psychosis. These types of disorders take time to be treated or stabilized. We are not talking about a blown tire or a broken camshaft, things that you fix. Treatments should last as long as they need to and shortening them will ultimately lead to failures.
To compensate for the lack of psychiatric/developmental disabilities referrals, RTFs are taking in clients from a very different population: juveniles. The judicial system is flooded with teenagers in trouble with the law which makes them a good source to be tapped in this times of drought (in a way, the recession is to be blamed for this too, but we are still not seeing the consequences of it to the fullest. Wait for five years and you’ll see). Families get marginalized due to lack of employment, crime rates go up. The equation is pretty straightforward.
In this regard, RTFs provide a half-way solution for these kids so they don’t end up in jail. They have a second chance to get their record straight. If we go back to the “shortening treatments” thing I’d say that sending these kids to placement is just a delay in their road to lock-down. Success rates for this population are already low (15-20%). Shorten treatments from 6 months/1 year to just 90 days, and conclusions are not difficult to make.
There is another problem that derives from this whole situation. Most residential programs are not tailored to accommodate this population. On one hand, it requires a completely different in-unit programming and treatment and on the other, these individuals co-exist in the same buildings with psychiatric clients and/or clients with mental disabilities. In this complicated landscape centers will have a daunting task. Re-tailor their well trimmed programs to fit the new population.
As centers struggle to retain their occupied beds in this new “high-client-turnover, low referral rate” climate, they face other problems like school districts that haven’t paid them for years, funding cuts from the government and more exigencies from funding agencies.
Projections aren’t good either. Some centers have ceased their operations, laying off hundreds of employees and financial recovery is in the distant horizon (2012-2013). As long as they can keep borrowing money they’ll be fine (bigger organizations are better positioned) but if cash doesn’t flow in, repaying those obligations is going to be hard. Which translates into a lower score, thus no more loans. Conclusion, bankruptcy.
I’d love to finish the article on a higher note, but to be honest, the near future looks kinda grim.
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4 Responses to The state of the Mental Health Care System in the US
Michael Benjamin
December 26th, 2009 at 7:54 am
I admire your approach.
I have been wondering how reform would effect mental health? In Israel we have reform. It is a series of insurers competing with each other. By law every one has to be insured. The insures then ‘buy’ from providers. Some services they provide themselves. This leads for great in effeciency. The ‘providibg arm ‘ of the insurer competes at an unfair advantage.
Providing Medicine is very much an exercise in cost containment. Efficiency is not really considered. Budgets are set by ‘ the power of the strong’. So no budget will cut an item which has powerful sectorial backing. Once the budget is set then the aim is to meet the budgetary goals of every item. There is a dialogue of interests between the ‘payer’ and the ‘provider’. This give rise to the juggling acts of Fees For Service & ‘Capping’.
No where is service requirements discussed as an overall goal. So, as your essay points out, there is enormous energy spent ‘ to provide work’ and ‘contain the cost’. So complex projects or ones with no clout are ignored. Preventive medicine is a great sufferer.
The Israeli system has been unable to address Mental Health. Mental Health is not part of this system. Severely Mentally Ill are funded directly by the government. As the government wants to bring theis to the ‘insurers’ too it is seriously underfunded. Funding again is according to the law of the strong. This means that the Hospitals are allowed to exist as community care is decimated. Consequently the revolving door has almost fallen of its hinges. The non severely ill finds himself being treated by the family doctor but as a side issue of his over-utilisation of medical; resources which he is prone to do. So many of them are ‘problem patients’ receiving anti-depressants. The compliance rate is staggeringly low. But the meds are cheap and generally covered by the the patients contribution to his meds.
There is no alternativ or bertter treratments. No one demands it except the Psychologists, again as a sectorial issue.
The situation in Chiuld Psychiatry is verging on a disaster. There is no community care at all, waiting lists are disasters. So the ‘problem child’ who is the school system anyway, appears with learning problems. He is seized upon by ‘Ritalinised’ Neurologists. The result is great pressure for children to take Ritalin.
The problems we are having making mental health part of an overall plan, I feel are not only ours. The magnifying of the problem in juvenile care is even more so.
I believe the bottom line to be this. It is impossible to divorce mental health from other community based fields. Especially so in Child Psychiatry. The reform is a fiscal one. The overall delivery goals, means and combination were ignored. This means that true mental health care has been inadequately costed. What is not costed is ignored. Even if it is essential. And that is an enormous problem.
Fernando Tarnogol
January 24th, 2010 at 11:20 am
Hi Michael,
I’ve read your comment several times. There was something that kept me thinking and I wasn’t sure what it was.
I was perusing it tonight and two of your phrases stood out in my mind.
The first one was [quote] “Providing Medicine is very much an exercise in cost containment. Efficiency is not really considered”.
And yes, that is something that I’ve observed and I think that the issue is worsened by the overall budgetary environment. Efficiency is completely left aside as long as the budgetary goals are met and the “ailing” individual becomes just a small piece of the puzzle or a mere three figure number. I also think this is collateral damage that emanates from capitalism and the “commercialization of every environment (including Health). An unavoidable characteristic of the paradigm.
When you say that “there is no alternative or better treatments [and] no one demands it except the Psychologists, again as a sectorial issue” I also agree that MH has always been the black sheep of the Health Care system, and that for historical reasons Psychology/Psychiatry has never been regarded “on par” with (non Mental) Health Care. Moreover, the centuries old segregation of the mentally ill from society provides a fallacious foundation for the dismissive treatment that Mental Health Care has received from every angle throughout modern history.
Thank you for sharing your thoughts
Fernando
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