Federal involvement in mental health care for the aged: Past and future directions.

Reviews federal legislative trends in mental health services for the elderly under the Reagan administration. The consolidation of 21 health programs into 4 block grants is considered for its impact on elderly mental health care, and Congress's support of important programs such as clinical training, social research, and research on Alzheimer's disease is discussed. Severe limitations for reimbursement of mental health care under Medicare are considered. It is concluded that Community Mental Health Centers under the Reagan administration will further limit non-revenue-producing services such as prevention, consultation, and education as they exhaust their 8-yr federal funding support, and it is unlikely that Medicaid will increase its coverage of services for the mentally ill. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Providing mental health care to older adults: Unraveling the maze of Medicare and managed care.

This article reviews fundamental information about mental health benefits for older adults. Major systems, including Medicare, Medicaid, and managed care, are described. Regulations and policies that influence mental health care for older adults are distinct from those for the general population. In addition, Medicare has adopted managed-care options more recently than the private insurance industry. This relationship between Medicare and managed care is chronicled and future directions are postulated. Finally, we examine several empirical questions that have been raised due to the recent changes in the delivery of mental health care to older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hidden problems in current health-care financing and potential changes.

Health-care costs in the US have risen significantly in the past 10 yrs, markedly affecting access to quality medical and mental health care. Deficit financing of our federal health-care expenditures adds billions of dollars annually to our national debt. Health-care reform is being hindered by both the inability of the government to pay for the uninsured and the unremitting spiral of the Medicare and Medicaid entitlement programs. The reasons for the total health-care cost increases include higher provider charges, overutilization of services, and the burgeoning technology; problems of malpractice, overspecialization, and consumer demands have also fueled the higher costs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Local Medicare policies: A pathway for providing mental health services to older adults.

Inconsistent local Medicare service coverage policies constitute one of the most prominent barriers encountered by mental health professionals who provide services to older adults. In this study, the authors analyzed the scope and delineation of local Medicare policies for 19 types of psychiatric and psychological services in 2003 and again in 2006. Results indicated policies now exist for all Medicare services in all the states, and many of the local policies provide definitive statements to guide practice. However, some policies lacked delineation and variability persists from one region to the next. While researchers ascertain how local policies can impact service outcomes, providers should form issue networks and resolve current problems such as the inequities surrounding service documentation requirements and the lack of guidance in providing mental health care to older persons with dementia. Given that the Medicare administrative structure will undergo substantive changes in the next five years, there is an exceptional opportunity for providers to address these problems successfully and pave a pathway for providing specialty mental health services to older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interview with Representative Cecil Heftel.

Heftel discusses (a) reasons for spiraling health care costs; (b) why cost-saving alternatives such as nonphysician practitioners (e.g., psychologists) have been excluded from Medicare coverage; (c) the Heftel and Inouye bill providing Medicare coverage of psychologists' services in health maintenance organizations; (d) the need to increase in general Medicare coverage of mental services for the elderly; (e) the high incidence of mental illness in the elderly; (f) lower usage of mental health services among the elderly compared to younger groups; (g) mental health services in Hawaii; (h) the issue of psychologists as independent practitioners within Medicare; (i) involvement of psychologists in political advocacy; and (j) use of media by behavioral sciences to promote their concerns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quality of care problems among Medicare and Medicaid patients

The purpose of this study was to characterize quality of care problems among Medicare and Medicaid inpatients in New York State. The patients selected for this study comprised 1991 and 1992 Medicare and all 1992 Medicaid inpatients in whom quality of care problems with actual or potential adverse effects were found. The patients in this study were drawn from public, proprietary, voluntary and teaching hospitals. A total of 1000 quality of care problems with either actual or potential adverse effects were found in 706 Medicare patients. Two hundred and seventy-five (275) quality of care problems with actual or potential adverse effects were found in 154 Medicaid patients. Premature death occurred in 53 (7.4%) of the 706 Medicare and in 42 (27.2%) of the 154 Medicaid patients. Treatment problems and monitoring failures accounted for the majority of quality of care problems with actual or potential adverse effects for both Medicare (63.0%) and Medicaid (75.7%) patients. Among Medicare patients, the treatment of infections and antibiotic use, fluid and electrolyte management, and inappropriate drug use were among the leading causes of quality of care problems. Attending physicians were associated with the majority of Medicare quality of care problems while house staff and attending physicians were associated with the majority of those among Medicaid patients. The results of this study indicate that there are several leading causes of quality of care problems among Medicare and Medicaid patients. Treatment problems and monitoring failures together comprise the majority of such problems. Among Medicare patients, it was found that most quality of care problems were associated with the treatment of infections and antibiotic use, fluid and electrolyte management, and inappropriate drug use. Most quality of care problems among Medicaid patients were associated with these categories as well as with labor and delivery problems, and poor discharge planning. The results of this study reflect the peer-review process in which providers are given an opportunity to respond to physician-reviewer decisions about the presence of actual or potential adverse effects. Such a process, which permits the presentation of additional data and information by providers, produces fewer final adverse outcome determinations than a process uniquely based on chart review. The quality of care problems observed in this study are amenable to focused educational interventions. Such remedial interventions could yield significant improvements in the quality of care for all patients.     

Mental health care: Access, stigma, and effectiveness.

Discusses the lack of commitment by the US as a nation to ensure that high-quality mental health care will be provided to all who are in need. The mental health benefits under Medicare and Medicaid programs are meager at best. Psychologists and other nonphysician health care providers are not considered bona fide professionals. Prevention, program evaluation efforts, and the use of alternatives to traditional inpatient care, such as halfway houses and crisis intervention programs, are not treated under the current reimbursement system. An "efficacy proposal" created by US Senators D. K. Inouye and S. M. Matsunaga is described. The essence of the proposal was modeled after the current Food and Drug Administration requirements for safety and efficacy for all new drugs and medical devices. In addition to these 2 requirements, the notion of "appropriateness" or "cost-effectiveness" was added. This proposal, which was deleted in 1980, would have established an interdisciplinary commission comprised of representatives of both the scientific and clinical communities. The commission would have been charged with the responsibility for making recommendations as to what types of mental health services, and under what conditions, should be reimbursed under the Social Security Act. It is concluded that the establishment of an independent entity with the charge of seriously reviewing the "probably public benefit" of providing psychotherapy would be in the national interest of the US. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Children's mental health: The gap between what we know and what we do.

There is widespread agreement that over 11% of our nation's children need mental health treatment, but the majority of these children receive inadequate or inappropriate treatment. This gap between what we know should be provided and what is provided is the result of a poorly structured health care financing system and a poorly coordinated treatment system. The treatment system fails to recognize that children's mental health problems are interactions between intraindividual difficulties and environmental conditions. A wealth of models of prevention and treatment have been developed, and a substantial scientific basis for children's mental health interventions now exists, but there is a shortage of community based services and a lack of coordination across services. Public policy toward children with mental health problems must encourage application of knowledge about effective treatment systems and encourage care in the least restrictive and most cost-effective settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric care and health insurance reform

Concerns about cost, access, and quality of health care in the United States have led to a variety of legislative proposals that would reform our health care system and its financing. Health insurance benefits for mental illness, including substance abuse, are treated differently from medical/surgical benefits, with stricter limits on outpatient visits and hospital days. Medicare, Medicaid, and most private health insurance plans contain this historic disparity of coverage for mental illness compared to general medical illness. Psychiatric services are also distinguishable because of the large public sector reimbursement for mental illness treatment and support. Principles for a more equitable design of mental health benefits include a non-discriminatory approach; payment on the basis of service rather than diagnosis; application of cost containment for care of mental illness on the same basis as care of general medical illness; retention of the public sector as a backup system for high-cost, long-term care; encouragement of lower-cost alternatives to the hospital through the development of a continuum of care; and a recognition of the distinction between psychotherapy and medical management. All current approaches to universal health care fall short of these principles. A research agenda is needed now more than ever in order to articulate the case for complete coverage of mental illness and substance abuse.     

Interactions of bupranolol with the polymorphic debrisoquine/sparteine monooxygenase (CYP2D6)

Health-care costs in the United States have risen significantly in the past 10 years, markedly affecting access to quality medical and mental health care. Deficit financing of our federal health-care expenditures adds billions of dollars annually to our national debt. Health-care reform is being hindered by both the inability of the government to pay for the uninsured and the unremitting spiral of the Medicare and Medicaid entitlement programs. The reasons for the total health-care cost increases include higher provider charges, overutilization of services, and the burgeoning technology; problems of malpractice, overspecialization, and consumer demands have also fueled the higher costs.     

Be prepared

Remember back when Medicaid was Medicaid and Medicare was Medicare? These state and federal programs, which respectively provide medical assistance to low-income families and health insurance for individuals with disabilities and the elderly, were complicated enough when they became law as part of the Social Security Act in 1965. Now we've added managed care to the mix.     

Outpatient benefits for mental health services in Medicare: Alignment with the private sector?

Revision of Medicare's benefit for outpatient mental health care is long overdue. The Omnibus Reconciliation Act of 1987 expands the covered limit to $2,200 (from the $500 set in 1966) but retains the 50% coinsurance requirement for beneficiaries. There are several strong arguments supporting further changes in the benefit to reduce the coinsurance and include psychologists as covered providers. These are need among the elderly, changes in Medicare's inpatient reimbursement system, and innovations in treatment. Outpatient mental health care is a very small portion of Medicare expenditures, amounting to less than .1% of total costs. Using data from the Bureau of Data Management and Strategy at the Health Care Financing Administration (HCFA), it was estimated that $41.8 million was paid by HCFA for outpatient mental health care in fiscal year 1984. This article estimates the costs to Medicare and beneficiaries of reducing the coinsurance to 20% and including psychologists as eligible providers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison of public/private health care insurance parameters for independent psychological practice.

Managed care cost-cutting strategies are more prevalent in the private (employer provided) than public (Medicare/Medicaid) health care sectors. The main organizational managed care strategy pertaining to the independent practice of psychology has been the separation of the administration of mental from medical health care though behavioral health carve-outs. These organizations typically offer lower reimbursement rates and have greater preauthorization requirements than non-managed care public plans for the same psychological service. Dispute resolution in the private sector involves lawsuits and state consumer protection programs while public plans utilize internal review and are subject to investigations of provider billing fraud and abuse. Behavioral health carve-outs have reduced mental health care utilization rates with unknown effects upon outcome. There is some evidence that psychologists have chosen to limit practice within the private sector, but national data on the overall effect is lacking. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Use of formal and informal sources of mental health care among older African-American public-housing residents

BACKGROUND: Elderly residents of public housing have high rates of psychiatric disorders, but most of those in need of care do not use any mental health service. This study examines the use of formal and alternative informal sources of mental health care in a sample of elderly African-American public-housing residents. METHOD: Data from an epidemiological survey of six Baltimore public-housing developments for the elderly (weighted N = 818) were analysed to examine the utilization of mental health services by older African-American residents. Logistic regression analyses were used to determine correlates of using formal and informal sources by those needing mental health care. RESULTS: Thirty-five per cent of subjects needed mental health care. Less than half (47%) of those in need received any mental health care in the previous 6 months. Residents in need were more likely to use formal (38.5%) than informal sources (18.6%) for care. The strongest correlates of using formal providers were substance use disorder (OR = 15.62), Medicare insurance (OR = 10.31) and psychological distress (OR = 10.27). The strongest correlates of using informal sources were perceiving little or no support from religious/spiritual beliefs (OR = 21.65), cognitive disorder (OR = 19.71) and having a confidant (OR = 15.07). CONCLUSIONS: Contrary to elderly African-Americans in general, those in public housing rely more on formal than informal sources for mental health problems. Nevertheless, both sources fail to fill the gap between need and met need. Interventions to increase identification, referral and treatment of elderly public-housing residents in need should target general medical providers and clergy and include assertive outreach by mental health specialists.     

Health care, Medicare, and health policy for older people: A conversation with Arthur Flemming.

Fleming, former secretary of the Department of Health, Education, and Welfare and former US Commissioner on Aging, addresses (a) national health policy and how it might be more supportive of mental and general health needs of older people; (b) the need for changes to the Medicare program, such as enabling psychologists to provide mental health services to the elderly; (c) the need for a national health insurance other than Medicare; and (d) the importance of the Age Discrimination in Employment Act. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Linking level of care to level of need: Assessing the need for mental health care for nursing home residents.

What are the mental health status and active treatment needs of nursing home residents? A stratified random sample of 828 residents in 25 facilities serving Medicaid recipients was assessed for levels of physical and psychosocial functioning. Although 91.2% had sufficiently high levels of medical and physical care needs to justify nursing home placement, 79.6% also had moderate to intense needs for mental health care. Older residents, relative to their younger counterparts, had more intense medical and mental health care needs. It was also found that psychiatric diagnosis was a poor indicator of mental health service needs, particularly among elderly individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of Medicaid managed mental health care on delivery of services in a rural state: an AMI perspective

In March 1995 Iowa implemented a statewide mental health carve-out program under a Medicaid Section 1915b waiver. A goal was to provide equal access across counties for Medicaid recipients by introducing a statewide network of service providers. Problems have included the contractor's authorizing only services considered medically necessary for persons with serious mental illness, who also need community supports; contractor staff's lack of knowledge about regional resources and the limited availability of community-based services in most rural areas; clients' difficulty in gaining access to the new system; denial of inpatient hospitalization; untimely provider payments; and lack of education for providers, consumers, and families.     

A summary of the Colorado Clinical Psychology/Expanded Mental Health Benefits Experiment.

Conducted an experiment to test 2 alterations in the Medicare program: (1) increasing the proportion of allowable charges for outpatient mental health services that Medicare will reimburse and raising the annual limit of reimbursement, and (2) reimbursing psychologists directly, rather than through a supervising physician, for providing mental health services. The experiment was conducted by Blue Cross/Blue Shield of Colorado from October 1976 to December 1978. All Medicare beneficiaries in that state were randomly assigned to 4 groups, each having a different combination of the 2 variables: coverage and practitioner status. The evaluation consisted of 2 primary components: assessing how successfully the operational aspects of the experiment functioned and determining the impact of the experimental changes on the use, cost, and delivery of mental health and medical services reimbursed by Medicare. There appeared to be no administrative barriers to implementing the changes necessary to select eligible psychologists to participate, select the services to be covered, or implement reimbursement procedures for clinical psychologists. However, the case-by-case peer review system developed for the experiment experienced administrative problems and was costly. There were no significant effects on the utilization of Medicare services, overall program costs, or the delivery of care. (4 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medicare/medicaid billing fraud and abuse by psychologists.

Medicare/Medicaid billing fraud and abuse can be prosecuted under a wider array of laws than apply within the private sector. Cases are typically initiated by whistleblowers or through detection of unusual billing patterns. Few psychologists in independent practice have ever been convicted of Medicare/Medicaid billing fraud or abuse, but government antifraud efforts against psychologists appear to be on the rise. These efforts are pursued under the auspices of containing spiraling health care costs, but they can uncover unintentional billing abuse by psychologists, arising from general ignorance of claim-processing procedures, lack of uniformity across insurance programs, constantly changing guidelines, and ambiguous interpretations. Recent investigations in south Texas have especially targeted the use of extenders for psychological and neuropsychological testing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)