Mental health care in the United States has been identified as an area substantively lacking in effective treatment approaches. The reason for this is rooted in ineffective networks of care and reimbursement structures. This paper evaluates a substance abuse treatment program at Mass General Hospital, establishes why the program is effective, and discusses how the ACA will expand access to higher-quality mental health treatment.
Behavioral Health Changes
Behavioral health, rehab, and detox diagnoses: Reimbursement and treatment philosophy
Although mental and physical health statuses are clearly interrelated, mental health diagnoses are treated differently both on a social and institutional level. According to the AHA Task Force on Behavioral Health (2007) one-fifth of patients who suffer a heart attack are also found to suffer from major depression. Depression after a heart attack significantly increases the likelihood of a patient dying from a second attack and mental health issues and heart problems are often co-morbid (Behavioral health challenges, AHA2007:1) However, despite this 'mind-body' connection, reimbursement services have been problematic, particularly for case management services and services provided by non-physicians, but also for more standard forms of mental health care for many patients (Mauch, Kautz, & Smith 2008:2).
Patients with all forms of health insurance have faced considerable obstacles in accessing high-quality mental health care. The privately-insured often have strict limitations on the types of services and number of services that will be reimbursed. Managed care has further fragmented psychological and mental-health-based care, given the need to justify mental healthcare through what can be a complex and bureaucratic referral system (Behavioral health challenges, AHA2007:3). As a result, there is often a greater emphasis placed upon psychopharmacological treatment vs. talk-based therapy. Since the rise of managed care fifteen years ago, there has been a corresponding rise in the prescription of psychotropic medication for both severe and mild conditions despite no evidence that there has been a corresponding rise in the actual existence of mental disorders, either in terms of the disorders' severity or comorbidity (Barkil-Oteo 2013).
The limited amount of talk therapy services covered by many plans has generated a greater reliance upon drugs which are covered by a patient's insurance company, regardless of whether drugs are the most suitable treatment for that particular patient. Many patients with very limited plans do not have psychological services covered at all, causing them to rely upon general practitioners for mental health care that these physicians are ill-trained to provide. This creates an overreliance upon and over-prescription of drugs for conditions like antidepressants which are not necessarily the most effective treatment for mild depression. Amongst the poor, who often have mental health conditions exacerbated by poverty, Medicaid programs offers low rates of reimbursement, causing mental healthcare providers to be reluctant to take on such patients (Behavioral health challenges, AHA2007:3). This causes a vicious cycle, given that untreated mental illnesses can lead to patients becoming further mired in poverty and joblessness.
Institutions such as general hospitals often act as 'stop-gap' facilities, providing services which they are unequipped to prove for the mentally ill on a long-term basis. ERs should not be regarded as the primary care facility for mental health treatment but that is the de facto outcome for many patients who lack access to care for financial or logistical reasons (Behavioral health challenges, AHA2007:6). In response to the need for specialized mental health care, specifically in the field of drug treatment, Massachusetts General Hospital has worked with the community to create a substance abuse treatment program to specifically address this issue with targeted and proven intervention strategies. The MGH-Harvard Center for Addiction Medicine (CAM) offers both inpatient and outpatient services for addiction treatment, as well as conducts clinical trials in this area.
One of the branches of CAM is called the Addiction Recovery Management Service (ARMS) is specifically designed to provide outpatient treatment to adolescents, including initial assessment; helping patients find inpatient treatment; and later providing support once the treatment program has been completed (ARMS, 2013, CAM). The program calls itself a 'bridge' program between inpatient and outpatient services provided by the hospital. Thus, it is an acknowledgement of the time-sensitive nature of inpatient care, but does not simply release patients back into the general population without support for their recovery.
The program also takes into consideration the greater knowledge of addiction and the psychological and physiological response to addiction in terms of its program structure. For example, many addicts are extremely ambivalent about entering treatment and giving up something that has structured their lives for so long. Addiction specialists called recovery managers work with parents to help them design effective strategies to get their children into treatment; they also work with families after treatment to provide them with support to return to the outside world. Family counseling is a critical component of the treatment, given that evidence-based medicine shows that creating an effective family support structure is critical to long-term, successful recovery (Treatment and services, 2013, MGH).
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