Women,Mental Health,and Managed Care

Abstract

Managed care has changed the way that mental health care is provided. These insurers manage such factors as length and type of therapy made available, access to therapy, and level of payment for therapy. Women, as the majority of those insured by managed care and as consumers of mental healthcare, are differentially affected by these changes.     

At the crossroads: managed mental health care,the ethics code,and ethnic minorities

Mental health clinicians are facing an increasing number of ethical problems related to the delivery of managed mental health care services to ethnic minorities. The authors argue that (a) economic pressures have led to the development of the managed health care movement; (b) the combination of such economic pressures and the development of that managed care movement have influenced the promulgated ethical standards of the American Psychological Association; and (c) those influences may have a negative impact on the mental health services available to ethnic minority individuals and communities. The authors review some of the specific potential threats to mental health services for minorities in the face of such health management policy and psychologists' professional standards.     

A qualitative study of primary health care access, barriers and satisfaction among people with mental illness

Research has found that a substantial proportion of individuals with mental illness have high morbidity and mortality rates, and high under-diagnosis of major physical illnesses. Furthermore, people with a mental illness tend not to seek out or utilise health care services. The reasons for the negative attitudes and behaviour towards health care services among this population have not been investigated. This paper presents findings from a study that investigated the health care service needs of people with mental illness (n = 20), and views from health care providers (n = 16) regarding access to these services by people with a mental illness. Results indicated that psychiatric patients identified a range of barriers to their health care usage and low levels of health care satisfaction. These views were shared with health care professionals. Reasons for these findings and strategies to address these problems so that there is better access to health care services for people with mental illness are discussed.     

Practicing psychology in the era of managed care. Implications for practice and training

Beginning with the HMO Act of 1973, managed care, a system for controlling health care costs, rapidly expanded and gained influence as the main vehicle for health care delivery in the United States. Implementation of managed care principles in the mental health arena has generated much debate, particularly with respect to issues of quality of care. The authors briefly trace the development of managed care and evaluate its impact on the practice of psychology. The extant literature is reviewed with specific attention to issues of quality of care, confidentiality of patient information, and shifting practice patterns of clinicians. Finally, the future of professional psychology within the context of managed care is examined, and the implications of newly created mental health roles for practitioners, training programs, and organized psychology are discussed.     

Aging and mental health in the decade ahead: what psychologists need to know

Until relatively recently, most psychologists have had limited professional involvement with older adults. With the baby boomers starting to turn 65 years old in 2011, sheer numbers of older adults will continue to increase. About 1 in 5 older adults has a mental disorder, such as dementia. Their needs for mental and behavioral health services are not now adequately met, and the decade ahead will require an approximate doubling of the current level of psychologists' time with older adults. Public policy in the coming decade will face tensions between cost containment and facilitation of integrated models of care. Most older adults who access mental health services do so in primary care settings, where interdisciplinary, collaborative models of care have been found to be quite effective. To meet the needs of the aging population, psychologists need to increase awareness of competencies for geropsychology practice and knowledge regarding dementia diagnosis, screening, and services. Opportunities for psychological practice are anticipated to grow in primary care, dementia and family caregiving services, decision-making-capacity evaluation, and end-of-life care. Aging is an aspect of diversity that can be integrated into psychology education across levels of training. Policy advocacy for geropsychology clinical services, education, and research remains critical. Psychologists have much to offer an aging society.     

A survey of mental health care provider's and managed care organization attitudes toward, familiarity with, and use of group interventions

Managed Care has had a significant impact on delivery systems for mental health services. Direct and indirect persuasion to provide more cost-effective treatments has been one consequence. The cost-saving qualities and the effectiveness of group interventions have produced clear expectations for an increased use of therapy groups. This study compared perceptions and uses of group treatments on a national sample of managed care organizations and mental health providers. Because group psychotherapy encompasses such a broad definition, five specific types of group interventions were defined: problem-focused homogenous, process-oriented heterogeneous, psycho-educational, self-help, and short-term groups. Implications of differences and similarities between directors of managed care organizations and treatment providers are examined and discussed across five response categories (familiarity/training, perceived effectiveness, likelihood of reimbursement/referral, daily use, and expectation for future use).     

U.S. mental health policy. Doomed to fail.

Changes in the de facto system of mental health care in the last decade reflect organizational and entrepreneurial responsiveness to changes in health policy, not mental health policy. Various other actions described here reduced statutory or institutional leadership roles in mental health and increased the pace at which mental health policy was becoming dependent on health policy. In turn, U.S. health policy in the 20th century has been inherently flawed. The short-term general hospital--the "doctors' workshop"--emphasizing acute care and surgery, has been the cornerstone of U.S. health policy throughout the 20th century. The mimicry of health services by mental health leads to demonstrably more expensive and less effective mental health care and dooms mental health policy to failure.     

Managed Mental Health: A Primer for Counselors

The mental health service delivery system is experiencing a transformation attendant to rapidly developing cost containment mechanisms. This article reviews various aspects of the new managed mental health care systems and details the gains and losses the various mental health service provider professions may experience depending upon how each responds to the changing demands of alternate service delivery systems. Recommendations are presented regarding how counselors can establish a solid base in the new managed mental health care system.     

The Financial Dimension of Integrated Behavioral/Primary Care

There are two reasons why mental health, now more appropriately termed behavioral healthcare, is declining: (a) a lack of understanding among psychotherapists of healthcare economics, particularly the intricacies of medical cost offset, and (b) our failure as a profession to see the importance of behavioral interventions as an integral part of the healthcare system inasmuch as the nation pays for healthcare, not psychosocial care. This paper will briefly describe the rapid changes in the economics of healthcare during the past 75 years, including the post World War II enthusiastic espousal of psychotherapy by the American public which was followed by a precipitous decline as our outcomes research in behavioral care remained ignorant of financial outcomes, leaving it to the government and managed care to arbitrarily curtail escalating mental health costs. At the present time psychology is on the cusp of becoming part of the healthcare system through integrated behavioral/primary care, renewing the primacy of financial considerations such as return on investment (ROI) and medical cost offset, as well as an urgency that we avoid the mistakes that are emerging in some flawed implementations of integrated care.     

National suicide prevention lifeline: enhancing mental health care for suicidal individuals and other people in crisis

Linking at-risk callers to ongoing mental health care is a key goal of crisis hotline interventions that has not often been addressed in evaluations of hotlines' effectiveness. We conducted telephone interviews with 376 suicidal and 278 nonsuicidal crisis callers to the National Suicide Prevention Lifeline (Lifeline) to assess rates of mental health care utilization following Lifeline calls and to assess attitudinal and structural barriers to service utilization. Postcall utilization rates were approximately 50% for suicidal and crisis callers who received mental health care referrals. Lack of health insurance and callers' perceptions about mental health problems emerged as significant barriers to accessing continued help.     

Training needs among nonmental health professionals working with service members: A qualitative investigation

Though many service members will not directly seek mental health care due to stigma and other factors, they may interact with the healthcare system in other ways including contact with first responders, nurses, and allied health care professionals. However, little attention has been spent in this regard on the educational needs of these professionals whose contact with service members and Veterans may provide the opportunity to assist Veterans in need with overcoming barriers to accessing mental health care. This qualitative study investigates the educational training needs of first responders and health care professionals in contact with military families and trauma survivors to determine whether, and what type, of additional training is needed. A sample of 42 first responders and health care professionals including emergency medical technicians, police officers, fire fighters, speech language pathologists, occupational therapists, physical therapists, and nurses were recruited to participate in 1 of 6 focus groups. Sessions were audiotaped and transcribed verbatim. Data analysis was guided by a thematic analysis approach. Thematic analyses suggest there is a significant knowledge gap with unmet educational needs of these professionals such as information on the invisible wounds of war, military culture, and screening and referring patients who present symptoms falling outside professionals’ scope of practice. Findings point to a need and desire for more robust education for first responders and health care providers around mental health concerns of military populations, including topics such as trauma, military culture, and screening tools. Efforts to develop curricula addressing these concerns are warranted.     

HIV prevention with persons with mental health problems

The HIV seroprevalence rate among persons with mental health problems (PMHP) is substantially higher than that of the general population in the United States. This study examines the efficacy over 12 months of an HIV prevention program with 99 individuals attending outpatient mental health clinics who were randomly assigned to receive either: (a) a seven-session, small-group intervention of Project LIGHT (Living in Good Health Together); or (b) a one-session video intervention. Regression analyses of data from 87% of the sample interviewed at 1-year follow-up revealed that intervention group membership was associated with significantly fewer sexual risk acts. A significant intervention effect for condom use was found for 72% of the sample who were African American, but not for Latino or Caucasian participants. Results from this study suggest that HIV risk reduction groups such as Project LIGHT may have utility in public mental health care settings.     

Acceptability and cost-effectiveness of military telehealth mental health screening

Telehealth has been touted as one solution to the shortage of mental health providers within the military. Despite developing evidence for the equivalence of telehealth mental health care, there is no research that covers the use of telehealth for population mental health screening, a standard component of postdeployment medical screening. This paper summarizes soldier perceptions of three separate screening events in which telehealth was used and the cost-effectiveness of telehealth versus in-person implementations of the same screening. Soldiers who have not been through telehealth screening report a strong preference for in-person screening. Soldiers who have been through telehealth screening still report preference for in-person screening, but they express more ambivalence about the screening method. Using telehealth-only mental health screening for large numbers of soldiers within a compressed time frame is more expensive than in-person screening. Telehealth resulted in higher referral rates than in-person screening. Government and military leaders should use care when making decisions about telehealth implementation. Although telehealth for small numbers may be sufficiently equivalent and economical, there is no evidence of cost savings or improved acceptability for telehealth mental health post-deployment screening.     

Mental health services for children. The state of the art

Throughout this century, people in the United States have been concerned about the serious deficiencies in the mental health care of our children. Despite eloquent needs assessment and recommendations for remediation, most of the unserved needs and deficiencies of our mental-health-care-delivery system remain the same. This article reviews the current status of mental health services to children, youth, and families to highlight the necessity of an integrated system of mental health care. The development of a continuum of care that is coordinated across the mental health and non-mental-health systems that naturally occur in all children's lives has the potential to vastly improve mental health services to children, youth, and families.     

Collaborative Communication Between Psychologists and Primary Care Providers

Psychologists frequently collaborate in the care of patients managed in primary care. Communication with a patient’s primary care team is important to ensure coordination and continuity of care. The communication is far from seamless. Although The Health Information Privacy and Portability Act (HIPPA) is designed to promote sharing of clinical information while protecting patient confidentiality, unique problems arise when mental health records are included. Mental health records are subject to different regulations to protect the patient’s confidentiality. Thus, what is communicated and how it will be accomplished are challenges. Further, psychologists and primary care providers often view documentation differently, resulting in different styles of documenting that may also impede coordinated care. Increasingly, health care systems are moving toward electronic medical records, creating greater opportunities for an integrated record. Improved communication through the record can keep other providers abreast of the mental health care being provided as well as suggestions they can use to reinforce the mental health care treatment plan.     

The mental health care revolution. Will psychology survive?

Managed mental health care, which encompasses a wide variety of approaches, is a response to precipitous increases in health care expenditures, particularly as they relate to mental health care. The shift from what seemed certain to become a national health insurance program only 15 years ago to the profit-driven corporate health care industry of today is truly revolutionary. These profound changes are beginning to have a major impact on the independent practices of psychologists. In this article, psychologist practitioners are exhorted to recognize this new development in the marketplace. Data are cited that show the rapid shift from free choice care to various forms of managed care, and practitioners are urged to participate in shaping the changes that are now in process in order to develop a humane and effective system of mental health care.     

Mental health measurement among women veterans receiving co-located,collaborative care services

Routine use of measurement to identify patient concerns and track treatment progress is critical to high quality patient care. This is particularly relevant to the Primary Care Behavioral Health model, where rapid symptom assessment and effective referral management are critical to sustaining population-based care. However, research suggests that women who receive treatment in co-located collaborative care settings utilizing the PCBH model are less likely to be assessed with standard measures than men in these settings. The current study utilized regional retrospective data obtained from the Veterans Health Administration’s electronic medical record system to: (1) explore rates of mental health measurement for women receiving co-located collaborative care services (N = 1008); and (2) to identify predictors of mental health measurement in women veterans in these settings. Overall, only 8% of women had documentation of standard mental health measures. Measurement was predicted by diagnosis, facility size, length of care episode and care setting. Specifically, women diagnosed with depression were less likely than those with anxiety disorders to have standard mental health measurement documented. Several suggestions are offered to increase the quality of mental health care for women through regular use of measurement in integrated care settings.     

Access to health care and social protection

In France, the access to healthcare has been conceived as a social right and is mainly managed through the coverage of the population by the National Health Insurance, which is a part of the whole French social security scheme. This system was based on the so-called Bismarckian model, which implies that it requires full employment and solid family links, as the insured persons are the workers and their dependents. This paper examines the typical problems that this system has to face as far as the right to healthcare is concerned. First, it addresses the need to introduce some universal coverage programs, in order to integrate the excluded population. Then, it addresses the issue of financial sustainability as the structural weakness of the French system--in which healthcare is still mainly provided by private practice physicians and governed by the principle of freedom--leads to conceive and implement complex forms of regulations between the State, the Social security institutions and the healthcare providers.     

Promoting and protecting mental health as flourishing: a complementary strategy for improving national mental health

This article summarizes the conception and diagnosis of the mental health continuum, the findings supporting the two continua model of mental health and illness, and the benefits of flourishing to individuals and society. Completely mentally healthy adults--individuals free of a 12-month mental disorder and flourishing--reported the fewest missed days of work, the fewest half-day or greater work cutbacks, the healthiest psychosocial functioning (i.e., low helplessness, clear goals in life, high resilience, and high intimacy), the lowest risk of cardiovascular disease, the lowest number of chronic physical diseases with age, the fewest health limitations of activities of daily living, and lower health care utilization. However, the prevalence of flourishing is barely 20% in the adult population, indicating the need for a national program on mental health promotion to complement ongoing efforts to prevent and treat mental illness. Findings reveal a Black advantage in mental health as flourishing and no gender disparity in flourishing among Whites.     

Characteristics and VA health care utilization of U.S. Veterans who completed suicide in Oregon between 2000 and 2005

Oregon Violent Death Reporting System data were linked with Veterans Affairs (VA) administrative data to identify and describe veterans who completed suicide in Oregon from 2000 to 2005 (n = 968), and to describe their VA health care utilization in the year prior to death. Twenty-two percent had received health care in the VA system. Of these, 57% did not have mental health diagnoses and 58% had not seen mental health professionals. A larger proportion of those who accessed care were VA-enrolled and received service-connected disability benefits. Fifty-five veterans were hospitalized during the year prior to death. Of these, 33% completed suicide within 30 days of a hospitalization. Further development of suicide prevention strategies for veterans in the community, including general medical treatment settings, is indicated.