The Kaiser Health Plan of Northern California, usually touted for excellence, recently was hit with a $4 million fine by the state's Department of Managed Health Care. Reportedly, the HMO did not provide mental health services comparable to that for physical illnesses for some of their more seriously ill patients, perhaps akin to not providing care for patients with heart disease who require cardiac rehab or patients with severe respiratory diseases that need more intensive and specialized treatments than usual office-based practices.
The population of people needing mental health services is like a pool with a shallow and a deep end, as Dr. Michael Hogan (who led the last Presidential Commission on Mental Health) described. The shallow end of the pool is comprised of the people who will annually suffer from common conditions like depression, anxiety disorders (including PTSD), and alcohol and drug problems. This population is large and typically seeks care (if they do at all) in primary care and general medical settings, delivery sites where Kaiser has shown innovation for integrated health and mental health treatment services.
But there is also a deep end of the pool -- people with bipolar illness, schizophrenia, suicidal states, eating disorders, borderline personality and other serious and persistent mental disorders. While this group may be fewer in number, their conditions require more comprehensive care, over time, like chronic physical diseases.
Quality care for the shallow end of the population pool can be delivered in primary care settings by embedding screening, medically-proven treatment paths, care managers and psychiatric consultation -- with repeatedly proven good results. Kaiser has focused on this population in order to not just treat their mental conditions but to contain their medical costs when diabetes, asthma, heart disease, hypertension do not improve because depression or problem drinking gets in the way. Integrated health and mental health care is often brief and effective.
But when a health plan, especially with its own delivery system, as Kaiser has, carries the responsibility for a population of people, working or poor, young or old, healthy or sick, they can't pick and choose. They can't say we do this and not that or possibly try to refer their high-need patients to public sector services that we all know are over-extended trying to serve those covered by Medicaid, a primary payer for the poor, or who have no health insurance at all. The deep end population has to be served wherever and whenever they appear, carpe diem, since they are often wary of doctors and hospitals, sometimes because of how their illness impairs their thinking, sometimes because of how they are treated, or not.
When ill people in the deep end of the pool are unrecognized or untreated, they don't simply go away. They show up in emergency rooms and on general hospital wards with out-of-control diabetes, heart attacks, pneumonia, trauma, and states of intoxication. That costs a lot of money. They are at high risk for homelessness and inhabit expensive community shelters. Their non-violent crimes get them arrested and confined to jails and prisons where some 400,000 inmates with mental conditions now reside in this country. These people drain government coffers when their illnesses progress and they come to depend on food stamps, welfare and disability payments.
Ironically, treatments for serious and persistent mental disorders are as effective as treatments for chronic physical conditions -- when patients' illnesses are properly detected and diagnosed, and when they are made welcome, kept in care and delivered proven interventions. There is no need to eschew the deep end of the pool because of misinformation that nothing will help; quite the contrary.
Responsible and good medical care does not confine itself to the shallow end of the pool. Restricting access and limiting services for those with serious and persistent disorders, mental or physical, abrogates a professional ethos to care for the patient and, over time, costs health care and communities far more money. A lot more than $4 million.
Dr. Sederer is adjunct professor at the Columbia/Mailman School of Public Health and author of The Family Guide to Mental Health Care (WW Norton, 2013).
Dr. Chung is vice president and chief medical officer of Montefiore Care Management at Montefiore Medical Center
The opinions offered here are those of the authors not their respective organizations.
For more by Lloyd I. Sederer, M.D., click here.
For more on mental health, click here.