Reforming Medical Treatment for People with Serious Mental Illness
Photo by Maurizio Polese
What group could health reform help most? The obvious choice (maybe the right one) would be people with no insurance, or lousy insurance. It is clear that un- or underinsurance is bad for your physical and fiscal health. How about people in need of skilled nursing care and assistance with activities of daily living? Some provisions of pending bills would allow these folks to avoid the Hobson’s choice of institutional care or too little care. But the cohort that might stand to gain the most from reform is the population of people with serious mental illness.
People with serious mental illness have long been known to have excess morbidity and mortality as compared to people without serious mental illness. Although much of this excess is attributable to “unnatural causes” - e.g., suicide – studies have identified in this population substantially elevated natural causes of illness and early death from conditions such as cardiovascular and respiratory disease.   Some of these conditions are caused or exacerbated by side effects of newer atypical antipsychotics.   Much of this excess morbidity and mortality is preventable, and some causes (e.g., poorly controlled diabetes) could be addressed through sound chronic care management techniques I’ve described in an earlier post.   Inadequate attention to the management of the medical concerns of people with severe mental illness could be a particularly attractive goal of health delivery reform.
The National Association of State Mental Health Program Directors issued a Technical Report last year on this issue. Its literature review rendered the following judgment:
Recent data indicates that, on average, persons with serious mental illness die 25 years earlier than the general population. Eighty-seven percent of years of life lost to premature death are due to chronic disease, especially infectious, pulmonary, and cardiovascular diseases, and diabetes. Cardiac events alone account for more deaths than suicide.
The data are emerging; more work needs to be done to evaluate comprehensively the connection between incidence of severe mental illness and lack of appropriate, coordinated medical care. Whatever exact relationship is revealed, the situation is clearly dire: the fragmentation of our health care system causes particularly severe problems for people with serious mental illness. The Association noted that emerging chronic care management techniques offer a way out of this unconscionable mess. It advocates the adoption and application of patient-centered medical home programs that bring together primary care, mental health care, and care for chronic medical conditions in a patient- and community-centered environment.
The current bills offer some funding for such measures, at least as pilots. The House bill, for example, contains language supporting Medicaid medical home demonstrations with initial funding tilted to the federal, in order to encourage states to try these programs out. Let’s hope these and similar measures, which offer hope for the correction of terrible health disparities in a cost effective manner, survive the production of final legislation.
