Mental Health Care: The Times They Are a-Changin'

Jeffrey A. Lieberman, MD


December 23, 2011

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Hello. This is Dr. Jeffrey Lieberman of Columbia University in New York City, talking to you today for Medscape.

Today I want to talk about a topic that could be titled -- to take a phrase from one of Bob Dylan's songs -- "The Times They Are a-Changin'." As everyone who is involved in healthcare, psychiatric medicine, and mental health care knows, for some years now we have been under increasing pressure from the forces of healthcare reform and cost containment, which are really affecting the way we deliver clinical care and our rates of reimbursement.

This is only going to become more intense in the coming months and years, and the end result, as most people who are knowledgeable about healthcare services, healthcare policy, and healthcare financing believe, is that it is going to transform the way healthcare is delivered and financed in this country. I would like to say that it is going to be a smooth and enlightened process that is going to guide us gently from where we are now: from an institution- and practice-based, largely fee-for-service system to an ideal one, in which affordable care is made available to the vast majority, if not all people. In other words, universal coverage in a way that provides adequate reimbursement to financially sustain the clinical services that are optimal and justified by scientific research and evidence. However, I can't say that that is going to be the case. It has been a bumpy ride so far and it promises to become bumpier.

This is all being driven by the fact that the rate of healthcare expenditures has risen at a level that has consistently exceeded inflation and has grown to account for a substantial proportion of our overall gross domestic product, now hovering at 16%-17% and projected to go higher. Economists say that this is unsustainable, that it will consume too much of the budget. It has to be reined in, and the way it is being reined in is through the process of healthcare reform.

Up until now, we haven't had a real thoughtful, comprehensive strategy to guide healthcare reform, and it has defaulted, for the most part, to more brute force approaches of the marketplace in the form of managed care. Given the urgency of the situation, this is likely to change in the next few years.

The question is, how is it going to affect psychiatry, psychiatric medicine practice, and mental health care? We don't know, but what we do know is that it is likely to change the way services are delivered. Entities called accountable care organizations, medical homes, and behavioral health organizations are being discussed, proposed, and implemented as we speak. Here in New York State, we have a Medicaid Redesign Team that is advising the governor on how to change the way Medicaid supports care of eligible individuals. What this is going to entail, at the very least, is that all Medicaid care will be managed. Medicaid, which has been fee-for-service in New York up until now, at least in mental health care, will now become managed. It will also involve bundling of services and integration of care, so psychiatrists and mental health care will be co-located increasingly with primary care, both for adult and pediatric medicine. There will be increased accountability in terms of qualifying services to be delivered and assessing outcomes.

As this is happening, it is more important than ever for us as professionals, either individually, through our healthcare institutions, or through our professional organizations, to be proactive in trying to determine what the optimal forms of healthcare service delivery should be within our respective professions. In the case of psychiatry, in terms of mental health care, we need to determine what would be necessary in terms of levels of reimbursement and work through our respective institutions and organizations, through the government relations and advocacy groups, to try to articulate these positions so that they are heard in the context of legislation that is being proposed and that will affect the way healthcare is delivered. Now is the time to be proactive. If we are not, we risk being further marginalized and potentially victimized by this process.

Our society and the medical profession will always need psychiatry and mental health care. The epidemiology of the disorders for which we provide care speaks volumes. The degree of psychiatric comorbidity with the array of medical conditions that are cared for by other specialties requires this. We need to be active now in terms of defining what is the best way, what are the best roles for psychiatrists, what are the best services that need to be delivered, and how those should be configured in the way that healthcare is changing. Then, importantly, we need to see that these are reimbursed at adequate levels so that we can afford to provide services that are going to be optimal and provide the best standards of care. If not, we are at risk of being the victims of a process that hasn't taken into account everything that should be.

This is both a message and an effort to try to encourage people to be more active in the ways that they can, to request that their organizations and their agencies be thinking about this and be active in terms of communicating with legislators and with policymaking organizations in the coming months and the next few years, when all of this will likely be determined.

I want to thank you for your attention. This is Dr. Jeffrey Lieberman, Columbia University, speaking to you today for Medscape.


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