When Healthcare Gets a Cold, Psychiatry Gets Pneumonia

Jeffrey A. Lieberman, MD


August 02, 2012

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Hello. This is Dr. Jeffrey Lieberman of Columbia University, speaking to you for Medscape. The title of my comments today could be "The Future Is Now," because it has to do with healthcare reform and the impact it will have on our healthcare delivery system and specifically on psychiatry and mental healthcare services.

The Supreme Court is going to render a decision on the Affordable Care Act any day now.* Regardless of what the decision is, the train has already left the station. Healthcare reform is under way, and there is no turning back.

The pressures that are driving this reform are largely financial ones. There is an economic imperative to reform the US healthcare system and finance it in a way that is different and more cost-effective. All of it will be transformed in this process -- all of the specialties of medicine, including psychiatry.

In the past, when a problem in healthcare and healthcare financing has emerged, it has generally affected psychiatry as badly as or worse than the other disciplines of medicine. Put another way, when healthcare medicine gets a cold, psychiatry gets pneumonia. We have to make sure that does not happen in this case.

The process of healthcare reform and the prospect of change that it heralds presents a challenge, but it also presents an opportunity. Why is that? Because psychiatry and mental healthcare services are essential. All you have to do is look at the epidemiology of mental illness to realize that. Conservatively, 1 out of 4 people will suffer from a mental disorder or an addiction that requires treatment at some time during that person's life. Again, that is a conservative estimate. Considering the aging population, those numbers could increase further.

Individuals who need mental healthcare and psychiatric services are divided into 3 main categories. The first group is chronic and persistently mentally ill persons -- the individuals most people think of in terms of persons needing mental healthcare.

Patients who need mental health services in the context of medical and surgical care is a second population of individuals needing psychiatric care. This includes individuals who have medical and surgical problems that are being treated by nonpsychiatric healthcare disciplines, but who also have comorbid psychiatric conditions. This has become increasingly important: having services available to patients in the hospital to reduce lengths of stays and to minimize the likelihood of rapid, unnecessary readmission, which is now being excluded for payment by Medicare.

The third group includes individuals who suffer from different types of psychiatric illnesses, anxiety disorders, mood disorders, potential for developing addictions, trauma and stress reactions, or cognitive disorders. Typically, these are highly functional individuals. They come from generally supportive families. They have private health insurance, or they are able to self-pay for services.

Add to these 3 groups the specialized services needed for the growing numbers of children who are presenting with psychiatric illnesses and the geriatric populations with mental health issues, and you can understand how this epidemiology falls into different segments of the population needing specialized care.

The question is, in what way will these services optimally be provided going forward, and how will they be reimbursed? The short answer is that they will be provided in ways that are likely to be markedly different from the way in which they are currently provided. The tradition of office-based fee-for-service individual, psychotherapy-based care is probably not going to be sustainable in large numbers or in large proportions of our profession.

Psychiatry must be proactive in this process of defining the models of care that will optimally provide service to these different segments of the population, and how those services will be aligned with services provided by other medical disciplines. The buzzword is "integrated care." What will the roles of psychiatrists be in these models of care? Psychiatrists will probably be teamed up with "physician extenders": psychiatric paraprofessionals, such as psychiatric nurses, social workers, psychologists, or individuals employed as lay therapists or rehabilitation therapists.

In addition, the requirements and mechanisms for financing and reimbursement need to be determined. Through professional associations, advocacy, and lobbying efforts, psychiatry must be proactive in influencing how policy is developed that ultimately will define these rules. It is important for the discipline of psychiatry, either at leading healthcare institutions or independently, to work to develop these new models of care now, test them to see how they work, and evaluate their effectiveness before deciding that this is the model of care that should be proposed as the one to be adopted by healthcare systems.

Another important element of this transformative process is our training programs. We will need to revise our training programs to provide the education and the training experiences for psychiatrists in the new roles they will be assuming and in the different ways of providing psychiatric services. This entails a radically different way of thinking, understanding that in the next several years a transformative process -- driven by healthcare reform and the financial imperatives -- will alter the way in which psychiatry, as well as the rest of healthcare, works and is reimbursed. Rather than deny it, resist it, or avoid engaging in the process, we need to be aggressively proactive in determining our future, how it should be financed, and making sure that we have a say in formulating the policy and the legislation that is enacted.

This is daunting, but at the same time it is exciting. If we stay focused and apply ourselves diligently, we will come out ahead and end up in a better place.

Thank you for listening. This is Dr. Jeffrey Lieberman of Columbia University, speaking to you today for Medscape.

*On June 28, 2012, the Supreme Court announced its decision to uphold the Affordable Care Act, including the controversial "individual mandate."


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