Implementation of the health care reform legislation, the Patient Protection and Affordable Care Act (PPACA), holds promise as well as potential challenges for people needing mental health care. A special section of three articles in the November issue of Psychiatric Services addresses key issues for implementation of the new law, such as
• how to structure state insurance exchanges so that they will fairly and efficiently serve people with mental illness
• what services and supports may and may not be covered under the new law for people with mental or substance use disorders, and
• how the new law supports integration of mental health care and primary care through initiatives such as patient-centered medical homes and new financing models such as accountable care organizations.
Psychiatric Services is a publication of the American Psychiatric Association.
Thomas G. McGuire, Ph.D., a professor of health economics in the Department of Health Care Policy at Harvard Medical School, served as guest editor of the special section.
In the first article, he and colleague Anna D. Sinaiko, Ph.D., describe a centerpiece of the reform law – state-run health insurance exchanges, which consolidate the market for individual private health insurance, allowing millions of Americans access to affordable individual and family coverage.
However, unless states carefully regulate the plans that compete in the exchanges and the benefits that they offer, people with mental illness, who typically have higher health care costs, are at risk of receiving poorer quality care.
The authors describe ways to structure and regulate exchanges to ensure that people with mental illness are served fairly and efficiently. They describe lessons learned from the Massachusetts Connector, an exchange established in 2006 when the state mandated health insurance for individuals.
Health reform will expand insurance coverage to some 32 million people, largely through broadening the Medicaid program to include for the first time single individuals with low incomes, a group with a large proportion of people with mental illness.
However, for this subgroup, coverage “may in many cases be inadequate, and it may even be less generous than the de facto coverage that is currently provided,” according to authors Rachel L. Garfield, Ph.D., M.H.S., and colleagues, the authors of the second article.
They identify potential gaps in coverage, particularly in the “benchmark” plans that will be offered to individuals newly eligible for Medicaid, and they discuss several options that policy makers have to address these gaps.
The reform law includes provisions designed to reorganize the delivery of health care to make it more efficient, and a third article looks at the potential implications of reorganization for people with mental illness. The authors, Benjamin Druss, M.D., M.P.H., and Barbara J. Mauer, M.S.W., C.M.C., describe the potential benefits of patient-centered medical homes for people with chronic medical and mental health needs.
Under reform, the federal government is funding a range of demonstration projects to integrate primary and mental health care, including Medicare and Medicaid initiatives involving patient-centered medical homes and other projects to co-locate primary care services in community mental health care settings.
The reform law has provisions to organize hospitals, specialists, and primary care organizations into “accountable care organizations,” collectives of providers that take responsibility for a group of patients and are funded via new financing mechanisms, which the authors describe.
The authors conclude that the “success of these efforts will hinge on the ability of clinicians, managers, and policy makers from various agencies to work across traditional organizational boundaries.”
In an introduction to the special section, Dr. McGuire concludes that “success means different things for payers, providers, and patients in these demonstrations, and it remains to be seen whether a win-win-win is possible within the constraints of existing public-payer financing structures.
” The three articles were commissioned by the Office of the Assistant Secretary for Planning and Evaluation, the policy research arm of the U.S. Department of Health and Human Services (DHHS). Financial support for developing the articles was provided by DHHS and Mathematica Policy Research, Inc.
Source:American Psychiatric Association