The Tragedy of Underfunded Mental Health Care

Today’s Managing Health Care Costs Indicator is  19,900

The NY Times  on Friday had a deeply disturbing article on a murder that stunned the mental health community here in Massachusetts.   A long-term schizophrenic man, off his medicine and spiraling into incoherence, killed a young female counselor who was the sole worker at a group home in a Boston suburb. 

His mother, who works at a Boston teaching hospital, was frantic with worry as her adult son, who had been arrested for assault multiple times, was becoming more psychotic.   It was hard for her to get anyone’s attention.

The counselor was the first in her family to get a college degree, and had just decided to go to nursing school.   Now she’s dead – and her family had trouble scraping together the resources for a burial.  The schizophrenic will be imprisoned for the rest of his life – which ironically could be the best chance for him to get appropriate medical care.

Both families are thrown in to turmoil – many lives have been inexorably altered.  How did we get here?

The Massachusetts Department of Mental Health is responsible for 19,900 people with severe and persistent mental illness.  Massachusetts has closed 20,000 inpatient mental health beds over the last decades, and the state is debating closing a quarter of the remaining 626 long-term mental health beds.  Hospitals that offer inpatient mental health services are struggling to survive – and patients who need inpatient mental health admissions can languish in Emergency Departments while psychiatrists scurry to find scarce placements. 

It’s just as bad on the outpatient side.   Very few child psychiatrists, in short supply, take any kind of private insurance, and waiting lists are long.  Adult mental health services have diminished, and psychiatrists have largely transitioned to medication management, leaving cognitive therapy to nonphysicians.  Health plans have historically done aggressive utilization review on mental health services, so that patients are discharged from outpatient or inpatient therapy more quickly – and it’s hard to get back into the system with a relapse.  With major psychiatric disease, relapses are common.

It’s much better in Massachusetts than elsewhere in the country, where the budget crisis has hit harder, and where few politicians will advocate for the mentally ill.  After Jared Loughner killed 6 and wounded 13 including Congressman Gabrielle Giffords in January, there were a series of articles about mental health cuts in Arizona and elsewhere in the country. But that attention didn’t last.

When we underfund mental health care, we bear the costs outside of the medical budget.

Families bear the majority of these costs; parents leave their jobs to watch their deeply ill children even as they reach adulthood, and spouses struggle to be case managers for their loved ones. 

We send many of those with severe mental illness to jail – at a very high cost.  In Massachusetts, a quarter of the prison population now requires mental health services, up by 2/3 since 1998.  

Employers bear some cost, as well, with lost productivity from those with mental illness, as well as from family members who are struggling to themselves compensate for the failings of our system.

Managed behavioral health care has been wildly successful, though.  While the cost of most medical services has burgeoned, the cost of professional services for those with mental illness has been pretty much flat.  The cost of hospitalization has shrunken dramatically, and we’re severely underfunding outpatient mental health services.

Those with mental health needs have dramatically higher overall medical expenses – and are more frequently readmitted to the hospital.  

The only place we’re spending more money on mental health services is in pharmaceuticals, which rose from 7% of total mental health spending (1986) to 27% of spending (2005).   Mental health drugs represent a third of total Medicaid drug spending in many states.    More irony – many of the newer antipsychotics that replaced inexpensive generic medications appear to be no better! 

I often argue for decreased spending in many areas of health care.  I think there is opportunity to lower the cost of pharmacotherapy in mental health, too. But it feels like we’ve gone too far in trying to lower professional and inpatient behavioral health costs.  We’ve transferred these costs from society (largely Medicaid) and risk  pools (employers) to prisons and to the individuals and families haunted by mental illness. 

There must be a better way.