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sector does not have the infrastructure to care for more severe mental disorders” because “most people with severe and persistent illness are primarily in the public sector.” These problems are compounded by poor information systems, a lack of clinical decision support and data analysis, and a lack of availability in the market of many established, evidence-based treatments. Individuals with schizophrenia, for example, benefit from evidence-based family psycho-education in addition to medication (UNC School of Medicine, 2011). Yet, Dr. Wells said, many people with schizophrenia in outpatient specialty mental health settings do not get adequate family psychosocial management in practice; most of this family management is informal rather than following evidence-based practices (Dixon et al., 2001; Young et al., 1998), and few families are referred to evidence-based family psychosocial treatment even when it is available (Cohen et al., 2010).
Science should inform the provision of services and help define future research questions, he said. However, there is a lack of adoption of evidence-based psychosocial treatments for many behavioral health disorders, especially in primary care, which tends to focus on medication management strategies. Furthermore, demonstrated competence in delivering a wide range of evidence-based psychosocial treatments is not necessarily a requirement of professional training programs. With more limited insurance reimbursement for behavioral health services, incentives have been poor for improving the market for delivering such services. With the passage of parity legislation and requirements to cover behavioral health services in the EHB package under insurance exchanges, Dr. Wells suggested that it was “time for a wide range of evidence-based treatments and system-based quality improvement interventions, to be viewed as essential benefits.” In addition, he suggested that in areas where evidence is limited but the need for services is great due to the severity of illness, benefits should include services that meet reasonable community practice standards.
Many persons with behavioral health needs can have difficulty obtaining care and finding providers in a timely manner even when they have private insurance (Wang et al., 2005). Furthermore, behavioral health conditions have their roots in both biological and social factors, and this requires a range of biological and psychosocial treatments. Current mental health and substance abuse providers for safety-net populations will likely be the only available, initial source of care even as low-income populations transition to the private insurance market or into the expanded Medicaid program. These providers have expertise in managing this population. In addition to covering such providers to have adequate capacity for expanded services, the covered services should include the necessary range of services (including psychosocial services outside of the traditional medical model) to improve outcomes, especially for severely ill populations. Otherwise, Dr. Wells argued, “we will continue to have people who are vulnerable, do not necessarily understand the conditions they have, and will not receive the best evidence-based care.” It is key, he said, that the full set of providers and service settings be eligible for reimbursement, thus requiring a broadening of insurer views of eligible providers and services, which in turn should lead to an improved market environment for the availability of evidence-based services.
Additionally, Dr. Wells suggested that individuals should be able to access care “for all of their illnesses.” This is especially important, he said, for people with behavioral health conditions because they have a higher prevalence of physical health conditions (De Hert, 2011; Goodell et al., 2011). Largely because of co-morbid medical conditions, people with schizophrenia have a life expectancy 20 years less than those without schizophrenia (Goodell et al., 2011; Wildgust et al., 2010), while people with bipolar illness have a 15-year shorter life expectancy (Roshanaei-Moghaddam and Katon, 2009), and people with depression also have reduced life expectancy (Schulz et al., 2000). Cost effectiveness for mental health and substance use services “has to be thought of differently,” Dr. Wells explained, to include the effects of treatments on reducing societal costs of illness, including premature mortality and morbidity (Schoenbaum et al., 2001; Wells et al., 2000). Behavioral health conditions are prevalent across the lifespan, have a relatively early age of onset, and tend to have long-term health and social consequences, including across generations in the same family (IOM, 2009). These factors increase the importance of assuring that affected individuals and families have access to the range of services needed to improve outcomes early in the course of illness and over time.