A Response to the GAO Report on the Federal Effort to Address “Serious Mental Illness”

by Thomas Miller

A recent Government Accounting Office (GAO) report was authorized by the Energy and Commerce Committee of the House of Representatives and completed in February 2015. This report considers the issue of “serious mental illness” in the United States population through the identification, coordination, and evaluation of programs within federal departments and agencies that address this effort. By design, this report is focused on the macro level, and is not reflective of the role of service providers that were funded directly through Medicaid, Medicare, or private insurers. The focus and conclusions of the GAO report are indeed worthy of discussion, yet beyond the pay grade of this response.

Our goal is to dissuade the general population from thinking that the national effort to reduce “serious mental illness” is limited to the identification and coordination of the 5% of programs that are specifically designated and funded through federal departments and agencies for that purpose.

The HHS response to the GAO report concludes that forty billion dollars were spent in FY/2012 on behavioral health. Direct insurance payments accounted for 66% of the total that was reimbursed by Medicaid(27%), Medicare(13%), and Private Insurance(26%) to behavioral health providers. Figures were not available for TRICARE that directly funds programs for Veterans and their families. These entities provide hospital systems and communities at large with the funds for direct treatment and service coordination for individuals with “serious mental illness.” Providers advocate for rate stabilization, cost containment, decreased regulation, and workforce development resources.

The following example illustrates behavioral health treatment that is funded through health insurance. Partial Hospitalization (PHP) and Intensive Outpatient Programs (IOP) represent an enduring service delivery model that meets the needs of those individuals who present with signs and symptoms of “serious mental illness.” This model is not new. It is the result of over twenty years of refinement due to multiple forces that include a clear mission to avert or reduce hospitalizations, a robust internal performance improvement focus, substantial regulatory oversight, and attention to consumer feedback.

Partial Hospitalization (PHP) and Intensive Outpatient Programs (IOP) are ambulatory services within the community that lie at the heart of a behavioral health continuum that includes Outpatient Providers and In-patient Services. Benchmarking data (2014) from the Association for Ambulatory Behavioral Healthcare (AABH) reveals that 55% of direct referrals to PHP and IOP programs come from community-based sources that include primary care and hospital emergency departments to avert in-patient care. 45% of referrals provide step down services from in-patient programs to assure patient safety and recovery. Access to treatment for these services occurs on average within two business days of referral. The same benchmarking data shows that an average of 20% of those treated in these programs are experiencing their first contact with treatment for “serious mental illness” which is a designated research priority of SAMHSA. This treatment combines diagnosis, medication management, problem identification, verbal therapy, education, and referrals to needed services. Adequate funding of evidence-based treatment through collaboration among insurers, service providers, and consumers is the key to success in the effort to address “serious mental illness.“

These programs are a part of a greater national behavioral healthcare effort (supported by Congress and advocated by SAMHSA) within both the public and private sector to address prevention, access, treatment, peer support, and coordination of services to consumers to reduce the impact of “serious mental illness” and enhance recovery.

The GAO report considers the implementation of program evaluations that address the problem of “serious mental illness.” Again, this macro focus is critical yet it does not examine the insurance benefit based programs that lie at the heart of the treatment initiative.

Real time program evaluation and improvement is happening at the service delivery level through professional peer collaboration and consumer feedback. The latest evidence based medication, education, and verbal therapy interventions are the result of this effort. In 2014, AABH polled the membership who reported that 66% of PHP and IOP programs use pre-post client outcome testing, and 84% use the data for internal program improvement. Over two thirds use client satisfaction tools as well. Coordination of these efforts to evaluate treatment effectiveness must occur across the behavioral health continuum that includes acute in-patient services, partial hospitalization and intensive outpatient treatment, and traditional outpatient services.

This focus on insurance funded treatment services is not meant to ignore new community-based initiatives such as “medical homes,” “suicide prevention”, and “trauma informed care” that have been funded through congress and overseen by SAMHSA through HHS. The “Assistant Secretary for Planning and Evaluation” of HHS, Richard Frank, Ph.D., and SAMHSA administrator, Pamela Hyde, Esq., discussed these projects at the February 11, 2015 congressional hearing. We wish simply to affirm the commitment by congressional leadership and federal policy to support service delivery within the evolving insurance structure.

The “Affordable Care Act” and “Parity legislation” are examples of such leadership through the authorization of funding to assure the delivery of essential services to those with “serious mental illness.” Prior to this congressional initiative, “essential services” to this population were not guaranteed as insurance benefits for those in need. SAMHSA administrator, Pamela Hyde presented implementation guidelines for “intermediate behavioral health” treatment services” in November of 2013 that reflected parity in the treatment of both “physical” and “serious mental illness.” “Substance abuse, screening, and other services such as residential, intensive out-patient, and partial hospitalization” were clarified and included in this presentation.

We applaud both Congress and the Executive Branch for their efforts to address “serious mental illness” in our country. We appreciate the renewed emphasis on the coordination of programs and a sustained evaluation of their effectiveness. Finally, we encourage Congress to continue to adequately support funding of programs within the current insurance benefit structure that are working hard to address serious mental illness for the 20% of individuals in the overall population who require prompt access to effective services each year.