Mental Health Exceptionalism: Causes and Implications: A Perspective from Economics and Policy Resea

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Mental Health Exceptionalism Causes and
Implications A Perspective from Economics and
Policy ResearchThomas G. McGuireDistinguished
Guest LectureLecture on Insight, Innovation and
Impact

• Louis De La Parte
• Florida Mental Health Institute
• October 6, 2008

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Integration vs. Exceptionalism

• Major theme of mental health policy
• Integration
• Mental illness and mental health care are like
  other medical conditions and care should be
  organized and paid for in the same way
• Exceptionalism
• Differences in mental illnesses and their
  treatment suggest they should be organized and
  paid for differently
• What makes mental health different?

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Integration vs. Exceptionalism Examples

• Integration
• Parity in insurance coverage
• Mental health care in general hospitals
• Integrating mental health care in HMOs

• Exceptionalism
• Differential health insurance coverage
• Public and private psychiatric hospitals
• Carve outs for behavioral health
• Medicare payment exemptions for psychiatric
  discharges

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A Sketch of the Scope of Mental Illness and Some
Consequences

• Roughly 20 of the population experiences a
  diagnosable mental disorder in a year
• Mental disorders create costly impairments and
  disability
• About 1/3 of SSDI and SSI recipients are disabled
  by mental illness
• 30 of women on TANF have mental disorders
• Mental illness is a source of major losses in
  labor supply and productivity
• Approximately 41 of people with a serious
  disorder do not get care in a year
• The U.S. spends about 6.2 of its health dollar
  on mental health care

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Figure 4.1Decomposing The Differences in Use in
the High and Low Option Plans for Federal
Employees, 1983
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Correlation of Physical and Mental
Health Status(MEPS, 2005)
Excellent
Very Good
Good
Fair
Poor
Poor
Fair
Good
Very Good
Excellent
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Figure 1Predictability and predictiveness
determine the incentive to under(over)provide
services
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Predictiveness ?(ms, M)

Increasing incentive to underprovide
0
?
Predictability CV(ms)
Increasing incentive to overprovide
-
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Figure 3US Medicare predictability versus
predictiveness Spending by provider specialty
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Overlap of Social Systems King County (Seattle)
WA, 1993-98
Source Domino et al.
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Elevated Likelihood of Jail Conditional on MH
Involvement Among Poor (Medicaid)
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Specialization and the Quality of Care for
Mentally Ill Nursing Home Residents

• David C. Grabowski, PhD
• Thomas G. McGuire, PhD
• Harvard Medical School

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MI and Dementia 2005Admissions to NYC Nursing
Homes
Fullerton et al., 2008, Under Review
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Racial Ethnic Disparities in the Treatment of a
Medicaid Population with SchizophreniaIdentifying
and Addressing Health Care Disparities among
Severely Mentally Ill Latinos

• Investigators Marcela Horvitz-Lennon MD
• Margarita Alegria PhD
• Richard Frank PhD
• Thomas McGuire PhD
• Consultant Jack Burke MD
• Data Analyst Christina Fu PhD
• Funding Support P50 MH073469 (NIMH)

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Methods, I

• Data Source 12 years of Florida Medicaid Claims
  Files (1994 2005)
• Subjects included (in each year) consecutively
  enrolled adults aged 18-64 years with 2 claims
  with ICD-9 schizophrenia diagnosis
• Exclusions Dual Medicaid/Medicare or HMO
  coverage
• Outcome Variables
• Psychotropic drug spending
• Inpatient psychiatric use/spending (2-part model)
• Total mental health spending
• Total health spending

Expenditure data represented inflation-adjusted,
log-transformed mean annual figures
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Sample Characteristics
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Differences in Psychotropic Drug Spending
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Differences in Psychiatric Inpatient Spending
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Longitudinal Racial/Ethnic Disparities in
Antimanic Medication Prescribing for Bipolar-I
Disorder

• Alisa B. Bushch, M.D., M.S.
• Haiden A. Huskamp, Ph.D.
• Brian Neelon, Ph.D.
• Tim Manning, B.A.
• Sharon-Lise T. Normand, Ph.D.
• Thomas McGuire, Ph.D.

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Mental Illness and XXX

• Positive correlation with negative things other
  health care costs, criminal involvement,
  homelessness,
• In broad terms inhibits access for persons with
  mental illness, establishing the underlying role
  for continued exceptionalism.