Mental Health Care for MothersMental Health Care for Mothers

Sherry Glied, Ph.D.Department of Health Policy and Management

Mailman School of Public HealthColumbia University

Sherry Glied, Ph.D.Department of Health Policy and Management

Mailman School of Public HealthColumbia University

Thanks to Sarah Downs for her extraordinary help in preparing this presentation.

OutlineOutline

Overview of the problem Harlem and Northern Manhattan

Trends in mental health care Local challenges and developments What can be done?

Ongoing Efforts in NYC Policy advocacy Innovative programs Immediate responses

Overview of the problem Harlem and Northern Manhattan

Trends in mental health care Local challenges and developments What can be done?

Ongoing Efforts in NYC Policy advocacy Innovative programs Immediate responses

Women and DepressionWomen and Depression

21% of women suffer from depression at some point in their lives

<40% seek care

21% of women suffer from depression at some point in their lives

<40% seek care

Maternal DepressionMaternal Depression

Rates are higher – about 10% -- during pregnancy and in the postpartum period Many cases begin before birth

Negative effects on women and on their children

Higher prevalence of depression among lower income women

Rates are similar by race and ethnicity

Rates are higher – about 10% -- during pregnancy and in the postpartum period Many cases begin before birth

Negative effects on women and on their children

Higher prevalence of depression among lower income women

Rates are similar by race and ethnicity

Recognition and Treatment of Maternal DepressionRecognition and Treatment of Maternal Depression Simple and validated tools for maternal

depression screening exist Interventions – both Rx and

psychotherapy – can successfully treat depression during pregnancy and the post-partum period

Variety of modalities for delivery of these services

Simple and validated tools for maternal depression screening exist

Interventions – both Rx and psychotherapy – can successfully treat depression during pregnancy and the post-partum period

Variety of modalities for delivery of these services

Barriers to AccessBarriers to Access

– financial burdens– time burdens– child care– stigma– service availability

– passive stereotype– lack of information– cultural obstacles– depression itself

Financial Access: Health Insurance CoverageFinancial Access: Health Insurance Coverage 1.8 million New York City residents are

uninsured Problem is worse in Harlem:

Less likely to be insured Less likely to have a primary care

doctor More likely to be experiencing

psychological distress

1.8 million New York City residents are uninsured

Problem is worse in Harlem: Less likely to be insured Less likely to have a primary care

doctor More likely to be experiencing

psychological distress

Even for the Insured: Copayment BarriersEven for the Insured: Copayment Barriers

0

0.01

0.02

0.03

0.04

Expected annual number of mental health episodes

Free 25% 50% 95%

Coinsurance plan

0

0.01

0.02

0.03

0.04

Expected annual number of mental health episodes

Free 25% 50% 95%

Coinsurance plan

Managed Care GrowthManaged Care Growth

General and specialized managed care Carve-outs cover almost 80% of insured Utilization management substantially

decreased LOS by over 40% for MH HMO paid for over 3X more visits for

depressed women in 1996 than 1985

General and specialized managed care Carve-outs cover almost 80% of insured Utilization management substantially

decreased LOS by over 40% for MH HMO paid for over 3X more visits for

depressed women in 1996 than 1985

Women Reporting Difficulty Obtaining Care

1110

15

11

15

0

2

4

6

8

10

12

14

16

18

Any Ins. Private Ins. Public Ins. Private HMO Public HMO

Mental Health in Managed CareMental Health in Managed Care Receive care mainly from GPs GPs may not be adept at diagnosis and

treatment Concerns over division between primary

and specialty care Utilization review

Receive care mainly from GPs GPs may not be adept at diagnosis and

treatment Concerns over division between primary

and specialty care Utilization review

Additional Financing: Public Mental Health SystemsAdditional Financing: Public Mental Health Systems State funded – grants (+ insurance +

Medicaid) Community Mental Health Centers OMH licensed outpatient clinics

State funded – grants (+ insurance + Medicaid)

Community Mental Health Centers OMH licensed outpatient clinics

Public Mental Health System: Population ServedPublic Mental Health System: Population Served The majority of NYC clients are Medicaid

enrollees: 71% of clients, ages 0-17 74% of adult clients, ages 18-64

71% of the NYC outpatient population are minority: 27% Non-Hispanic Black 37% Hispanic 3% Asian 5% Other/Multiracial

The majority of NYC clients are Medicaid enrollees: 71% of clients, ages 0-17 74% of adult clients, ages 18-64

71% of the NYC outpatient population are minority: 27% Non-Hispanic Black 37% Hispanic 3% Asian 5% Other/Multiracial

Trends: ImprovementTrends: Improvement

Use Financing Quality

Use Financing Quality

Treated Prevalence in Epidemiologic StudiesTreated Prevalence in Epidemiologic Studies

0

5

10

15

20

25

1958 NewHaven

1962 Midtown 1980 ECA Balt. 1994 NCS 2004 NCSfollowup

In-Patient Out-Patient Specialty Out-Patient Any

Changes in Recognition: Women with DepressionChanges in Recognition: Women with Depression In 1987, 1.9% of women diagnosed with

depression In 1996, 6.1% diagnosed

In 1987, 1.9% of women diagnosed with depression

In 1996, 6.1% diagnosed

Changes in Treatment: Women with DepressionChanges in Treatment: Women with Depression Rate of diagnosis w/o prescription didn’t

change from 1987 to 1996 All additional diagnoses included

prescription for a psychotropic Pharmacotherapy Psychotherapy

Rate of diagnosis w/o prescription didn’t change from 1987 to 1996

All additional diagnoses included prescription for a psychotropic

Pharmacotherapy Psychotherapy

Trend: Changing Co-Payment Patterns – OOP ShareTrend: Changing Co-Payment Patterns – OOP Share

1987 1996

Women with Depression – MH

41% 26%

Women with Depression – Physical Health

29% 16%

Women with Depression – Total

33% 19%

Women without MH Problem – Total

20% 16%

Quality of CareQuality of Care

Depression – adherence to guidelines up 15% since 1991

Attention Deficit/Hyperactivity – care likely to be effective up from 18 to 50%, 1975 to 1997

Schizophrenia – Care consistent with guidelines up from 22 to 42%, 1975 to 1997

Anxiety, Bipolar, etc.

Depression – adherence to guidelines up 15% since 1991

Attention Deficit/Hyperactivity – care likely to be effective up from 18 to 50%, 1975 to 1997

Schizophrenia – Care consistent with guidelines up from 22 to 42%, 1975 to 1997

Anxiety, Bipolar, etc.

… but still below epidemiologic estimates

Summary: Mental Health AccessSummary: Mental Health Access

Absolute and % of OOP Absolute and % of OOP

• Diagnosis rateDiagnosis rate

… but still above rates for physical health

… and total MH spending has decreased too

Quality Quality … but still well below desirable levels

Harlem/Northern ManhattanHarlem/Northern Manhattan

Local challenges Local developments: NYS Parity Local opportunities

Local challenges Local developments: NYS Parity Local opportunities

Local ChallengesLocal Challenges

Access to care For those who do seek treatment,

delays of up to 8 weeks reported between screening and access to a professional therapist

Access to care For those who do seek treatment,

delays of up to 8 weeks reported between screening and access to a professional therapist

Insurance Coverage Patterns, 2005

0

10

20

30

40

50

60

All NYC

Central Harlem

East Harlem

Policy Development: Timothy’s Law -- Parity in MH CoveragePolicy Development: Timothy’s Law -- Parity in MH Coverage

Passed 12/22/06; Effective 1/1/07 Requires all private insurers to cover 20

outpatient/30 inpatient visits - same as current Medicaid benefit

Requires that cost-sharing and other requirements be the same for mental health and other services

Passed 12/22/06; Effective 1/1/07 Requires all private insurers to cover 20

outpatient/30 inpatient visits - same as current Medicaid benefit

Requires that cost-sharing and other requirements be the same for mental health and other services

Will Parity Solve the Local Problem?Will Parity Solve the Local Problem?

Private insurance only Increased financial protection -- Decreased

out-of-pocket spending for MH service users Access to care – not greatly affected by parity

itself Parity + MBHO = increased service use

among those with mild or moderate mental distress

Private insurance only Increased financial protection -- Decreased

out-of-pocket spending for MH service users Access to care – not greatly affected by parity

itself Parity + MBHO = increased service use

among those with mild or moderate mental distress

Managed Care in NYCManaged Care in NYC

Almost all insured NY’ers are enrolled in managed care

Mandatory for most Medicaid Mandatory for FHP Now also mandatory for SSI population Plans pay providers directly at negotiated

rates

Almost all insured NY’ers are enrolled in managed care

Mandatory for most Medicaid Mandatory for FHP Now also mandatory for SSI population Plans pay providers directly at negotiated

rates

Expanding the Specialist Provider PoolExpanding the Specialist Provider Pool Raise NYS Medicaid reimbursement for

mental health treatment to encourage more providers But doesn’t affect managed care contracts

Raise NYS Medicaid reimbursement for mental health treatment to encourage more providers But doesn’t affect managed care contracts

How Much can Specialists Do?How Much can Specialists Do?

4000 births per year in Central and East Harlem

About 400 women with need for services for depression

Unlikely to handle this many in specialty care

4000 births per year in Central and East Harlem

About 400 women with need for services for depression

Unlikely to handle this many in specialty care

Public Mental Health System:Harlem & Northern Manhattan FacilitiesPublic Mental Health System:Harlem & Northern Manhattan Facilities

Approximately 50 different OMH licensed outpatient programs are located in Harlem and Northern Manhattan 10 of these programs limit their practice to

children and adolescents

Only 10% of the treated outpatient population is female, ages 13-34.

Approximately 50 different OMH licensed outpatient programs are located in Harlem and Northern Manhattan 10 of these programs limit their practice to

children and adolescents

Only 10% of the treated outpatient population is female, ages 13-34.

Open New Public Programs: NYS Medicaid NeutralityOpen New Public Programs: NYS Medicaid Neutrality Can only use existing funds to open

new facilities (e.g., must close an old facility to open a new one)

Only applies to mental health Effectively blocks any new Article 31

(OMH-licensed) facilities Questionable value

Can only use existing funds to open new facilities (e.g., must close an old facility to open a new one)

Only applies to mental health Effectively blocks any new Article 31

(OMH-licensed) facilities Questionable value

NYS Medicaid Neutrality: Fiscal ImplicationsNYS Medicaid Neutrality: Fiscal Implications Outdated policy DOH can also license mental health providers

(e.g., hospital outpatient clinics) DOH payment rates are higher The trend may also decrease quality of care,

since the DOH mental health providers are not regulated by OMH, an agency with mental health expertise

Outdated policy DOH can also license mental health providers

(e.g., hospital outpatient clinics) DOH payment rates are higher The trend may also decrease quality of care,

since the DOH mental health providers are not regulated by OMH, an agency with mental health expertise

NYS Medicaid Neutrality: ResponseNYS Medicaid Neutrality: Response The NY assembly

Legislation was introduced by James Brennan in January 2005 but did not proceed beyond the Ways & Means Committee

The NY assembly Legislation was introduced by James Brennan in

January 2005 but did not proceed beyond the Ways & Means Committee

Potential Significance for Depression in Mothers?Potential Significance for Depression in Mothers?

•Important for most severe cases

•Population is not a strategic priority

•Not well integrated

What Else Can Be Done?What Else Can Be Done?

Expanding access through other providers Current Programs in New York City Innovative Programs

Immediate Responses

Expanding access through other providers Current Programs in New York City Innovative Programs

Immediate Responses

Train Alternate ProvidersTrain Alternate Providers

Most mental health professionals are not specifically trained to understand the unique aspects of depression in pregnant and post-partum women.

Need is great and immediate. Stigma is a significant barrier to the use

of specialized services.

Most mental health professionals are not specifically trained to understand the unique aspects of depression in pregnant and post-partum women.

Need is great and immediate. Stigma is a significant barrier to the use

of specialized services.

Non-Specialized Providers can Treat Many in this PopulationNon-Specialized Providers can Treat Many in this Population

Ongoing Efforts NYCOngoing Efforts NYC

NY DOHMH “Take Care NY” Campaign TCNY #5: Get Help for Depression

To make depression screening and management standard practice in all primary care settings in New York City.

To increase the rate of New Yorkers in treatment for depression by 10% by 2008.

Development/promotion of PHQ-9 screening tool

NY DOHMH “Take Care NY” Campaign TCNY #5: Get Help for Depression

To make depression screening and management standard practice in all primary care settings in New York City.

To increase the rate of New Yorkers in treatment for depression by 10% by 2008.

Development/promotion of PHQ-9 screening tool

Ongoing Efforts NYCOngoing Efforts NYC

HHC includes depression screening tool in EMRs of Diabetes patients, to be expanded to other chronic conditions Simultaneously PCPs are trained to treat

mild and moderate depression so treatment closely follows screening

Private insurers and managed care organizations also commit PHQ-9 as standard screening tool

HHC includes depression screening tool in EMRs of Diabetes patients, to be expanded to other chronic conditions Simultaneously PCPs are trained to treat

mild and moderate depression so treatment closely follows screening

Private insurers and managed care organizations also commit PHQ-9 as standard screening tool

Innovations from other states:Illinois Medicaid ReimbursementInnovations from other states:Illinois Medicaid Reimbursement Implemented in December 2004 Goal: improve children’s health by improving

maternal mental health Providers who use designated screening tools

are reimbursed $14.50 for their efforts, whether while providing an adult service or at an child’s acute care or well-child visit.

Women must either be A) Pregnant or post-partum Medicaid enrollees B) Mothers of infants <1yr who are Medicaid eligible

Implemented in December 2004 Goal: improve children’s health by improving

maternal mental health Providers who use designated screening tools

are reimbursed $14.50 for their efforts, whether while providing an adult service or at an child’s acute care or well-child visit.

Women must either be A) Pregnant or post-partum Medicaid enrollees B) Mothers of infants <1yr who are Medicaid eligible

Innovations from other states:Illinois Medicaid ReimbursementInnovations from other states:Illinois Medicaid Reimbursement

Can bill mother’s Medicaid id or INFANT’s ID

Physicians were provided with extensive referral resources, including a statewide Perinatal Mental Health Consultation Service accessible via toll-free phone number

Can bill mother’s Medicaid id or INFANT’s ID

Physicians were provided with extensive referral resources, including a statewide Perinatal Mental Health Consultation Service accessible via toll-free phone number

Innovations from other states: Dartmouth screening effortsInnovations from other states: Dartmouth screening efforts 80% of pediatricians rely on observation

alone to detect depression. Only 8% ask mothers about depression symptoms

These methods fail to detect half of mothers suffering from depression

Dartmouth study evaluates feasibility of a 2-question screening tool during well-child visits

80% of pediatricians rely on observation alone to detect depression. Only 8% ask mothers about depression symptoms

These methods fail to detect half of mothers suffering from depression

Dartmouth study evaluates feasibility of a 2-question screening tool during well-child visits

Innovations from other states: Dartmouth screening effortsInnovations from other states: Dartmouth screening efforts Screening rates reached 70%. 1/20 mothers screened positive for

depression 10% of encounters prompted physician action

(referrals or further discussion) <2% of encounters required conversations

longer than 10 minutes

Screening rates reached 70%. 1/20 mothers screened positive for

depression 10% of encounters prompted physician action

(referrals or further discussion) <2% of encounters required conversations

longer than 10 minutes

Innovations within NYS:Pay-for-PerformanceInnovations within NYS:Pay-for-Performance New York State’s Medicaid incentive program

offers financial and other incentives to Medicaid managed care programs that perform well on specific measures

Monthly premiums are increased by 0.25-1% for meeting certain goals

For the ‘03-’04 FY, state-wide payments totaled $7 million with some plans receiving bonuses of over $1 million

New York State’s Medicaid incentive program offers financial and other incentives to Medicaid managed care programs that perform well on specific measures

Monthly premiums are increased by 0.25-1% for meeting certain goals

For the ‘03-’04 FY, state-wide payments totaled $7 million with some plans receiving bonuses of over $1 million

2006 New York State Managed Care Plan Performance Report :http://www.health.state.ny.us/health_care/managed_care/qarrfull/qarr_2006/

Innovations within NYS:Pay-for-PerformanceInnovations within NYS:Pay-for-Performance

Innovations within NYS:Pay-for-PerformanceInnovations within NYS:Pay-for-Performance 2006 measures included management of

anti-depressant medication, mental health inpatient utilization, follow-up after hospitalization for mental illness, drug treatment, etc.

2006 measures included management of anti-depressant medication, mental health inpatient utilization, follow-up after hospitalization for mental illness, drug treatment, etc.

Immediate ActionImmediate Action

Most pregnant women and mothers with newborns are enrolled in or eligible for public insurance programs

Most public insurance programs employ managed care contracts

Most pregnant women and mothers with newborns are enrolled in or eligible for public insurance programs

Most public insurance programs employ managed care contracts

Getting CoverageGetting Coverage

Many are already eligible for public programs (Medicaid or FamilyHealthPlus)

http://www.nyc.gov/html/hia/html/home/home.shtml

Many are already eligible for public programs (Medicaid or FamilyHealthPlus)

http://www.nyc.gov/html/hia/html/home/home.shtml

Enforcing Contract ObligationsEnforcing Contract Obligations

Contract ObligationsContract Obligations

How to ComplainHow to Complain

Managed care plans certified by the Department of Health must have a process to receive and respond to complaints and grievances.

Community Services Society (CSS) is the lead agency for New York City Medicaid Managed Care Consumer Assistance Program (MCCAP) -- http://www.nycmccap.org/.

Managed care plans certified by the Department of Health must have a process to receive and respond to complaints and grievances.

Community Services Society (CSS) is the lead agency for New York City Medicaid Managed Care Consumer Assistance Program (MCCAP) -- http://www.nycmccap.org/.

Recap - StrategiesRecap - Strategies

Policy Advocacy Medicaid neutrality Medicaid payment rates

Innovation Work with primary care providers – ob/gyn and pediatrics Develop payment mechanisms

Immediate action Insure women Ensure enforcement of managed care contract provisions

Policy Advocacy Medicaid neutrality Medicaid payment rates

Innovation Work with primary care providers – ob/gyn and pediatrics Develop payment mechanisms

Immediate action Insure women Ensure enforcement of managed care contract provisions

Questions?Questions?