Treatment Perspectives: Cost and Quality Alexander S. Young, M.D., M.S.H.S. VA VISN 22 Mental Illness, Research, Education, and Clinical Center (MIRECC) UCLA Research Center on Managed Care for Psychiatric Disorders

Healthcare in the U.S.: Cost u Treatment costs –14% of GNP (up from 7% in 1970) »highest per-capita spending in the world –$1,000,000,000,000 per year »half of corporate pre-tax profits –2.5% for treatment of schizophrenia

Healthcare in the U.S.: Quality u Health status outcomes (of 13 nations) –infant mortality: 13th –life expectancy: 10th at 40 years, 7th at 65 years –overall: 12th u Potential explanations –many with no insurance (> 40 million) –expensive treatments with minimal effectiveness

Depression & Anxiety u Major Depression, Dysthymia u Generalized Anxiety Disorder, Panic Disorder u Effective Treatments –medications: antidepressant and antianxiety –psychotherapy

Depression & Anxiety: Two Thirds Receive No Effective Care Depressive or Anxiety Disorder (n=1641) % Effective medication21 Effective counseling18 Either effective antidepressant or effective counseling31

RACE AGE % with no effective medication or counseling 63% 81% 76% 79% 69% 62% 67% White Black Hispanic % Older, Younger, and Minorities Receive Worse Care

Schizophrenia u Effective Treatments –antipsychotic medications –PACT –family/caregiver involvement –vocational rehabilitation u Stigma and disadvantage

Schizophrenia: Quality Problems Are Severe and Differ By Organization Medication Management Severe symptoms or side effects Poor quality medication management CMHCVA 43% 31% 55% 44%

SPMI: Key Quality Problems u 50 – 70% receive no treatment –incarceration u Mortality and morbidity u Treatment organizations –substantial cost –consumers with little power over service provision –medication management: > 1/3 with poor care –family/caregiver involvement, PACT, vocational rehabilitation: usually not provided

Methods for Improving Care u Improve policy –how can we change policy so that it supports effective, efficient care for serious mental illness? u Managed care u Reduce system fragmentation –RWJF experiment u Monitor performance –NCQA: HEDIS –VA: report card

Methods for Improving Care (cont.) u Improve clinicians’ competencies u Implement disease management –change division of labor and responsibilities –increase focus on clients’ needs u Really empower consumers –self-help and peer support –recovery model

Panel u Steve Segal, Ph.D. –School of Social Welfare, UC Berkeley u Barbara Havassy, Ph.D. –Department of Psychiatry, UCSF u Judge Harold E. Shabo –Los Angeles Superior Court u Dave Hosseini –Sacramento Consumer Self-Help Centers and Office of Patients' Rights

u References –Starfield B: Is US health really the best in the world? JAMA. 2000; 284: –Young AS, Sullivan G, Burnam MA, Brook RH: Measuring the quality of outpatient treatment for schizophrenia. Archives of General Psychiatry. 1998; 55: –Young AS, Forquer SL, Tran A, Starzynski M, Shatkin J: Identifying clinical competencies that support rehabilitation and empowerment in individuals with severe mental illness. Journal of Behavioral Health Services & Research. 2000; 27: –Young AS, Klap R, Sherbourne CD, Wells KB: The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry. 2001; 58: u For further information –Alexander S. Young, MD, MSHS –VISN 22 MIRECC, West Los Angeles Veterans Healthcare Center & UCLA, Wilshire Blvd. (210A), Los Angeles CA 90073; phone: (310) x42460