HSCI 678 Intro to US Healthcare System

The Care of Special Populations and Special Disorders

Chapter 18

Dr. Tracey Lynn Koehlmoos

Introduction

• Defining special populations

• Systems that exist

• Types of providers

• Policy issues

American Psychiatric Assoc.

• A mental disorder is a clinically significant behavior or psychologic syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability). (APA 1980)

Conceptualization

• Mind/Body Schism—historical

• Emotional/Mental distress = Morbidity– Immune functions– Cancer– Heart Disease

Biologically perceived health is a strong predictor of mortality

Defining Mental Illness

• Multiple disorders

- More than 15% (30% annually)

- 1% unable to care for themselves

• Common diagnoses– Schizophrenia, Schizoaffective, Bipolar

• Notable Exclusions– Developmental disabilities– Substance abuse: lack of data/excessive care

Providers

• Psychiatrists, psychologists, counselors, therapists, social workers, ARNP, etc.

• Numerous facilities– State, VA– Private (health plan participants)

Public/Governmental Role

• Chronic Mental illness: some can be treated/some limited recovery options

• Government institutions (48 states)

• Mental health care unresponsive to financial incentives; outside continuum of care

• State mental hospitals—long tradition– 80% had chronic mental illness in the 1930’s– Population peaked at ~1/2 million in 1955

Movement toward Community Care

• Shift of psychiatrists out of mental hospitals/replaced by FMGs—problematic

• Psychoanalytical transition—little proof

• Social welfare increases

RESULTS:

Smaller in-patient population

Allowed for treatment/ not warehousing

Only care for severely mentally ill

Deinstitutionalization

• 33-40% homeless, chronic illness

• Elderly residents—to nursing homes (Medicaid/ Medicare)

• Payment shift from State to Federal govt.

• Federal programs:– SSDI– SSI

MEDICAID big payer for mental health services

Un-met Need

• About 150,000 chronic residential patients

• Where is everyone else?– No access to care– 15% uninsured—hard to get to Medicaid– Private insurance—inadequate provisions– Managed care—discourage enrollment– Social stigma

Policy Issues

• Physical/Mental health schism

• Institution/Community schism

• Unmet treatment needs– Substance abuse– Young, disturbed and alcoholic

• Stigma, stigma, stigma

• Managed Care-advent of mental healthcare

Conclusion

• Diverse population--disparities

• Difficult to reach

• Difficult to treat

• Difficult to project prognosis

• Lack of advocacy

• Lack of parity