Behavioral Health Care Parity and Integration

Finance: Behavioral Health Care When Americans Need It: Ensuring Parity and Care Integration, March 30, 2022

Parity is a worthy and enduring goal that is more aspirational than achievable. 

Behavioral health wards and rehabs are run very differently than the standard hospital floor. You simply cannot treat patients who may be having suicidal ideation in settings with electrical cords and intravenous bags. 

There are also security concerns Behavioral health patients have different medication issues - and sometimes must be court ordered to take meds if they are out of control. They (actually we, as I have been a patient more than once) may have self-control issues.. 

Leaving AMA from a standard hospital room is unlikely and is usually only a danger to the patient. Behavioral health patients are held on a somewhat involuntary basis. Behavioral health patients held in the criminal justice system cannot leave at all.

Please see the attached comments from last year before this committee and Ways and Means from February, where mental healthcare in the criminal justice system and the need to hold patients longer and deal with either alcoholic relapse or medication noncompliance are discussed.

Behavioral health is a specialty like no other. Prescribing psychiatric meds takes training and is an art, rather than a science. Not just any nurse can work in behavioral health wards and social workers to protect children and manage behavioral health patients have very different tasks. Nurses in a cardiac unit do not have to provide group therapy three times a day.

Without a massive infusion of public funding, it is hard to create behavioral health beds - which will require dedicated staff (in more than one meaning) and facilities that can only be used for behavioral health. In the current environment, getting a treatment bed is not easy (unless you are in custody). Behavioral health care is ultimately custodial care in the early stages.

Patients sometimes need more intense care after initial care. Once one is discharged, it is almost impossible to get back in - especially for “medication management.” Changing medications can be unpredictable and painful. Patients should have the ability to do this in a  safer space than a shelter - or even subsidized housing. Likewise, it takes a long time to be able to cope with medication management from a patient perspective - and even then it is sometimes hard to get on the right meds with minimal side effects. 

Hypomanic (bipolar 2) patients have it harder, mostly because what is needed by bipolar 1 patients in terms of antipsychotic medication is not needed for them. Some antipsychotic meds are prescribed for sleep - and insomnia is a concern for such patients - but may be better managed with other treatments like hydroxyzine and Melatonin. 

Patient education through Psychiatric Rehabilitation Programs are a valuable resource - but the supply is nowhere near the demand. While some patients will never work again if their issues are disabling, others need PRPs as a form of workforce (re)development. Quoting from testimony from June 2021 before this committee:

For workforce development and general recovery, Psychiatric Rehabilitation Programs, such as the Center for Behavioral Health in Rockville and Cornerstone Montgomery in Gaithersburg are essential. To make them more attractive, and to increase our ability to manage - especially in the period before disability programs kick in, participation should be paid at the minimum wage. 

People will participate in this care more frequently if their opportunity costs are met. Those with less than a full education should receive it through public and private providers and also be paid to do so.

Health care currently provided through Medicaid should be dual eligible for everyone, regardless of income and before it kicks in entirely be a public option. Instead of using a larger system, clients should have the option of receiving coverage through the PRP provider’s employee plan.

In the old days, behavioral health patients were locked into asylums. Now we are often locked up in jail (again, as discussed in the attachment), burden relatives or live on the street.. We have been penny wise and pound foolish. 

Society cannot work for merely parity. Behavioral health patients need special attention and the system needs a huge influx of resources - both for physical infrastructure, housing for disabled and partially disabled clients, and trained personnel. The latter requires its own set of incentives - including willing workers.

One way to free up case management resources is to move them from other social services. Having higher minimum wages, paid ESL, remedial, technical and associates degree level training and much higher child tax credits will take many clients out of the anti-poverty sector. Signing up for programs like TANF needs to be replaced with enrollment in a training program with easy entry and pay to meet client opportunity costs. This will free up an army of social workers who might be interested in more client contact and less paper shuffling. It is harder work, but more satisfying - especially if funded correctly.

Attachment: Mental Healthcare in America Video