Patient compliance and disease management programs appear to be more common in the private sector than the public sector. This observation likely reflects several trends currently operating in the mental health services sector. These trends include:
- Public sector programs such as Medicaid and State Mental Health agencies have been aggressively moving their mental health patients into managed care programs. These agencies likely look to the managed care vendor to provide compliance and disease management.
- Private sector insurers are increasingly cost-conscious and seek to manage costs by insuring quality of care via these programs.
Health care payers are not necessarily convinced of the economic value of compliance and disease management programs. While patient confidentiality remains a barrier to data collection, adequate data is not available to discern the cost-effectiveness of these programs. Despite this uncertainty, some payers continue to offer patient compliance and disease management programs as an added value to patients. Several payers interviewed (mostly private sector) are currently developing or have implemented patient registries or quality of life initiatives for depression. As is the case with treatment guidelines, compliance/disease management programs are less common for schizophrenia than for depression.
Although the national consumer and provider associations do not run patient compliance programs, both NAMI and NMHA maintain outreach programs to underserved populations and are beginning to increase those efforts.
- Public Programs
The outstanding public sector example of disease management and compliance is TMAP. TMAP worked with 20-30 patients, consumers and NAMI to design a 6-step patient and family education program. This program includes an array of educational materials ranging from pamphlets to videotapes. These materials cover issues such as how to monitor medications, and speak with physicians about mental illness. Twelve States have requested copies of these pamphlets, which are available from the Texas Department of Mental Health and Mental Retardation.35
In the DoD health care programs, the goal of military service is to maintain worldwide deployability of its active duty officers. Therefore, if a mental illness is documented, medical retirement might be mandated, regardless of disease severity. These policies vary among the service branches. For instance, the Navy and Marine Corps are more likely to allow individuals with a mild mental illness, such as depression, to continue service than the Army and Air Force. An individual might be asked to retire if a particular mental illness affects his/her "fitness to do duty." Dependents and retirees are not affected by this rule unless they would be stationed overseas with an active duty officer. One DoD health care product has the motto: "We are the HMO that goes to war." Therefore, ensuring that an individual who could go to war and handle weapons is of sound mental health lies at the heart of the military's mission of worldwide deployability.
- Private Payers
Although it is widely assumed that patient compliance with therapy should ultimately reduce overall medical costs, it is clear that private payers are only beginning to investigate whether this is actually the case.
Manufacturers focus on physician compliance rather than patient compliance due to concerns for patient confidentiality and greater ease of tracking physicians. Furthermore, patient compliance and disease management programs have not necessarily proven financially beneficial to manufacturers. One manufacturer noted that their depression guidelines have not been widely adopted and, in general, there is no accurate measurement of effectiveness for these programs.
Despite these limitations, several manufacturers have begun to develop or implement programs that attempt to assist patients in complying with antidepressant or antipsychotic treatment regimens. Strategies include automated refill systems, 800 hotlines, patient education programs, and the sending of reminders to providers. Manufacturers distribute programs/guidelines to consumers, families, providers and sometimes health plans.
PBMs, MCOs and employers are beginning to implement case management programs for depression and to a lesser degree, schizophrenia, even though case management is often delegated to behavioral health carve-outs. Programs that focus on screening and diagnosis are more common than programs that actually focus on case management.
One integrated HMO interviewed has implemented a confidential health risk assessment program for members that is administered via telephone. Confidential feedback is provided to the health plan member, with recommendations for individual lifestyle and health improvements. Results of the employee's risk data are also sent to their health care provider. This payer is also testing new approaches to chronic care delivery. One recent initiative involves the use of telephone follow-up. Nurses and care managers make a total of six telephone calls during the first six months following a mental health episode -- initially at two-week intervals and phasing into one call every two months. Staff are evaluating the success of this approach and believe that it contributes more to health outcomes than more traditional chronic care (e.g., medications, self-care, other types of follow-up).
This HMO has also implemented programs to monitor and insure follow-up after hospitalizations for mental illness and proper management of antidepressant medications. For example, the HMO tracks the percentage of hospitalized mental health patients age six years and older who were continuously enrolled for 30 days after discharge and who received some form of outpatient treatment (ambulatory care or day/night treatment). Sixty-eight percent of the patients who met these criteria sought outpatient care within seven days of discharge; 86% sought such treatment within 30 days of discharge. Similarly, this HMO monitors three performance indicators that assess multiple facets of appropriate treatment. Each measures the percentage of patients with new episodes of depression who were treated with antidepressant medication and who meet specified treatment criteria.
Employer-sponsored programs designed to assist patients in recognition and treatment of mental illness are not as common as physician-targeted programs. Employers expressed reluctance to implement these programs due to patient confidentiality, the difficulty of data acquisition and the difficulty of demonstrating value of these programs. When in place, they are usually designed and run through the MCO or PBM. Employee assistance programs (EAPs) often serve as a triage mechanism for minor episodes of mental illness or as screening and referral services. When presented with more serious cases, EAPs serve as a referral mechanism to get patients experiencing mental illness into the proper treatment system. At one employer, patients are targeted for a depression screening/education/awareness program through DUR. Pharmacotherapy is an essential part of this employers depression program.
Once employees are undergoing treatment for mental illness, BHO carve-outs may provide generic case management. However, few formal programs are in place, again, due to the difficulty of data acquisition and patient confidentiality.
In general, PBMs are reluctant to operate patient compliance programs due to confidentiality concerns. However, one PBM offers compliance assistance for antidepressants and will survey physicians for effectiveness. Others are planning programs to improve patient compliance (e.g., packaging medications in a box that can be placed on a kitchen counter or dresser).
- Special Populations
In designing disease management programs, the manufacturers interviewed did not report explicitly considering physiological differences based on ethnicity (although one manufacturer considers gender). Neither do manufacturers consider sociological perceptions of psychotherapeutics among different cultural groups, although one manufacturer acknowledges that the condition and treatment of schizophrenia is highly dependent on the social/cultural environment (e.g., stigma).
Our respondents reported that patients in correctional facilities of New York State are not forced or coerced to take their medications, but are encouraged through education.
One respondent from within the Indian Health Service indicated that difficulties in patient compliance with "Anglo" medicine is no greater in patients with mental illness than in those with any other disease. This respondent indicated that if the consumer accepted "Anglo" medicine, then compliance with therapy was generally pretty good. In attempting outreach among Native American populations who are suspicious of "Anglo" medicine, the IHS may attempt to work with traditional medicine men and women to increase their credibility among these patients.
- Severely Mentally Ill Populations
The management of patients who become severely mentally ill (SMI) is not uniform across service sectors. Most patients in public programs already meet the criteria of SMI or SED (for severely emotionally disabled children). However, the experience of patients in other insurance programs may be somewhat different.
Pharmaceutical companies have developed no major programs for high cost episodes of care or lifetimes of care (e.g., one that might offer discounts/incentives to increase access/compliance/utilization in high cost cases). One manufacturer believes the greatest costs (in high-cost cases) are generated by hospital days, not drug utilization, and should be accounted for through the medical benefit, not the pharmacy benefit. Another manufacturer is planning a program for combination therapies and additional drugs for treatment resistant patients.
One mixed-model HMO has organized a team of case managers to attempt to reduce inpatient admissions among its high utilizing mental-health population. The case managers are bachelors' level social workers who conduct outreach, help patients with medication, keep appointments, and increase compliance. The team approaches the appropriate clinician about each high-utilization patient and tries to help the provider treat the patient. This HMO believes this program has been very helpful in reducing the number of admissions among the high utilization population and is popular among patients.
The benefits consultant interviewed suggested that employers are rarely familiar or experienced with cases that become eligible for public assistance under SMI/SED guidelines. This is because employees who become this ill generally leave the workforce and are cared for under SSI disability provisions. One employer interviewed provides 60% of pay until age 65 for those out on disability and provides health coverage for two years (i.e., until Medicare eligibility under SSDI has been established). Furthermore, employers may not be aware that a patient has exceeded his or her maximum lifetime benefit until that patient has done so. In these cases administrative override is at least possible. The focus continues to be on maintaining the patient within least intensive locus of care. Strategies to promote least intensive locus of care include providing a flexible benefit design (e.g., exchange inpatient days for other types of treatment; no limit on benefits up to 1 million dollars for a lifetime). For example, in some behavioral health carve-outs, high cost/lifetime of treatment cases are managed separately.
Currently the PBMs interviewed do not have case management programs for patients on psychotropics or for high cost cases. Nor are there special programs for underserved populations.