Care Management - Complex Behavioral Illness

Many behavioral disorders are complicated by the presence of chronic emotional, cognitive, and medical problems which pose significant challenges for patients, families, and their care management providers. Such complex behavioral illnesses, also termed Serious and Persistent Mental Illness (SPMI), are among the most complicated and difficult diseases to successfully treat.

There are several million individuals in the United States with SPMI, tilizing $25 billion dollars annually in state and federal government healthcare resources, through an evolving financial structure involving both Medicare and Medicaid. This spending includes pharmacy and care services, primarily in emergency and inpatient care. Overall, individuals with SPMI experience poorly coordinated healthcare which is generally sub-optimal, particularly for those with co-occurring medical conditions. The result is inadequate care, poor outcomes, and excessively high spending. As state and federal government agencies grapple with controlling health care, the SPMI population has been largely overlooked.

One SPMI, schizophrenia, is substantially disabling and associated with chronic physical illnesses resulting in a 20% shorter life expectancy compared to the general population. The reasons for the higher health risks among persons with SPMI are often inter-related, thought to result from a combination of lifestyle behaviors (smoking, alcohol, street drug use) and medication side effects these individuals must take to treat their illness. The experience of Don illuminates these facts.

For example, nearly three-quarters of SPMI patients smoke tobacco, while simultaneously carrying significant risk factors for Type 2 Diabetes (sedentary lifestyle, poor nutrition habits, lack of exercise, particular medication use), elevating the prevalence of diabetes among these patients by almost two-fold compared to the general population. In addition, risk factors for other conditions such as heart disease, asthma, and respiratory disorders are similarly higher. For persons with SPMI, medical conditions are more likely to be under-screened, under-diagnosed, and untreated. These higher health risks are further amplified by a patient’s lack of consistent access to medical care, the need for coordination among systems of care, and the limited success of specialized educational interventions aimed at changing the lifestyle behaviors of individuals with SPMI.

Because the successful management of medical and behavioral healthcare for people with SPMI requires attendance to both psychiatric and medical needs, adherence to complicated and multiple drug regimens, the effectiveness of care can be substantially impaired from a variety of sources. Here, pharmacy ‘effectiveness’ collectively depends on quality prescribing by doctors and accurate adherence to doctor’s prescription by patients. Medical or Care ‘effectiveness’ requires physicians and case managers to understand the medical risks faced by these individuals, and actively coordinate and share information on behalf of those under their care.

Because SPMI are complex and long-term conditions, they are often associated with long-term dependency on government payers. The SPMI population is among the most costly for state Medicaid programs even though many individuals also receive Medicare coverage. Because the inpatient mental health benefit covered by Medicare is limited, Medicaid pays over 50% of all hospital stays for mental illness and nearly all costs associated with continuing care coordination (community support) and psychosocial rehabilitation. Costs associated with treating SPMI continue to trend upward at 15% a year, far above the overall Medicaid trend of 9% a year.

Medicaid and Medicare programs have accelerated their emphasis on optimizing and economizing care associated with chronic conditions. A growing number of state Medicaid authorities are promoting disease management programs as a strategy to improve the health status of Medicaid beneficiaries, many of whom are individuals with a primary diagnosis of SPMI and a co-occurring condition. Some policy makers recognize the need for a more specialized and comprehensive approach tailored for people with SPMI, but few states have focused on this population. While many individuals with SPMI will be enrolled in disease management programs because of their co-occurring medical conditions (diabetes, respiratory illness), the absence of a tailored approach recognizing the unique characteristics of this population, suggests that these programs may not lead to improved outcomes.

Through Medicaid Managed Care and Medicare Advantage special needs plans, a growing number of dually-eligible beneficiaries are being enrolled in managed care organizations, which are often not prepared for the management of the SPMI population for the same reasons faced by disease management programs. CNS specializes in products and services designed specifically to address the characteristics and treatment needs of individuals with SPMI, which extends beyond schizophrenia, to treatment-resistant, debilitating mood disorders (depression, bipolar disorder) and complicated behavioral disorders experienced by elderly and child/adolescent patients. While a daunting clinical challenge, our knowledge around the best treatments and care delivery systems for these patients is steadily growing. Here, specialized products and interventions designed for improving the quality of psychotropic prescribing, identifying those individuals at risk for poor outcomes earlier, and managing complex care and treatment adherence become all the more critical for the successful management of people challenged by SPMI.

Sources

Marder, Stephen and Essock, Susan et al; Physical Health Monitoring of Patients with Schizophrenia; American Journal of Psychiatry; 161:8; 2004

Kaplan A. Teacher of the Year Addresses Psychiatric Education, Schizophrenia Treatment
Nasrallah HA, MD. Psychiatric Times (Feb 2006), Volume XXV, Issue 2

Edington, DW. Health Management Research Center. University of Michigan.
Dolder CR, Lacro JP, Jeste DV. (2003). Adherence to Antipsychotic and Non-psychiatric Medications in Middle-Aged and Older Patients with Psychotic Disorders. Psychosomatic Medicine, Vol. 65, 156-162

Lieberman JA, Stroup TS, McEvoy JP et al. (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia, New England Journal of medicine 353 (12):1209-1223