Massachusetts is leading the way on an effort to redress one of the major health inequities we face as a society — caring for the severely disabled and mentally ill.
There are about 11,000 adults in Massachusetts with serious mental illness such as schizophrenia and bipolar illness who are clients of our state Department of Mental Health and are eligible for Medicare and Medicaid but have lacked the care they deserve. The consequences for those with serious mental illness have been truly catastrophic.
While the general population of the United States has enjoyed steadily increasing life expectancy for the past two decades, those with severe mental illness have actually experienced a decline in theirs. According to Dr. Steve Bartels, professor of health service research at Dartmouth Medical School, the average life expectancy for individuals with serious mental illness is now 53 years, a decline of 5 years since 1991. Unlike most health status indicators, this rate of premature death is the same in Massachusetts as it is in Louisiana, with very little regional variation.
In the past, the most common causes of premature death for those with serious mental illness were suicide or accidents. Today it is cardiovascular disease and diabetes. We certainly know how to treat diabetes and how to prevent or delay the adverse consequence of cardiovascular illness. So why is this happening?
We don’t have to look too far to see why. Often individuals with serious mental illness do not have a meaningful primary care relationship and many receive no primary care at all, for that matter. Few individuals with mental illness have what we would call a “primary” psychiatrist who is able to manage psychiatric care and anti-psychotic medications across all settings at all times. When there is primary care, it is just about impossible to get information about the mental health treatment plan, or when a psychiatrist attempts to provide continuity care, it is nearly impossible to have a say about where psychiatric hospitalizations occur. Thus, where there is the greatest need for personalized continuous integrated medical and mental health clinical management, those with mental illness are treated as if they were anonymous pieces of baggage. It is really “medical marginalization.” And the cost in dollars is billions a year. The cost in lives is immeasurable.
In the context of this total care delivery failure, the Department of Mental Health despite years of constrained budgets, has done a remarkable job at putting in place all the right components of an enlightened community based care system for those with serious mental illness. The problem is that these community services are grossly under resourced, because another huge funding stream, Medicare that pays for all that hospital care as a consequence of the fragmentation and missed opportunities, is entirely disconnected.
The Affordable Care Act intends to redress this with the creation of the “One Care” demonstration that started here on Oct. 1 with expansion planned in 2014 to 14 other states. In this first in the nation demonstration, Commonwealth Care Alliance is one of three health plans participating along with Fallon Total care and Network Health. Commonwealth Care Alliance, in close collaboration with community-based human service providers, the mental health consumer, family and recovery learning communities intends to become that missing accountable entity that is responsible for the care in all settings at all times. By reimagining and redesigning what meaningful primary care looks like, we will develop coordinated inpatient and outpatient medical and mental health care and we will metaphorically finally reconnect the head to the body in all aspects of care.
It must be recognized that there is no precedent for what we will be trying to do. Thus, the challenges will be many and formidable. But for no other set of Medicaid and Medicare beneficiaries is the promise of dual integration so important. Our job will be to realize that promise for thousands in the months and years ahead.