Women's Preventive Health Care: As our nation experiences the steady implementation of President Obama's landmark health care reform legislation, the
The preventive services and screenings specified in PPACA, and ultimately expanded by HHS, will be fully covered without patient copayment. The three sets of guidelines currently being utilized to define "preventive services" include recommendations made by the U.S. Preventive Services Task Force, the Bright Futures for Adolescents of the American Academy of Pediatrics, and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. The charge to the IOM: "Convene an expert committee to review what preventive services are necessary for women's health and well-being and should be considered in the development of comprehensive guidelines for preventive services for women. The committee will also provide guidance on a process for regularly updating the preventive screenings and services to be considered." Issues to be explored included: What is the scope of preventive services not included? What additional screening and preventive services have been shown to be effective for women? What services and screenings are needed to fill gaps in recommended preventive services for women? And, What models could HHS and its agencies use to coordinate regular updates of the comprehensive guidelines for preventive services and screenings for women and adolescent girls?
In fulfilling its mission, the IOM sought to identify preventive measures that were aimed at filling the gaps that it had identified. In most cases these measures had already been proposed in the guidelines of other professional organizations. Those preventive measures that were clearly not developed, tested, or known well enough to have a measurable impact were eliminated from consideration. Fundamentally, the IOM asked: Are high-quality systematic evidence reviews available which indicate that the service is effective in women? Are quality peer-reviewed studies available demonstrating effectiveness of the service in women? Has the measure been identified as a federal priority to address in women's preventive services? And, Are there existing federal, state, or international practices, professional guidelines, or federal reimbursement policies that support the use of the measure available?
The IOM noted that prevention is a well-recognized, effective tool in improving health and well-being and has been shown to be cost-effective in addressing many conditions early. Prevention goes well beyond the use of disease prevention measures. Historically, the many disparate components of our health care system have relied more on responding to acute problems and the urgent needs of patients than on prevention. The provision of preventive health care services is inherently different from the treatment of acute problems, but our nation's health care system has fallen short in the provision of such services. Compared with a system that prevents avoidable conditions early, a system that responds to the acute health care needs of patients can be inefficient and costly, and a focus on response instead of prevention is a major barrier to the enactment of optimal health and well-being by Americans. Our nation's current orientation is in spite of the fact that for nearly two decades we have collectively known that nearly half of all deaths in the
Although none of the IOM committee members were psychologists, one of the important "Identified Gaps" addressed by the IOM was mental health care. Depression is a widespread mental disorder that affects approximately 121 million people worldwide and has been identified to be 1 of the top 10 leading causes of disease burden. Depression may lead to suicidal ideation and actions. Postpartum depression is a condition specific to new mothers. Depression can occur throughout the life cycle, from childhood to late in life. Suicide rates in women are highest within the age range of 45 to 54 years. Across the life course, women may develop depression more often or more prominently around the time of certain reproductive events, such as menstruation, pregnancy, loss of a baby, birth of a baby, infertility, and menopause. Women are consistently rated as a high-risk group for depression as depression is significantly more prevalent in women than in men at almost twice the rate. Between 10% and 20% of mothers experience postpartum depression within the first year after giving birth, which has significant consequences for both the child's development and the mother's well-being. Depression is a condition commonly encountered in primary care because those with major depression utilize health care at higher rates and mental health issues are increasingly becoming a part of primary care, in part because of increased physician education. The primary gap in prevention services recognized by the IOM is that the current recommendation for depression screening and follow-up does not address suicide and postpartum depression as related conditions to be evaluated. We would postulate that if psychology had been more actively engaged in this important IOM study a significantly broader recommendation would have evolved. As
MACPAC: One of the most satisfying aspects of serving in the public policy arena is the opportunity of working closely with our nation's next generation of public servants. Coming from varying backgrounds, these leaders of tomorrow are extraordinary bright, enthusiastic, and dedicated. Hopefully, as they mature into seasoned professionals, they will retain these defining traits. "Only a year out of my undergraduate studies and interning in
"Persons requiring mental health services, while representing a comparatively small portion of the Medicaid recipient population, also incur a disproportionately high level of associated cost. The APA reports that most Medicaid beneficiaries are not entitled to psychological services. With the exception of children under the age of 21, who are covered by Medicaid as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits for psychological services, access for low-income families and disabled persons varies from state to state. Because it is considered an 'optional benefit,' only 50% of the states offer psychological services through independent practices while the other half may cover services in certain situations only, such as through a hospital, according to the APA. However, in those circumstances, psychologists are not able to bill Medicaid directly. States' policies on psychological treatment as an 'optional benefit' vary considerably and are at risk for cuts as states facing budget shortfalls must make tough choices.
"In an effort to confront the national goal of cutting spending while improving the care management necessary for this population's complex needs, states have been increasingly trending away from fee-for-service and towards managed care in Medicaid, a movement that is likely to continue, according to the Medicaid and CHIP Payment and Access Commission's (MACPAC's) recent Report to Congress: The Evolution of Managed Care in Medicaid. Managed care can be used to define many different arrangements for delivering and financing health care services, though the main three arrangements are comprehensive risk-based plans, primary care case management programs, and limited benefit plans. While each state takes a slightly different approach, 48 states and the
"This being said, another paradox exists regarding Medicaid and behavioral health patients. Medicaid enrollees generally tend to have a higher prevalence of behavioral health issues than the greater population; and further, mental health conditions can exacerbate other existing medical conditions. Conversely, behavioral health services are often the most 'carved out' services in Medicaid programs, causing enrollees to have to struggle with a complex system and coordinating services. These problems are further compounded when, in some states, the behavioral health services are 'carved out' of the plan benefit package but the pharmaceutical costs associated with them are included. Other states have taken a more limited-benefit approach to their plans and have contracts to manage the subset of benefits and services required for particular subpopulations, such as individuals in need of inpatient mental health services.
"The particular and increasing relevance of managed care in Medicaid comes not from its apparent discrepancies or from the challenges it has had in securing provider participation, but rather from PPACA, which is expected to be fully implemented by 2014. Notably, this Act will require the states to establish coverage for nonelderly parents, childless adults, and adults with disabilities with incomes up to 138% of poverty. It also calls for the creation of Accountable Care Organizations (ACOs), which are networks of hospitals, doctors, and other health professionals that agree to share responsibility for the care received by patients. Falling under the broader category of 'other professionals,' psychologists and other behavioral health specialists will undoubtedly play an integral role as part of these health teams. Perhaps as we look to the future of healthcare reform in this country, the need for psychologists to be more than just 'other professionals' legislatively will become more apparent and both the government and the psychological community will be called upon to provide both the funding and the necessary professionals to meet the needs of the American people" (Anna Borris, Intern for U.S. Senator Daniel K. Inouye).
Conditions of Participation for Community Mental Health Centers: This Summer HHS proposed regulations for community mental health centers which would require comprehensive patient assessments by a "physician-led interdisciplinary team in consultation with the client's primary health care provider, if any. The interdisciplinary team would be composed of a doctor of medicine, osteopathy or psychiatry, a psychiatric registered nurse, clinical psychologist, a clinical social worker, an occupational therapist, and other licensed mental health counselors, as necessary." The required psychiatric evaluation must be "completed by a psychiatrist or psychologist with physician counter signature, that includes the medical history and severity of symptoms." "The CMHC must designate a physician-led interdisciplinary treatment team that is responsible, with the client, for directing, coordinating, and managing the care and services furnished for each client. The interdisciplinary treatment team is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and therapeutic needs of CMHC clients." We would suggest that Katherine's message is extraordinary important if psychology is to remain an independent health care profession under PPACA. I will soon be retiring from the U.S. Senate staff after 38+ years of a fascinating journey. "If you miss the train I'm on, you will know that I am gone. You can hear the whistle blow a hundred miles." Aloha,
