The Delivery of Mental Health Care: Where Are We and Where Are We Going? J. Michael Houston,
ixty years is a long time, or is it? The American Medical Association was founded 166 years ago. The American Psychiatric Association traces its origins back 169 years. The American Academy of Child and Adolescent Psychiatry is no longer in its infancy yet we may still be decades away from adulthood. What’s happened in those 60 years? At our inception, we were a small, very small, group of child psychoanalysts and academicians. Now we have grown to more than 8,500 members practicing in ofﬁces, hospitals, schools, residential treatment centers, juvenile justice institutions, and research facilities. We work as clinicians, educators, research scientists, administrators, and policy makers. As we have changed, the provision of mental health services has changed, driven largely by forces outside our profession: the implementation of Medicare, Medicaid, the Community Mental Health Act, health maintenance organizations, and managed care. Despite our growth and despite the changes around us, only 20% of the children and adolescents in need of psychiatric treatment receive help.1 As a maturing ﬁeld, should we begin to lead the provision of services in a manner that begins to address this gross deﬁciency? Our ﬁeld often traces its origins to the child guidance clinics, ﬁrst established in the 1920s to address juvenile delinquency. Supported by donations, grants, and state funding, by the 1950s these clinics served as the foundation for our nation’s children’s mental health delivery system. They also served as the foundation for training for child psychiatrists in a multidisciplinary model that also brought together pediatricians, psychologists, and social workers into a functioning team sharing the expertise of each discipline. Alongside this model and oftentimes An interview with the authors is available by podcast at www. jaacap.org or by scanning the QR code to the right.
D. Richard Martini,
integrated within it was the blossoming ﬁeld of psychoanalysis focused to a greater degree on the individual treatment of the child in intensive psychotherapy. The numbers of academic departments of child psychiatry began to multiply after the American Board of Psychiatry and Neurology established child psychiatry as a subspecialty in 1959. Although focused primarily on training and education, academic centers often merged with child guidance clinics and integrated the interdisciplinary model of providing care. Alongside this developing system emerged “employer-sponsored” health insurance as the default method of paying for medical care. With wages frozen during World War II, companies began to offer health insurance policies as a means of attracting and retaining employees. Compared with current policies, the beneﬁts were generous and managed care had not yet been invented. In 1965, Medicare and Medicaid were established by expanding the model of private health insurance into government-funded and managed care for the elderly, the disabled, and impoverished children. Add to this the adoption of current procedural terminology codes in the early 1980s, which began as an attempt to classify surgical procedures and became the all-encompassing method of categorizing the work of all health care professionals. Although none of these individual developments are at fault, the combination is thought to have led to marked expansion of health care costs that has plagued the United States over the past 4 decades. Varying degrees of fragmentation in the delivery of mental health care also transpired as each discipline provided an individually billable service. Other pieces ﬁt into this puzzle—the Health Maintenance Act of 1973, the overuse of inpatient hospitalizations for adolescents in the 1980s, and the implementation of managed
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 52 NUMBER 11 NOVEMBER 2013
care in the 1990s, which together helped overvalue our skills as psychopharmacologists and undervalue our training as diagnosticians, therapists, and consultants. Where does that leave us? Although stronger in number, we are just one, relatively scarce and relatively expensive, component within a fragmented system that together leaves 80% of children and adolescents with psychiatric illness untreated. We have grown sufﬁciently in number and in voice that we can take leadership in developing systems of mental health care delivery that begin to provide universal access to high-quality psychiatric treatment. To that end, the Affordable Care Act, also known as Obamacare, might provide us with just such an opportunity. The changes proposed in the Affordable Care Act strive to improve the efﬁcacy and efﬁciency of health care delivery. Using models of health care access, such as accountable care organizations, as the focus of care delivery will shift toward the integration of specialty-based services into primary care medical homes tasked with the coordination of care for individual patients and their families. Primary care practitioners are beginning to embrace the pediatric medical home model, where services provided by primary and tertiary care specialists are coordinated, with an emphasis on the role of the patient and family in decision making. The integration of mental health care into the primary care practice is an essential component of the pediatric health home, and currently pediatricians and family practitioners are encouraged to develop their skills in the diagnosis and treatment of child and adolescent psychiatric disorders.2 It is anticipated that these systems will involve population-based screening with a focus on prevention and early detection and intervention as a means of improving outcomes and decreasing overall costs.3 Child and adolescent psychiatrists will be encouraged to engage in models of collaborative care, serving as consultants and team members for primary care–based clinicians and helping them provide anticipatory guidance and identify and treat some psychiatric illness in their practices. The use of “midlevel” clinicians, such as nurse practitioners, physician’s assistants, and social workers, will expand.4 Children and adolescents with more complicated and severe psychiatric disorders will be referred to child and adolescent psychiatrists, pushing us as clinicians to practice at the “top of our license.” The pediatric medical home is not yet well deﬁned for those
young patients with chronic psychiatric disorders that require close monitoring and frequent contacts. In these situations, the pediatric health home may rest on the child and adolescent psychiatrist. Multiple additional forces are at work that will change the way we practice and affect the development of population-based coordinated care. As a result of mental health parity and the expansion of insurance coverage, the number of children and adolescents seeking care will increase. The changing demographics of our nation will lead to dramatic increases in the ethnic and cultural diversity of our patients. Integration also will include community-based services, particularly the provision of mental health care in schools. As child and adolescent psychiatrists, we must be prepared to address these issues and incorporate these changes into our training and clinical practice. Advances in technology already outpace our capacity to integrate these tools into our practice, and this trend is likely to continue. In addition to taking the basic step of integrating electronic medical records into patient care, we should become fully literate and facile with the use of telepsychiatry, Web-based screening and treatment, and the uses of social media. Although advances in neuroscience and our understanding of psychopathology will ultimately improve the quality of mental health care, efﬁcient means of integrating these developments into practice will continue to evolve. The emphasis for child and adolescent psychiatry in the future will be on caring for more patients for less money while providing evidence of better clinical outcomes in the process. If we are to meet the mental health care needs of children and adolescents, rather than resisting the changes that will occur, we have the opportunity to assist in the design, development, and implementation of models of care that hold the promise of greatly increasing access to effective treatment for the large number of children who currently receive none. Patients should ﬂow seamlessly from the community into child and adolescent psychiatric services and back, and from one program to another, with evidence of constant care coordination and an emphasis on quality. Available resources should follow patient demand so that we can be responsive to populations and to immediate clinical need.5 These are exciting times for health care, and child and adolescent psychiatry has the expertise and
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 52 NUMBER 11 NOVEMBER 2013
HOUSTON AND MARTINI
commitment necessary to lead this process as it moves forward. The past 60 years have brought incredible change to our profession. Where the next 60 years, or for that matter the next 10 years, take us will depend to a great degree on our willingness and capacity to take the lead in developing efﬁcient and effective models of providing mental health care to all of our nation’s children and adolescents. &
a series of editorials from current and former AACAP leaders, key ﬁgures in AACAP’s development, and prominent members who help to provide perspective and context for AACAP’s accomplishments and its role in the ﬁeld of child and adolescent psychiatry as it turns 60. Dr. Houston is with the George Washington University Medical School. Dr. Martini is with the University of Utah School of Medicine. The authors thank Robert Hilt, M.D., of the University of Washington School of Medicine, for his assistance in the preparation of this article. Disclosure: Drs. Houston and Martini report no biomedical ﬁnancial interests or potential conﬂicts of interest. Correspondence to J. Michael Houston, M.D., 5506 Connecticut Avenue, NW, Suite 23, Washington, D.C. 20015; e-mail: [email protected]
Accepted July 25, 2013.
0890-8567/$36.00/ª2013 American Academy of Child and Adolescent Psychiatry
In 2013, the American Academy of Child and Adolescent Psychiatry (AACAP) celebrates its 60th anniversary. In collaboration with the AACAP 60th Anniversary Committee, the Journal presents
REFERENCES 1. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. 2. American Academy of Pediatrics Task Force on Mental Health. Children’s mental health in primary care—collaborative projects. http:// www.aap.org/mentalhealth/mh3co.html Accessed July 24, 2013. 3. Fisher ES, McClellan MB, Safran DG. Building the path to accountable care. N Engl J Med. 2011;365:2445-2447.
4. Katon W, Un€ utzer J. Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim. Gen Hosp Psychiatry. 2011;33:305-310. 5. American Academy of Child and Adolescent Psychiatry. Guide to building collaborative mental health care partnerships in pediatric primary care. http://www.aacap.org/App_Themes/AACAP/ docs/clinical_practice_center/systems_of_care/Collaboration_Guide_ FINAL_approved_6-10.pdf. Accessed July 24, 2013.
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 52 NUMBER 11 NOVEMBER 2013