An Avoidable Tragedy -- the Relationship of Premature Death and Serious Mental Illness

New research indicates that people with seriousreorganization of practice systems and provider roles;
mental illness -- which include schizophrenia, bipolarimproved patient self-management support; increased
disorder, and major clinical depression -- die, onaccess to expertise; and greater availability of clinical
average, 25 years earlier than the general population.information. The challenge is to organize these
Sixty percent of premature deaths in persons withcomponents into an integrated system of chronic
schizophrenia are due to medical conditions such asillness care. One approach to meeting these goals is
cardiovascular, pulmonary and infectious disease.through the creation of disease management
Unfortunately, people with serious mental illness alsoprograms.
suffer from a high prevalence of modifiable riskDisease management (DM) is an approach to care
factors, in particular obesity and tobacco use.coordination for individuals with chronic or persistent
Compounding this problem, people with serious mentalmedical conditions for two important reasons:
illness have poorer access to established monitoringimproved quality of care and decreased cost. Quality
and treatment guidelines for physical health conditions.is improved because treatment is coordinated across
Our nation?s healthcare system tends to bethe spectrum of care for individuals with these
fragmented, with increased reliance on specialists whoconditions using evidence-based practice guidelines and
address very focused aspects of the health/illnesseducation on illness self-management. States have
continuum.also been able to reduce costs through this approach.
Fragmentation is most notable in the separationThe Centers for Medicaid and Medicare Services
between the treatment for mental and physical(CMS) issued a letter to state Medicaid directors
illnesses. This separation is an artifact of how servicesencouraging the adoption of DM. Currently, DM is now
have been funded historically, with the preponderancewidely used in states for asthma, diabetes,
of funding for mental illness treatment coming fromhypertension and other persistent medical conditions,
states and directed toward state psychiatric facilitiesand increasingly for enrollees with serious mental
that were often -- literally and figuratively -- far awayillnesses.
from the mainstream of medical delivery.Washington State Example
What Can Be Done to Address this Tragedy?On June 28, CMS approved a state plan amendment
There are solutions to this epidemic of premature(SPA) for Washington State that uses the Benchmark
death and morbidity among persons with mental illness.Plan option to offer regular Medicaid State plan
Policy makers can provide the policies, resources, andservices plus disease management (DM) services to
leadership to close this gap. We will haveadult Medicaid recipients with complex medical needs.
accomplished this goal when we can say that:The benchmark State plan option provides States with
- Adequate funding is available to allow every providerthe opportunity to offer an alternative benefit package
of public mental health services to assess the physicalto beneficiaries without regard to comparability of
health status as well as mental status of clients servedservices, a traditional Medicaid requirement.
in the public mental health system.Medicaid recipients statewide will be identified by a
- States are learning from and following the examplescontractor based on claims history, referred by a
of states such as Missouri and Louisiana, which areprovider, or may be self-referred. Eligible recipients
implementing primary care medical home initiatives withinclude those who are diagnosed with certain chronic
explicit mechanisms and financing integrated treatmentmedical conditions, including: diabetes, heart failure,
between the mental health and primary care providerscoronary artery disease, cerebrovascular disease,
for coordination of services.renal failure, and chronic pain associated with
- State legislatures can create the policy infrastructuremusculoskeletal conditions and other chronic illnesses,
through statute or regulation to ensure that there is aincluding co-morbid depression and/or anxiety.
strong working partnership between community mentalIn addition to the traditional State Medicaid plan
health and community health provider organizations.services, individuals enrolled in the DM program will
These policies can define roles for these organizations,receive assistance in locating a primary care provider
establish referral protocols, or allow for the("Medical Home") and additional benefits tailored to
cross-placement and reimbursement of clinical staff.specific health needs, including:
Disease Management: Another Promising Approach- Condition-specific education;
Usual medical care often fails to meet the needs of- Access to a nurse call line;
chronically ill patients, even in managed, integrated- Regularly scheduled telephonic health care
delivery systems. The medical literature suggestsmanagement and support; and
strategies to improve outcomes in these patients.- Care coordination, including feedback to the primary
Effective interventions tend to fall into one of fivecare physician.
areas: the use of evidence-based, planned care;