Health Care for Patients with Serious Mental Illness: Family Medicine's Role

Abstract

Background: Medicare Part D and the U.S. Department of Veterans Affairs (VA) use different approaches to manage prescription drug benefits, with implications for spending. Medicare relies on private plans with distinct formularies, whereas the VA administers its own benefit using a national formulary. Objective: To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA. Design: Retrospective cohort. Setting: Medicare and the VA, 2008. Patients: 1 061 095 Medicare Part D beneficiaries and 510 485 veterans aged 65 years or older with diabetes. Measurements: Percentage of patients taking oral hypoglycemics, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) who filled brand-name drug prescriptions and percentage of patients taking long-acting insulins who filled analogue prescriptions. Sociodemographic- and health status–adjusted hospital referral region (HRR) brand-name drug use was compared, and changes in spending were calculated if use of brand-name drugs in 1 system mirrored the other. Results: Brand-name drug use in Medicare was 2 to 3 times that in the VA: 35.3% versus 12.7% for oral hypoglycemics, 50.7% versus 18.2% for statins, 42.5% versus 20.8% for ACE inhibitors or ARBs, and 75.1% versus 27.0% for insulin analogues. Adjusted HRR-level brand-name statin use ranged (from the 5th to 95th percentiles) from 41.0% to 58.3% in Medicare and 6.2% to 38.2% in the VA. For each drug group, the 95th-percentile HRR in the VA had lower brand-name drug use than the 5th-percentile HRR in Medicare. Medicare spending in this population would have been $1.4 billion less if brand-name drug use matched that of the VA. Limitation: This analysis cannot fully describe the factors underlying differences in brand-name drug use. Conclusion: Medicare beneficiaries with diabetes use 2 to 3 times more brand-name drugs than a comparable group within the VA, at substantial excess cost. Primary Funding Source: U.S. Department of Veterans Affairs, National Institutes of Health, and Robert Wood Johnson Foundation.

Primary Mental Healthcare and Integrated Services

“…Key elements for development of effective shared care, as per the literature (Kringos et al, 2010;Upshur & Weinreb, 2008), include: the development of electronic medical records; physician leadership; incentives for inter-professional collaboration and management of complex patient profiles; team vision; recognition of diversified expertise requirements; absence of hierarchical structures among professionals; adequate space and locations; effective management and clinical skills; strong commitment to innovation and patient empowerment; and established clinical relationships. To improve the quality of mental healthcare services, other recurring issues to pay attention to are: long waiting times for psychiatric care or psychotherapy at no charge; limited primary-care team practice; general practitioners' limited training or experience with effective team practice (Rothman & Wagner, 2003); inappropriate modes of remuneration; and lack of financial incentives for general practitioners to manage patients with mental disorder (Collins, 2006;Morden et al, 2009). General practitioners' busy schedules and the competing demands of other patients are other contributing factors (Starfield, 1998;Craven & Bland, 2006).…”

“…Best models depend on the context (for example, practice settings, network organization of care) and patient profiles. Shared-care component models can include the following: (1) informal care support for general practitioners by psychiatrists; (2) "specialized mental health general practitioners" -i.e., general practitioners are both trained in physical medicine and psychiatry; (3) formal and more rapid referral process and efficient telephone support from psychiatrists; and (4) onsite mental healthcare specialists into the general practitioners' surgeries, which imply general practitioners' consultations with mental healthcare specialists (psychiatrists or other psychosocial professionals such as case managers), patients' consultations with psychiatrists or both general practitioners and psychiatrists, and linking patients with case managers, including follow-up with a general practitioner (Morden et al, 2009). As the mental healthcare literature reveals, a key feature of shared-care models is the increasingly important role played by case managers, a source of systematic and proactive psychosocial follow-up, which involves screening, patient psycho-education, subsequent treatment (including drug adherence), and patient self-management techniques.…”

Women's Physical Health, Mental Health, and Practical Hints for Common Practice Issues

“…Morden et al 13 suggest that "serious mental illness should be considered a cardiovascular disease risk equivalent"; these patients are most likely to die of cardiovascular disease and do so at a substantially higher rate than the general public. Thus, much of our effort should be toward decreasing all modifiable cardiovascular risks when we see patients with serious mental illnesses.…”

A Primary Care-Public Health Partnership Addressing Homelessness, Serious Mental Illness, and Health Disparities

“…By some estimates, people with SMI die approximately 25 years earlier than those in the general U.S. population. 5 Cardiovascular conditions and other treatable and preventable chronic diseases contribute heavily to excess morbidity and mortality in this population. 5,6 In addition, the health problems of people experiencing homelessness are substantial and complex.…”

“…5 Cardiovascular conditions and other treatable and preventable chronic diseases contribute heavily to excess morbidity and mortality in this population. 5,6 In addition, the health problems of people experiencing homelessness are substantial and complex. Most chronically homeless individuals have multiple disabilities including SMI, chronic medical conditions, and co-occurring substance use disorders.…”