Jackie Smith, a highly experienced nurse, has seen firsthand how a holistic approach to treating patients with severe mental illness can improve their overall health and quality of life.

Smith is now part of what appears to be a sea change in the way in which the nation’s health care system treats people with serious mental illness (SMI). Historically, treating these individuals has been a process fraught with frustrations for patients and providers alike, as patients often don’t take medications on schedule, miss appointments and are not attentive to their physical health. That has created an increasing number of seriously mentally ill people with co-occurring chronic medical conditions including diabetes, hypertension and emphysema. 

One such effort to improve treatment and curb spending on this high-cost, high-use population is the coordinated care model, in which a single provider acts as the main point of engagement for the patient. What’s unique about coordinated care programs for the SMI patient population is that it’s increasingly likely that a behavioral therapist will act as that point person, as opposed to a primary care physician, which is the case more frequently in the coordinated care model that is expanding across the health care spectrum.

“We try to coordinate all of it and keep the patient in the middle so they understand what’s going on and why they need to do certain things to stay healthy,” said Smith, who is a care manager at Community Care Behavioral Health, which is part of the UPMC Insurance Services Division in Pennsylvania. “A positive consequence of the people becoming healthier is lower costs because of fewer emergency room visits and hospital readmissions.”

SMI is defined by the Centers for Medicare & Medicaid (CMS) as a person having one of five conditions: biopolar disorder, major depressive disorder, paranoid disorder, schizophrenia, or schizoaffective disorder. Because of the nature of the conditions, those with SMI are more likely to form a trusting relationship with their behavioral health therapist than a primary care physician, experts say.

An analysis by Avalere Health, a health care consulting firm, found that approximately 2.8 million Medicare beneficiaries were treated for SMI in 2010. Of those, almost half were dual eligibles, meaning they qualify for both types of government-funded health care: Medicare, which covers people age 65 and older and the disabled of all ages, and Medicaid, which covers poor people.

For this particular study, SMI was defined as major depression, mood disorders and psychoses. Furthermore, the analysis only looked at Traditional Medicare beneficiaries, not those enrolled in Medicare Advantage programs. About a quarter of the nation’s 51 million Medicare beneficiaries are enrolled in Medicare Advantage programs, so the estimate of those treated for SMI is likely low.  

In a pioneer program, insurance provider UPMC Health Plan has partnered with Community Care, a behavioral health managed care organization, to create the UPMC Community Care special needs plan targeted at Medicare beneficiaries living in Allegheny County, Pennsylvania. The patient-centered approach is intended to reduce duplication in medical testing and foster a more seamless treatment experience for the patient.

“The idea behind the plan is to really enhance the capacity of the behavioral health provider because often the illnesses associated with SMI are better managed when patients are engaged with their behavioral health provider,” said James Schuster, chief medical officer for Community Care Behavioral Health.

While the UPMC Community Care special needs plan is only a couple months month old with more than a dozen enrollees, UPMC says it has a much larger potential, as there are some 10,000 Medicare beneficiaries diagnosed with SMI across Allegheny County.

The focus on the SMI population comes at a time when state governments, not the federal government, are increasingly controlling the health care purse strings, and the states have greater incentive to cut costs.

Those with SMI have been pushed under the rug for a long time, said Sally Rodriguez, senior manager at Avalere Health. “There have been misaligned incentives that prevent people from going to high-cost settings (i.e. hospitals). The thought with integrating care now is the state is controlling the dollars so they’re more interested in aligning incentives so they will be able to realize savings.”

According to Smith, the benefits of what she calls whole person care are clear because mental health impacts physical health, and visa versa. Furthermore, many SMI patients have had a lifetime of being rejected by physicians who were frustrated by their inability to follow through with treatment.

“I know if we get in there, get the communication going and provide enough support, they can be healthy,” Smith said. “Everybody wants to be healthy.”

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