Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0127The United States System of CareChristopher C. Colenda 1 , Stephen J. Bartels 2 and Gary L. Gottlieb 31 Michigan State University, East Lansing, MI, 2 Dartmouth Medical School, Hanover, NH,and 3 Harvard University School of Medicine, Boston, MA, USAOVERVIEWIn the first edition of this book Fogel characterized the US systemof health care for older adults with late-life mental disorders as a‘‘non-system of care’’, plagued by irrational incentives andmultiple access barriers 1 . This description highlighted a systemthat encouraged entrepreneurial activities among practitionersand health systems, was best at delivering specialized high-qualityhospital-based care, and was constrained by perverse fundingmechanisms that incentivized hospital-based and institutional care(nursing homes) but disincentivized outpatient and home-basedcare. While the individual elements of a comprehensive continuumof care could be found, services were described as fragmented,inadequate and poorly financed. As we move from one centuryinto the next, considerable attention has been focused on the rapidchanges occurring in health care and the changes that will need tooccur in order to accommodate an aging population.Has mental health care kept pace with these developments? Hasmuch changed since Fogel’s original assessment? Since theoriginal report, the USA has struggled with the need to slow thegrowth of rising medical expenditures. The efforts to reduce globalmedical expenditures have centered on the application ofmanaged care principles and practices and government cutbacks.The emphasis has been on cost reduction, not system’s integration.In this chapter we will provide an update and overview of thecurrent system of mental health care for older persons in the USA,with a specific emphasis on the organization and financing ofservices. The following components and trends will be addressed:(a) The structure and organization of mental health services forthe elderly; (b) fee-for-service financing of mental health servicesfor the elderly; (c) mental health managed care for older adults;and (d) emerging and future trends in integrated services andfinancing.THE STRUCTURE AND ORGANIZATION OFMENTAL HEALTH SERVICES FOR THE ELDERLYIn an ideal system, the organization, financing and delivery ofmental health services to the elderly would be a seamlesscontinuum involving acute and continuing services acrossinpatient, outpatient and long-term care service settings, andnetworked with the general medical sector. Since mental disordersare a leading risk factor for institutionalization, improving theprovision of mental health services in community settings is amajor focus of public policy 2 . The following section summarizescurrent mental health service settings and highlights severaldemonstration projects designed to provide integrated care for thefrail elderly.Psychiatric Service SettingsPrimary CareInitial access to care for older adults is usually through theprimary care sector, especially for older adults without a historyof severe and persistent mental illness (SPMI). Many olderpersons prefer to receive treatment in primary care, and thisservice sector offers the advantages of proximity, affordability andcoordination of medical and psychiatric co-morbidity 3 . Manyolder adults may present to primary care physicians (PCPs) withsymptoms of mental distress, difficult to classify in currentpsychiatric classification systems 4 . The most prevalent disordersin the primary care sector are depression, anxiety, anxietysymptoms, dementia syndromes and misuse of prescriptionmedications and alcohol use. Adequate detection, treatment andreferral to the specialty mental health sector remain problematic,and have been attributed to such issues as: stigma; low priority ofmental health issues in patients with serious medical disorders;inadequate referral resources; complexity of patient needs(psychiatric, medical and social); and lack of time and expertisein dealing with psychiatric problems 5 . Additionally, PCPs tend toapproach psychiatric disorders using a medical model, whichencourages over-reliance on medications for common disorders 6 .Despite the problems identified, PCPs will continue to beimportant mental health service providers. Thus, training ingeriatric psychiatry and research that focuses on how to improvePCP effectiveness remains an important challenge for the comingdecades 4,7 . PCPs will also be important mental health careproviders for geriatric minority populations with late-life mentaldisorders in coming years 8 .Outpatient Psychiatric Service SettingsThe proportion of psychiatrists reporting large geriatric case loadshas steadily increased over the last two decades 9,10 , a trendparalleled by other mental health providers, such as psychologistsand social workers. More services are being delivered, in largepart due to consumer demand, better treatments, an increasedrecognition of how untreated late-life mental illness contributes toexcess disability, and more favorable Medicare reimbursementpolicies.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd