July 31, 2013

Improving Health Care Delivery

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Alan J. Gelenberg, MD

Penn State University, Hershey, Pennsylvania


The health care delivery infrastructure is undergoing a sea change. Soon, almost everyone who lives in the United States will be eligible for health care. Implementing the Affordable Care Act (ACA) has been a long, complex process. But the continuing escalation of health care costs is unsustainable—especially when these greater costs are not buying improved care for our citizens. How does the ACA affect psychiatry?

The ACA will supplement the Mental Health Parity and Addiction Equity Act of 2008, providing more coverage for people with psychiatric disorders. With more patients to serve, increased efficiency is paramount. Three methods to increase efficiency are using technology wisely, focusing on prevention, and working in teams.

Information technology plays a growing role in every aspect of health care—for medical records, communication among clinicians and with patients, decision support, and patient education and adherence. Clinicians must enhance patients’ understanding of their conditions and care, secure their buy-in to treatments, and prompt them (often electronically) to take medicine and come to appointments.

The focus on preventive care requires the integration of mental and physical health care. Recognizing and effectively treating depression, for example, will improve outcomes and save costs in patients with diabetes, heart disease, and many other chronic medical illnesses. Additionally, I sincerely hope the chronically mentally ill will begin to receive the medical care that has often been denied them.

To integrate mental and physical health care, different types of professionals must work in teams. There are nowhere near enough physicians to care for all of the patients the ACA creates—especially as the population ages. Primary care providers (PCPs) will use algorithms and protocols created by specialists. Specialists will be available for electronic or phone consultations and some one-on-one consultation with patients. A psychiatrist will see a patient and refer the patient back to a PCP, providing backup as needed. Sometimes we may see the patient for a few visits to ensure stability. A small cadre of chronically ill patients will require ongoing care from specialists, eg, for schizophrenia or bipolar disorder.

Improving the health care system requires patience. But I am convinced we will get to a better place.

Financial disclosure:Dr Gelenberg is a consultant for Zynx, has received grant/research support from Pfizer, and is a stock shareholder in Healthcare Technology Systems. His own blog can be found at

Category: Mental Illness
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4 thoughts on “Improving Health Care Delivery

  1. “A psychiatrist will see a patient and refer the patient back to a PCP” Currently, it takes 6-12 weeks on average to see a psychiatrist. How does that improve under the ACA?

    Individuals in psychiatric crisis are sitting in ER holding cells for 3-5 days with no treatment received at all. How does that improve under the ACA?

    A confusing and contradictory mess of very restrictive state regulations makes integration of care and electronic medical records virtually impossible. How does that improve under the ACA?

  2. Thomas, You are correct in identifying areas that ACA will influence only minimally. Here in NE we have the same problems. They have been exacerbated by the privatization of the State’s mental health system. Costs have gone up, the number of patients treated has decreased. The ACA cannot fix this state created problem. However it will help in other areas. For example, if you see no benefit in ending limits to mental health benefits you are probably not looking honestly at the ACA. You are probably pursuing a political agenda while ignoring your patients’ concerns/needs.
    I have to agree with Gelenburg that preventative care is important in controlling costs and limiting expensive acute care for the chronically mentally ill.
  3. Why not seriously, with open minds and hearts, examine how (almost) universal access works in the rest of the Westernized world?! All of the insurance companies and CMS share data in real time, essentially 24/7. Technology and obtaining the necessary consents are hardly the issues. I have written a number of mental health and addiction-related, and geriatric psych CME items for a family medicine journal and am well aware of our present realities, such as the fact that more than twice as many persons who attempt suicide will have seen their PCP than their psychiatrist (if they have access to one) in the month preceding their attempt! Improved training for everyone on a dynamic care team, which must include PCPs as well as the range of psychiatric providers from RNs and NPs, to psychologists and other therapists, to psychiatrists must also include team-building skills. We tend not to practice in true interdisciplinary fashion outside of hospice and palliative care. The application of evidence-based algorithms, as well as the wealth of validated screening instruments, has been shown to work especially well in remote, rural settings — some bright, creative docs and others in Texas have developed several. We simply must get our heads out of our silos, look around, and put our patients’ interests ahead of our own. Oh, and be willing to work together with all stakeholders and disciplines.
  4. the ACA will not help the millions of Americans with mental illness. It may help a few of them but not the vast majority. Mental Health education to the public is not a new concept! It has been a goal for many years. This is where our focus needs to be so that in some instances it can be prevented and in some instances show patients that what they are experiencing is not the norm and that their lives could be different. We need more help in this field in a form that will really benefit the people in need and not just glorify those in power. Please this is a national and worldwide CRISIS. Let’s take it seriously.

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