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A Comparison of Mental Healthcare System; Germany and United States Bri Weed HCA 422 Dr. Erlyana July 10, 2014
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ABSTRACT: Mental Illnesses can have a devastating effect throughout a healthcare system. In the United States, Canada and Western Europe, mental illness ranks first among illnesses that result in disability, with a global cost of nearly $2.5 trillion dollars (Mental Health 2013, 2013). The fundamental goals of any healthcare system are to keep people healthy, treat the sick and protect families against financial ruin from medical bills. It is crucial for a healthcare system to incorporate mental health into their system as it effects a person’s entire well being. In Germany, the healthcare system is set up by the government with regulations and laws but run by the states and financed through independent, not-‐for-‐ profit and non-‐governmental statutory health insurance or “sickness funds.” The German healthcare system also has a private insurance sector. In the United States, the federal government creates laws and regulations but passes much of the control onto the states. There are many different payment models and rates determined by each insurance company, organization, physician and facility making the reimbursement system very complicated and fragmented. In recent years, the mental health system in these countries has been neglected with much of their funding being cut. However, mental illness and disorder rates have risen at astronomical rates, attracting much needed criticism and attention, influencing reforms. This paper aims at dissecting the United States and German mental health system and identifying areas where each system can be improved. As a global society, it is essential each country to learn from one another and adapt effective practices to improve their own outcomes.
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Mental illness is an important public health challenge in both Germany and the United States. These types of illnesses do not discriminate, it can affect anyone including, men, women and children, regardless of gender, race, ethnicity, socio-‐economic status or age (Mental Health, 2014). Mental illnesses fall among a continuum of severity, which determines the treatments and services used to treat the patient. In the past few years, especially in the United States, the mental health system has attracted much attention due many events occurring in society. In Germany and United States, mental health has very similar definitions. A definition of mental health is “a state of well being in which the individual realizes his or own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (Mental Health Basics, 2014). In both countries, mental illnesses have been placed with stigmas, which have lead to isolation and discrimination in daily life for mentally ill patients. Recently, mental health has become a very large social issue. In 2012, in the United States there was a mass shooting at Sandy Hook Elementary School, which caused the nation to look more closely at how Mental Illnesses are addressed (Ciha, 2013). Mental health problems are among the most important contributors to the global burden of disease and disability. It is reported by the World Health Organization in 2013 1 in 4 people suffer from mental disorders in both developed and developing countries. In the United States, 81.6-‐million citizen experience some form of mental disorder each year and 46.4% will experience a mental illness in their lifetime (Mental Health Basics, 2013). It is estimated by the CDC that only about 17% of U.S. adults are considered to be in a state of optimal mental health (Mental Illness, 2013). Nationally, the direct cost of care for mental
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disabilities is $217.5 billion, however, this number does not include the indirect cost of mental illness, and such has lost productivity at work, public support payments and cost of incarceration. Mental disorders are very prevalent in adult Germans with the rates of mental disabilities being are very similar to the United States (Wittchen, 2004). In the United States, the mental healthcare system is very fragmented with major concerns on financing and access. In the United States, healthcare system is treated as a market system where there are many price setter and price takers. There is also a very clear divide between the public and private sectors. In the public sector most if not all of healthcare is paid through taxes. These taxes at both the state and federal level are what sponsor many programs such as Medicare and Medicaid. Medicaid is the single largest payer for mental health services in the United States and is increasingly playing a larger role in the reimbursement of substance use and disorder services. A person’s income must be below a certain threshold, be diagnosed with a disability or be pregnant in order for them to qualify for Medicaid. The government then contracts with different organizations to facilitate the care under a set price. In the private sector, it is usually sponsored through an employee where the employee contracts with private insurance companies to negotiate price and benefits. The employee, in-‐turn will contribute half of the premium while the employee would pay the rest. The premiums are based upon living conditions, health status, demographics and income level. Typically, private insurance reimburses more than the government in exchange for better quality and access. There has been a strong effort to increase the quality and access of the public sector and bridge the treatment and access gaps between the public and private sector. The Patient Protection and Affordable Care Act
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(PPACA), is a step in the right direction to bridge the treatment gaps in the healthcare sectors. In 2010, President Barak Obama, passed the Portability and Protection Affordable Care Act, is revolutionizing the way the United States Health Care is financed, delivered and organized. The goal of PPACA is to improve quality, access and affordability to all citizens in the public and private sector. There are many provisions in the act, which benefit all healthcare users. Through this act mental health benefits and coverage is being expanded, health plans must cover preventive services at no cost and plans will no long be allowed to deny or charge more for pre-‐existing health conditions (mentalhealth.gov, 2014). The PPACA, attempts to bridge the treatment gaps as well as build a continuum of care. This act forces every United States citizen to hold some type of health insurance whither in the public or private sector. The PPACA is also attempting to correct inconsistent, improper and repetitive care through different quality measures. The idea of the United States healthcare is to integrate mental health and primary care to reduce cost, fragmentation, improve access and quality. Another key reform is the Mental Health Parity and Addiction Equity 2008, which ensures that financial requirements and treatment limitations-‐ applicable to mental health or substance use disorder benefits-‐ are no more restrict than the predominant requirements or limitation applied to substantially ill medical benefits (United States Department of Labor, 2010). This act is in conjunction to the Mental Health Parity Act of 1996 which prohibited large group health plans imposing annual or life-‐time dollar limits on mental health benefits that would not be placed on other medical conditions. The most
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significant different is adding substance use disorders. This new addition reveals two things; one, substance abuse is a serious disorder with technologically advance and costly treatments and two, substance abuse has grown and attracted the attention of the public and policy makers. Germany’s healthcare system is founding on principles of solidarity, subsidiarity and corporatism. The system works on a check and balance system between the State, federal and civil society organizations. German citizens are required to be apart of a statutory health insurance however; they have the autonomy to choose which SHI will provide them with the best benefits. Each SHI must cover broad benefit package but compete through coordination of care and more extensive benefits. Statutory sickness funds are financed through payroll taxes, which are 15.5% of gross wages. Of this 15.5 percent; 8.2 are to be paid by the insured and the employers pay the remaining 7.3%. The social fund covers the unemployment while tax revenues cover the children. These sickness funds act as a third-‐party payer with patients receiving care from a provider and the provider being paid by the insurance. As the diagram below shows, most Germans are insured through the SHI, it is roughly about 90%.
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The remaining 10% are either covered by private health insurance, extremely rich or too poor and cannot afford it. Private Health Insurance is insurance tailor to the needs of its purchaser. Typically these plans cover wider treatment options and patients can expect more from a medical profession. These patients are usually chosen before public patients due to larger reimbursements to supplement the physician’s income from the public sector. Whether in the public or private sector, the healthcare is financed mainly through employee and employer contributions. The United States healthcare system is and has been broken for many years. It has problems with treatment gaps, access, bad quality, fraud, stability, workers shortages and many more. In the mental health sector, there are clear treatment gaps between inpatient and outpatient services because they are funded and staffed by different teams (Salize, 2007). The main issue is the divide between the public and private sector of the United States Health Care. The mental healthcare provided by the public sector does not have the same quality or access that is provided by the private sector. Medicare and Medical have a lot of bureaucracy leading to shorter visits, long wait times, treatment caps and limited treatment options. While in the private sector, the treatment options are much larger with more of an urgency placed on the patients needs. However, the patients in the public sector are truly every U.S. citizens concerns due to the financial structure of the healthcare system. Medicaid, being the largest mental health financer, is a government-‐tax-‐run program. If the mentally ill patients do not receive the required treatment or do not have access or adequate care, it can constitute into larger health concerns; development of multiple disorders, worsen conditions or suicide, which creates larger financial burdens
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(Vargas, 2014). The equality between the public and private access and treatments, for the mental health is one of the largest concerns. In recent years, “burn-‐out” and depression have caused mental illness rates have increases dramatically. The system in Germany requires health insurance but does not guarantee access to medical treatment. Because the levels of payment to the providers differ the SHI subscribers may be placed behind a PHI subscribers leading to limited access. It has been noted that some physicians or clinics will only take PHI patients blocking SHI patients from those certain services. Another challenge facing the German healthcare system older population leaving the workforce and needed more healthcare. The challenge is the aging workers are leaving faster than their spots can be filled. Within the mental health sector there has become a decreases in the amount of new hires into the field. With a limited work force it becomes increasingly harder to access treatments and services. Mental healthcare is also not the most prestigious or lucrative areas in the healthcare industries, therefore leading many to choose a different sector. The challenges must be address as Germany’s population age and mental illness rates continue to increase. In many areas, the United States and Germany falter on the same issues. There are clear divides between the public and private sector that could be leading to better treatment options and inequality. There are different payments or reimbursements given to physicians and organizations’ depending on the type of insurance a patient has. Currently in Germany there is a shortage in the mental healthcare workforce due to the environments, cliental and salary. Both governments need to face these challenges in order to fix and sustain the mental healthcare system.
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The main recommendation this paper has to offer is to offer incentives to see and treat mentally ill patients and work in the mental healthcare system. According to Mankiw’s ten principles of Economics number four, “people respond to incentives.” If there incentives as in better reimbursement ratios, tax write-‐offs or medical school debt forgiveness the mental healthcare system could be much off. If the government in the United States was to offer physicians and clinics a higher reimbursement or public patient tiered system more than likely pubic patients would be seen more. In a public patient tiered system it works as follows; if the facility sees a certain number of public patients then they would receive a percent of the reimbursement on top of the original reimbursements. For example if a facility saw 300 public patients they would receive 2% on top of the reimbursements for the services. This would be a monetary incentive that is quite feasible to implement in the United States. It has potential to have a high return on investment, save many lives and improve the health of all citizens. In the United States, the fate of medical school debt discourages many intelligent and dedicated students from pursuing a career in the healthcare field especially in mental healthcare. It is proposed as a recommendation, a physician or nurse work for a public organization for allotted amount of years in exchange for student loan forgiveness. This has great potential to improve the public sector of mental health. The newly train clinical staff can practice cutting edge treatments and services while gain experience. There will be a large increase of staff that can better serve and provide access to the public patients. Another benefit would be to build better patient relationships at the beginning of a
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physician’s career and follow through with patient’s treatments until remission building a better continuum of care. Overall, this would be an excellent program to increase access and the workforce in the mental health sector. As for German, the recommendations are very similar to the United States just with minor adjustments. Medical school is not as expensive as it is in the United States. However, the admission process is very rigorous which has very strong emphases on the students GPA. It has also been noted that foreigners have a much easier time being admitted into Medical school than a citizen of Germany. This is the first recommendation, especially in the mental health sector, to admit Germans and possibly open more sites where mental health can be studied. By accepting Germans, there is a higher chance of the students staying and practicing for their country than a foreigner. More physicians and clinical staff needs to enter needs to the work force to assist the large amounts of elderly and mentally ill. No healthcare system will be perfect, just like no treatment can restore the body completely. The mental healthcare system must be re-‐evaluated and developed into a more efficient and affective system. The mental health epidemic will only get worse as the populations around the world grow older. There needs to be better program innovation on how to attract qualified candidates to treat the mentally ill. It is clear, each system has been making progress on address the challenges demonstrated in this paper. However, there need to be continual improvement in order to have a stainable and equitable system for all citizens.
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Work Cited Ciha, C. (2013). Can We Fix Mental Health Care?. Journal of the catholic Health Association of the United States Health Progress, 2, 7-‐11. Retrieved June 6, 2014, from https://www.alexianbrothershealth.org/upload/docs/ABBHH/Can_We_Fix_Mental _Health_Care_Clay_Ciha_Mar_Apr_2013.pdf Mental Health 2013: An Important Public Health Issue. (n.d.). NAMI-‐GC. Retrieved June 6, 2014, from http://www.namigc.org/wp-‐ content/uploads/2013/01/MentalIllnessFactSheet-‐July-‐2013.pdf Mental Health Basics. (2013, October 4). Centers for Disease Control and Prevention. Retrieved June 6, 2014, from http://www.cdc.gov/mentalhealth/basics.htm Mental Health: Types of Mental Illness. (n.d.). WebMD. Retrieved June 5, 2014, from http://www.webmd.com/mental-‐health/mental-‐health-‐types-‐illness Mental Illness. (2013, October 4). Centers for Disease Control and Prevention. Retrieved June 4, 2014, from http://www.cdc.gov/mentalhealth/basics/mental-‐illness.htm Mental health. (n.d.). WHO/Europe |. Retrieved June 6, 2014, from http://www.euro.who.int/en/health-‐topics/noncommunicable-‐diseases/mental-‐ health/mental-‐health Salize, H., Rossler, W., & Becker, T. (2007). Mental health care in Germany. European Archives of Psychiatry and Clinical Neuroscience, 257(2). Retrieved September 25, 2012, from http://dx.doi.org/10.1007/s00406-‐006-‐0696-‐9 United States Department of Labor. (2010, January 29). The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Retrieved June 4, 2014, from http://www.dol.gov/ebsa/newsroom/fsmhpaea.html
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Vargas, Rick. Phone interview. 5 June 2014 Wittchen, J. F., & Holting, C. (2004). Mental Disorders are highly prevalent in Germany. Evidence-‐Based Mental Health, 34, 597-‐611. www.mentalhealth.gov. (n.d.). Health Insurance and Mental Health Services. Retrieved June 6, 2014, from http://www.mentalhealth.gov/get-‐help/health-‐insurance/