THE USE OF MEDICAL SERVICES FORThe treatment of mental health disorders in Manitoba accounts for one-tenth of all days spent in hospital and one-tenth of all fees paid to physicians. All told, this province spends more than $200 million each year in publicly-funded mental health care. Recent reforms by Manitoba Health are shifting a large portion of mental health care out of hospitals and into community-based settings. As these changes take place, it is important to better understand this major area of health care spending and the people who need these services. Who are the users of mental health care services? Where is the most need? Are those needs being met? How is care delivered? How do we measure the effect of these reforms? This report, by the Manitoba Centre for Health Policy (MCHP), addresses those important questions.
MENTAL HEALTH DISORDERS: Manitoba 1991-1992
Of the one in ten Manitobans who have received mental health care (fig. 1), most were treated for relatively short-term, mild problems. In 1992, less than 15% of the mental health disorders were of the severe kind (such as major depression, schizophrenia, psychosis and personality disorders) (fig. 2). Yet more than two-thirds of the acute (non-chronic) mental health care resources were used in the treatment of severe disorders - $65 million of the $96 million spent. Of that, $58.5 million was spent on hospital care alone.
The distribution of patients in treatment for severe mental disorder is notably uneven. These patients are concentrated in Central, Westman and Interlake regions where the three provincial mental health institutions are located, as well as in Winnipeg, with its acute care hospital resources. What does this suggest? It is likely that many of these people moved into these regions to be closer to where specialized care was available.
Adults with serious mental health disorders are concentrated in neighbourhoods with low average household income. People who develop severe mental illness have difficulty maintaining social relationships and keeping a job, which often forces them to move to lower income areas. Administering to the needs of this very needy group represents a challenge to social service agencies and health service agencies alike.
Access to Mental Health Care
When we speak of mental health care we are not speaking exclusively about treatment delivered by psychiatrists, as many might think. General practitioners and other physicians also routinely deliver mental health care in Manitoba. The type of care one receives very much depends on the type of physician contacted.
Psychiatrists saw their patients more often and over a longer period of time than did the non-specialists. This might be expected since psychiatrists are usually referred the more difficult and complex cases. Less understandable is the disproportionately high number of psychiatrists concentrated in Winnipeg despite a relatively equal distribution of mental health disorder in the province. Consequently, Winnipeg residents with severe disorders had many more visits with psychiatrists than their non-Winnipeg counterparts - four times as many.
Therefore, it is not surprising that provincial spending per year on mental health disorders is substantially higher for Winnipeggers than for non-Winnipeggers - $943 per person in treatment compared to $620. Approximately one-third of this difference is due to the higher frequency of psychiatric care in Winnipeg. The remainder is due to the higher inpatient costs in Winnipeg hospitals. Whether any therapeutic benefit is attributable to this higher cost is unknown.
Discrepancies were also found in the distribution patterns of mental health care across income groups in urban Manitoba. Unlike non-specialist physicians who provided an equal measure of mental health care across all income groups, psychiatric practice preferentially provided care to individuals from middle and upper income neighbourhoods-the wealthy received up to three times more ambulatory (outside of hospital) psychiatric care than did the poor (fig. 3 & (fig. 4). These data raise concerns about the commitment of psychiatry to equal access of citizens in our tax-payer funded health care system.Mental Health Reforms
As part of larger mental health reforms, a recently implemented 25% reduction in the number of short-term psychiatric beds in Winnipeg will mean significantly less hospital-based mental health care available. We estimate that fully 80% of the reduction will be in the care of adults with severe disorders. To counter the negative effects of these reductions, the Mental Health Division of Manitoba Health has responded with initiatives to expand community-based social and housing services in Winnipeg. These reforms represent important initiatives which have the potential to improve the mental health status of Manitobans.
At the non-specialist level, access to mental health care in this province is equivalent from region to region, across all income groups. However, for those needing more specialized psychiatric care, the mental health care system has shown ironic imbalance. It's not that there are not enough psychiatrists available (Manitoba has a reasonable supply relative to other provinces), it's that far too many of them are in Winnipeg in proportion to the overall demand across the province. What's more, psychiatric care is disproportionately received by middle and higher income groups, yet the greatest proportion of severe disorders are found in the lower income groups. In part, these imbalances have resulted in a higher cost for mental health care delivered to Winnipeg residents. But perhaps more importantly, they fly in the face of a population-based, tax-payer funded system that prides itself on equal access for all citizens.
The needs of those with severe mental disorder are profound. Though a relatively small group, they consumed $65 million of the $95 million spent on mental health care in 1992. Their impact on the mental health care system is immense. So too, will be the impact of mental health reforms on them. The importance of monitoring both cannot be understated.
The move away from institutionalized mental health care, however, has made monitoring the effectiveness of mental health reforms increasingly difficult. These difficulties could be greatly reduced - first, with the cooperation of non-billing psychiatrists (such as those on salary) in submitting patient evaluation slips and second, by the introduction of a system of recording patient encounters with community-based mental health services. Reporting of information on the use of mental health services was never more important. We recommend both these improvements.
Mental health reforms represent fundamental changes in a system that has changed little in its organization over the last twenty years. They are redefining the role of mental health institutions, of psychiatrists and of the patients themselves, allowing them to remain in their communities. There are new challenges, new questions. What effect will these reforms have on the training of physicians and psychiatric nurses? Are the new community-based services being coordinated in the most effective manner? What effect will the reduction of inpatient care have on persons with severe mental disorder - especially given the already high readmission rates? Will we see an increase in the use of hospitals for emergency treatment of mental health? These are key questions to be answered in planning and evaluating mental health care services in Manitoba.
Summary written by Amy Zierler and RJ Currie, based on the report: The Utilization of Medical Services for Mental Health Disorders Manitoba: 1991-1992: by Cam Mustard.
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