The NIMH defines Coordinated Specialty Care (CSC) as recovery-oriented treatment for people with first episode psychosis. In fact, the definition has expanded to cover a broader range of treatments, i.e. all recovery- and person-oriented programs for individuals with psychosis.  These evidence based practices include

• First Episode Clinics (FEP)
• NAVIGATE programs [1]
• PACT (Program of Assertive Community Treatment)/ACT (Assertive Community Treatment) [2] 

Common components of CSC/PACT programs include

• Person-centered approach to a personal treatment plan
• Job, work or school supports
• Family support and education
• Peer supports
• Case management
• Traditional clinical supports like therapy and medication

The onset of psychosis is typically in teenagers and young adults aged 16-22. When young people experience a psychotic episode (schizophrenia, bipolar & schizoaffective disorder), they are often hospitalized during an acute crisis and given large doses of medication to be stabilized. Without programs like First Episode and ACT, once discharged these individuals are on their own to figure out how to navigate their illness and find a path to recovery.  Although they are told to go to an outpatient clinic 10 days later, few are able to do that. At this point, they cycle in and out of the hospital from crisis to crisis.  First Episode and ACT provide much needed wrap-around services that include school and job supports and help individuals figure out what will work for them to achieve and maintain their recovery.

Although PACT programs have been around since the 1970’s, it wasn’t until the NIMH (National Institute of Mental Health) concluded the RAISE (Recovery After Initial Schizophrenia Episode) project that the incredible real possibility of improving recovery rates was understood. Since that time (2008), there have been multiple studies confirming the value of CSC for individuals with psychosis.
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Coordinated Specialty Care has not been covered by commercial insurance, but now with the Affordable Care Act requiring insurers to cover dependents to age 26, they are more and more confronted with providing payment for services to this population.  Rather than continue the expensive practice of only providing supports and services during acute episodes, insurers can save money and improve lives by covering these services that lead to recovery and avoiding hospitalization.

Beyond having a much better outcome for the individual, providing CSC helps reduce the overall cost burden on insurers. Individuals with psychosis are high utilizers of health care benefits.  Average excess medical costs for individuals with severe mental illness (SMI) annually are ~$67,000. [3] In some cases 0.5% of the insured population is using 50% of the resources.  In addition to the cost of hospitalization, individuals who have been hospitalized typically incur $22,704 more than those with SMI who are not hospitalized. [4]  Employers may not realize that their employees who are caregiving for someone with SMI have a higher rate of productivity loss (7.7%) than all other types of caregiving (3.7%). [5] In addition, research shows that “ACT is more cost-effective than brokered approaches” [6] meaning separate programs cobbled together to provide these services.  Research shows that “ACT services are justified from an economic point of view to the extent that they generate more benefits per dollar than alternative programs.” [7]  Here in Massachusetts, the PACT program at McLean, established in 2017, reports an average decrease in hospitalization from an average of 2 hospitalizations per year before PACT, to 0.7% per year in PACT. In addition, those hospitals stays are shorter, as the PACT team works with the hospital on the treatment plan and the individual can be quickly discharged back to PACT. [8] 

Recently passed legislation in Illinois [9] that requires commercial insurance to cover both FEP and PACT included a provision to sunset this coverage in five years if studies show that premiums increase by more than 1% based on an independent review.  Insurance carriers are therefore protected from any variance of expected costs in a time-limited fashion.

1. Required insurance companies to cover CSC & PACT in their benefits packages
2. Pursue a parity complaint
3. Talk with large self-funded plans about voluntarily including CSC & PACT in their benefits packages 
4. Get a billing code to assist in getting payment (in collaboration with experts at PEPPNet)
5. Work with payers and Medicaid to define a bundled rate (in collaboration with MAPNet)

[1]  The NAVIGATE Program for First Episode Psychosis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4490051/

[2] https://en.wikipedia.org/wiki/Assertive_community_treatment

[3] Cloutier, M. & Aigbogun, M. & Guerin, A. et al  (2016). The Economic Burden of Schizophrenia in the United States in 2013. The Journal of Clinical Psychiatry. 77. 10.4088/JCP.15m10278. 

[4] Zhu, B.  & Ascher-Svanum, H. & Faries, D. et al (2008). Costs of treating patients with schizophrenia who have illness-related crisis events. BMC Psychiatry. https://doi.org/10.1186/1471-244X-8-72

[5] Lerner, D., Benson, C., Chang, H., et al (2017) Measuring the Work Impact of Caregiving for Individuals With Schizophrenia and/or Schizoaffective Disorder With the Caregiver Work Limitations Questionnaire (WLQ). Journal of Occupational and Environmental Medicine: October 2017 – Volume 59 – Issue 10 – p 1016

[6]  Latimer, E. (2005) Economic considerations associated with assertive community treatment and supported employment for people with severe mental illness, J Psychiatry Neurosci. 2005 Sep; 30(5): 355–359.

[7] Bond, G.R., Drake, R.E., Mueser, K.T. et al. Assertive Community Treatment for People with Severe Mental Illness. Dis-Manage-Health-Outcomes 9, 141–159 (2001). https://doi.org/10.2165/00115677-200109030-00003 

[8] Contacts at McLean Hospital: Program Director https://www.mcleanhospital.org/treatment/pact

[9]  http://www.ilga.gov/legislation/101/HB/PDF/10100HB2572lv.pdf