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Today's Document
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Mike Driver
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@collaborativecare
"We are headed toward spending $1 of ever $5 of national income on health care. We should expect a better return on this investment."
http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Oct/Why-Not-the-Best-2011.aspx
Yes, our healthcare system still needs work.
When will healthcare have its "Occupy Wall Street" moment?
In order to answer this question, let me first define what the occupy wall street movement is about. According to ABC News:
"Their [Occupy Wall Street] causes include everything from global warming to gas prices to corporate greed, and the Occupy Wall Street website says organizers took their inspiration in part from the so-called Arab Spring demonstrations that have tried to bring democracy across the Arab world.
But while their message might be a tad muddled, all are united by their anger over what they say is a broken system, a system that serves the wealthy and powerful at the expense of the rest.
Protester Brendan Burke insists he and the others are fighting for more than 99 percent of the American population."
Let me highlight one section from above:
"...all are united by their anger over what they say is a broken system..."
Would anyone argue that healthcare is not broken? At the heart of this brokenness lies fragmentation that perpetuates this brokenness.
Those of you who have looked this blog before know that I like to talk a lot about integrating mental health and primary care. No doubt this is a solution to the problem of fragmentation, but I digress.
What I want to know is why the public is not more outraged at the broken healthcare system?
While healthcare costs continue to grow uncontrollably, the public continues to suffer. In the face of this suffering, there does not appear to be much relief. Thankfully, the Affordable Care Act does try to mitigate some of these issues (especially cost), but is this sufficient without adequate community "outrage" over healthcare?
As Gawande has written - "In every industrialized nation, the movement to reform health care has begun with stories about cruelty."
Not to be overly melodramatic here, but one needs look no further than "mental health" to see how the system has often failed folks who have this as their presenting problem. Not to imply that this is cruelty, but when one starts to cite statistics about mortality in the severely mentally ill, there should be some outrage.
There should be a demand from across the community that healthcare should be high quality, affordable and integrated as to avoid fragmentation. Yet where is the demand?
Maybe healthcare has not had it's "Wall Street" moment because there is no one place the national community can gather to express their outrage. Yes, we advocate in our own unique ways - write letters to our legislators, visit them and on speak up in town hall meetings, but is this sufficient? Even if we had a special street corner to meet to talk about healthcare, would we?
How can we begin to engage the community so that healthcare can have its "Occupy Wall Street" moment? Or, as the Occupy Wall Street movement has shown, where are the select individuals who will rise up and fight for "the 99%"?
Isn't it time?
Maybe soon seen we will start to see the beginning of an Occupy Healthcare movement.
Sometimes it is the simple things that have the most significant impact.
Take for example a recent article published in the European Journal of Applied Physiology - Time magazine had a nice succinct write up on the topic:
"...researchers from the University of Exeter and the University of Copenhagen tried recruiting homeless men off the streets of Copenhagen to see whether they could get the men to play soccer and improve their health.
Fifty-five men enrolled in the study and were randomized either to receive soccer training two or three times a week or to serve as a control group. After 12 weeks, the group who regularly played soccer reduced their body fat and lowered their blood pressure and cholesterol levels, compared with the control group. The soccer players also improved other markers of cardiovascular health, which the authors suggested may help reduce their risk of early death.
The study found high attendance among the homeless men, suggesting that organized soccer games could have some potential to improve health outcomes in the homeless or in other underserved populations."
Soccer, yes soccer began to make a difference in these fifty-five lives. Sometimes health can be so simple. Yes, these folks began moving around more and playing soccer thus improving their health, but is there something else at work here?
I think so, and I think it is a word we often take for granted in health.
Community.
Think of all the various ways we use the word community healthcare.
Probably the most common use is when we discuss "community health centers" but what do we mean by community in this context? According to the National Association for Community Health Centers:
"Each health center takes a unique approach to meet the needs of the people in the surrounding community. That local approach to health care, combined with an innovative emphasis on comprehensive preventative care, generates $24 billion in annual savings to the health care system – to taxpayers and private payers alike."
People want to have a sense of belonging. They want to have a sense of being apart of something bigger than them. Community does this. Community single-handedly accomplishes connection, and can be defined in multiple ways.
At the heart of much of the social media movement, there is a sense of engagement and community. Twitter, Facebook, Linked In - they all build off of the idea that people need connection and have a voice. Community.
In primary care, the largest platform of healthcare delivery in the country, continuity is one of the "secret ingredients" for success (and improved health outcomes). At the heart of continuity is a relationship. This relationship may lead the patient to feeling an enhanced sense of a community with their healthcare provider.
This is also the basis for the patient-centered medical home (PCMH) -consider one of the PCMH "joint principles":
"Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner."
Primary care aims to bridge across all elements of healthcare, including the community. In the process, does primary care become its own community for patients. Is it already?
My point with this post is that if we forget about the most simple thing in healthcare, community, we begin to miss the boat entirely for improving people's lives. How we define community is often unique to us as individuals; however, our health may be more connected to our definition of community than we are willing to admit.
Be afraid, be very afraid.
There are two graphs that I have seen that make me quite worried about healthcare and the majority of the public in need of healthcare. The "one" (really two) above is definitely one of those.
The report from the New York Times summarizes the recent release of the 2011 Employer Health Benefits Annual Survey conducted by the Kaiser Family Foundation.
From the Times:
"A new study by the Kaiser Family Foundation, a nonprofit research group that tracks employer-sponsored health insurance on a yearly basis, shows that the average annual premium for family coverage through an employer reached $15,073 in 2011, an increase of 9 percent over the previous year."
Yes, healthcare cost continue to rise and often the public must take on these additional costs as employers are running out of places to find the money to pay this benefit.
What happens if nothing changes?
Well it just so happens that the other graph that scares me is from the Robert Graham Center and is an example of what could happen:
Essentially this graph shows that by the year 2025 the annual household income in the US will be surpassed by the average health insurance premiums.
They conclude:
"Shifting health care coverage from a commodity to a social good could reduce disparities and produce better population health. Changes in health care coverage will require more equitable and sustainable models of health care delivery and aligned advocacy to support them. The instability of health care financing and delivery provides an opportunity for family physician leaders to develop new models of efficient practice, with care that is accessible to everyone."
So in the face of statistics like the ones mentioned above, how will we respond? Healthcare expenditures and premiums are growing at an uncontrollable rate. When cells do this we call it cancer - when healthcare does this, what do we call it?
Now is the time to start to demonstrate that there are indeed innovative models of healthcare that are out there that can bend the cost curve, improve quality and enhance overall healthcare.
Let your voice be heard.
The CMS Innovations Center has a section where you can send in your ideas on healthcare. How many ideas have you sent in?
Let's try and avoid coming to a place where the average family cannot afford healthcare insurance.
AHRQ Mental Health Town Hall Meeting
The important investments that AHRQ has made in addressing mental health issues was highlighted during this forum and town hall. Specific topics include the integration of behavioral and mental health into the primary care setting, the role of the PCMH in improving the quality of mental health care, and the AHRQ Academy for Integrating Mental Health and Primary Care.
“ Awaiting mental health town hall mtg. Interested in how ICSI work with many MH groups and DIAMOND aligns w/ discussion. #ahrqac
norskedoc
September 21, 2011
“ Hanging out here this morning: AHRQ Mental Health Town Hall Meeting - AHRQAcademy http://t.co/zvm7V6ML <-- Worth watching. #ahrqac
unxpctdblessing
September 21, 2011
The AHRQ mental health town hall meeting was set up to be as interactive as possible. Various leaders in healthcare, including Dr. Ofttedahl ( @norskedoc ) were there to participate both in the room and virtually. There were 9 national leaders in healthcare on the stage prepared to talk about the clinical/community, financing/policy and research aspects of integrating mental health into primary care.
“ RT @miller7: Starting in 5 minutes - the #mentalhealth town hall forum at #AHRQac http://t.co/EqvhSYRJ
PhilBaumann
September 21, 2011
“ RT @miller7: We want active questions from the Ustream and Twitter audience - #AHRQac
eHealthcareAll1
September 21, 2011
“ The event features a series of 3 open ended discussions on the topics of clinical and community questions #AHRQac
vananie
September 21, 2011
Some of the first questions were to provide overview of where mental health integration currently stands.This panel specifically examined the role of clinical integration and the community.
“ Q1 What is “state of field” for clinicians/pt interested in integration of #mentalhealth & healthcare into the “new” primary care? #AHRQac
miller7
September 21, 2011
“ Wish we wld be taking more about creating meaningful #mentalhealth conversations btw patients & their HC providers #ahrqac
Annie_LeBlanc
September 21, 2011
“ Dr. Korsen discussing the importance of integrating #mentalhealth into the patient-centered medical home #AHRQac
miller7
September 21, 2011
“ Dr. Hogan - commissioner for #mentalhealth #NewYork http://t.co/Gd9ZHCpM discussing urgency of solving problem around #mentalhealth #AHRQac
miller7
September 21, 2011
“ Believable, but high # RT @miller7: "40% of those referred to psychotherapy (from #primarycare don't make first visit" - Dr. Hogan #AHRQac
Gigi_Peterkin
September 21, 2011
“ I cannot believe the battles we still have to fight to integrate #mentalhealth - Dr. Khatri #AHRQac
miller7
September 21, 2011
“ @epatientdave "there are a ton of really smart people working hard on hard problems but the needle is not moving in right direction" #AHRQac
miller7
September 21, 2011
Recognizing the artificial separation between the mind and the body, a discussion broke out about addressing the whole person.
“ RT @miller7: @epatientDave coming up with new slogan for #mentalhealth integration - "hello neck" #AHRQac
KansasPCMH
September 21, 2011
“ @ePatientDave expresses surprise at policy disconnect in MH issues-- "need to rediscover the neck" #ahrqac
norskedoc
September 21, 2011
We also wanted to make sure the audience in the room knew that there was an audience outside the room participating - hence the live twitter feed.
“ Live twitter stream in #AHRQac #mentalhealth town hall http://t.co/4IOGCnk1
miller7
September 21, 2011
Once Dave was done with his panel, he started doing what Dave does best.
“ I'm out of "the chairs" now, in "the chorus." Fav guy in panel just ended: Mike Hogan, dir of #mentalhealth for New York State #AHRQac
ePatientDave
September 21, 2011
“ Numerous Hogan jots about why it's impt to integrate #mh with primary care. 1: 40 studies show it's effectiveness in care & costs #AHRQac
ePatientDave
September 21, 2011
“ 2: 40% of ppl who get a psych referral never go (ergo the effectiveness never materializes). #AHRQac
ePatientDave
September 21, 2011
“ Hogan 3: technical ability in psychotherapy is shown 2b important but QUALITY OF THERELATIONSHIP turns out to have BIGGER impact #AHRQac
ePatientDave
September 21, 2011
“ Hogan 4: how about "reverse integration" - put med services in #mh institutions? Living in an institution shortens life 25 years(!!) #AHRQac
ePatientDave
September 21, 2011
“ Hogan 5: cites "the deep end of the pool" - serious illness, which is NOT what all mental well-being is. #AHRQac
ePatientDave
September 21, 2011
“ Hogan 6 (last): the key place to integrate is pediatrics.(!) Almost all adult problems showed up by age 23. (profound, IMO) #AHRQac
ePatientDave
September 21, 2011
“ RT @ePatientDave: Yeh, you didn't know that?? RT @miller7: Apparently, #Medicare used to pay when a surgeon cut off the wrong leg - yikes #AHRQac
ADR_Rocks
September 21, 2011
“ RT @ReginaHolliday: @ePatientDave is taking on mis-diagnosis, a poorly implemented scientific method and explaining the biology of hope. I love Dave. #AHRQac
ePatientDave
September 21, 2011
Not to be lost in the brilliant discussion, an upcoming project from AHRQ - the Academy for Integrating Mental Health and Primary Care will coming out soon to be a "one stop shop" for resources on integration.
“ RT @miller7: The video from #AHRQac, and many more resources on #mentalhealth and #primarycare integration to be available soon http://t.co/OhJQ9Vkc
unxpctdblessing
September 21, 2011
Regina Holliday, live painting throughout the town hall, was not content - rather disappointed at the number of attendees in the room.
“ RT @miller7: @ReginaHolliday painting live at #AHRQac http://t.co/Py2OqLYe
norskedoc
September 21, 2011
“ RT @kaitbr: RT@ReginaHolliday: The size of the crowd in the mental track is unacceptably small. Twitter folks spread this stream! #AHRQac @kaitbr
CedarHillMom
September 21, 2011
“ Thanks to @ReginaHolliday for putting out the call for mental health advocates to attend meetings such as #ahrqac where is everyone?
soulflsepulcher
September 21, 2011
“ RT @ReginaHolliday: @postpartumprogr Maybe if more folks realized mental health affects all of us they would be here.. #AHRQac
postpartumprogr
September 21, 2011
Regina also made her presence felt with brilliant insight and commentary.
“ @ReginaHolliday told yet another moving story of toy store customer who in years of kid's devel NEVER heard of autism. Integrate MH! #ahrqac
ePatientDave
September 21, 2011
“ @ReginaHolliday Discussing the importance of involving lots of people with lots of viewpoints #AHRQac
miller7
September 21, 2011
The second panel took on the challenges of integration and policy/financing.
“ Next panel on #mentalhealth policy and financing http://t.co/TLh5TBLw #AHRQac
miller7
September 21, 2011
“ Discussion on the Need to make sure clinical and financial support is in place for the #mentalhealth and #primarycare workforce #AHRQac
laura3530
September 21, 2011
“ RT @miller7: We need disruptive innovation in #healthcare financing - we pay too much for the wrong things #AHRQac
s_eller
September 21, 2011
“ Dr. Kavita Patel from @brookingsinst discussing the need for better data to inform #Medicare around integration http://t.co/ALLRBoDw #AHRQac
miller7
September 21, 2011
“ Dr. Patel - describing the importance of, and how to, apply metrics in #healthcare for policy #AHRQac
miller7
September 21, 2011
“ "The carve out system makes it impossible to integrate services" - Dr. Kathol regarding #mentalhealth integration #AHRQac
miller7
September 21, 2011
“ RT @miller7: Having the separation of payment is an impediment for better integrated #healthcare delivery - Dr. Kathol #AHRQac
JoelHigh
September 21, 2011
“ RT @miller7: "From a policy standpoint, we need to put the management of payment as a parallel process to the changes in the delivery system" #AHRQac
janine_payne
September 21, 2011
Finally, the last panel addressed the importance of researching integration.
“ RT @norskedoc: Not many of us live in a randomly controlled world-- many variables occurring at once, adding to complexity! #ahrqac
apjonas
September 21, 2011
“ Need research, but based on DIAMOND experience, need to think differently--"partnership research" #ahrqac
norskedoc
September 21, 2011
“ There is a difference between rigidity and rigor in research #AHRQac
miller7
September 21, 2011
“ The patient-centered medical home (#PCMH) is one opportunity for integrating #mentalhealth #AHRQac
miller7
September 21, 2011
“ Don't know about the patient-centered medical home? Check out #AHRQ resources http://bit.ly/aK917Q #AHRQac #PCMH
miller7
September 21, 2011
“ Dr. Peikes http://bit.ly/riJpuO asking what are the different types of #mentalhealth integration - #AHRQac
miller7
September 21, 2011
“ RT @miller7: RT @ePatientDave: Can we introduce high-tech "agile" methods into research? Can we distinguish between rigidity and rigor? #ahrqac
apjonas
September 21, 2011
“ Drs. Peikes, Chapa and Korsen about to discuss #mentalhealth research http://bit.ly/p0p55x #AHRQac
miller7
September 21, 2011
“ Dr. Korsen from Maine Health http://bit.ly/o34Qju discussing the Collaborative Family Healthcare Association www.cfha.net #CFHA #AHRQac
miller7
September 21, 2011
“ RT @miller7 The field of integrating #mentalhealth and #primarycare has a research agenda: http://t.co/2eYsFfwf (PDF) #AHRQac
cherylholt
September 21, 2011
Overall, the event was a success. There was tremendous audience participation throughout! Thanks to all that joined!
“ RT @miller7: How can we activate the entire populous to be disruptive in #healthcare? via @ReginaHolliday at #AHRQac
janine_payne
September 21, 2011
“ Pt-md relatship shld include 3) discussion/agreemnt about how best meet preferences in relatn to information #ahrqac #Shareddecisionmaking
Annie_LeBlanc
September 21, 2011
“ RT @healthythinker: RT @ReginaHolliday: Yes! Someone is talking about mental health in relation to the spirit and a FAITH! Whole body medicine #AHRQac #epatcon
chronicbabe
September 21, 2011
“ The #mentalhealth system is dysfunctional, entities and doctors do not know the others' jobs; as a whole it needs WORK, CHANGE #ahrqac
soulflsepulcher
September 21, 2011
“ great discussion this morning #ahrqac
soulflsepulcher
September 21, 2011
This week is the Agency for Healthcare Research and Quality (AHRQ) annual meeting. For those not familiar with AHRQ, from their website:
"The Agency for Healthcare Research and Quality's (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research."
While the AHRQ annual meeting has had sessions that address mental health in the past, what is happening this Wednesday is quite spectacular. AHRQ is hosting a half day mental health town hall meeting. This town hall will address the future of mental health in a transformed delivery system. Undoubtedly, there will be a great deal of discussion on the research behind integrating mental health, the various ways to clinically integrate mental health and the need for patient and community engagement with any redesign effort. There will be various leaders from the healthcare community there dialoguing around mental health. No doubt, this will be a very exciting event.
To add a layer of innovation to an already innovative event, the event this year will be broadcast online through ustream (URL to be announced) and have a robust active twitter feed (#AHRQac is the general hashtag for meeting).
Want to participate?
Join us this Wednesday (September 21) from 8:00 AM to 11:30 AM at the AHRQ meeting to discuss mental health and healthcare.
There are few things that we know for certain about mental health in healthcare:
1) Half of Americans will experience some form of mental health problem within their lifetime
Consider the recent CDC report on the topic. USA Today reported:
"There are 'unacceptably high levels of mental illness in the United States,' said Ileana Arias, principal deputy director of the CDC. 'Essentially, about 25 percent of adult Americans reported having a mental illness in the previous year. In addition to the high level, we were surprised by the cost associated with that -- we estimated about $300 billion in 2002.'"
Take away: Mental health issues are real, growing, and becoming increasingly more visible within healthcare.
2) Mental health and primary care are inseparable.
With more mental health being seen in primary care than anywhere else, it seems like there is a unique opportunity to impact mental health by better identifying, treating and studying mental health in primary care.
From the seminal IOM report on mental health and primary care:
"Most likely this country will retain a parallel primary mental health system. Among the most interesting and complex issues we face are those having to do with the complementarity and integration of services between these two systems, the proportion and makeup of the population that will avail themselves of these respective systems, the factors that affect the interface between primary care and specialty mental health care, and the relative cost and effectiveness of mental health care rendered by clinicians within these different systems."
3) When mental health conditions are often identified in primary care, accessing mental health services can sometimes be tricky.
From a Health Affairs article examining the impact of mental health parity on primary care:
"About two-thirds of primary care physicians (PCPs) reported in 2004–05 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care."
Next steps?
In the face of adversity, we must seek opportunities for innovation. Nowhere is this more evident than in integrating mental health providers into primary care.
While the road to accomplishing this is fraught with challenges, isn't it time to consider an alternative to what is currently happening in healthcare? Isn't it time to consider that some of the things we have taken for granted in healthcare are in need of refinement?
I believe so. If we do not start changing, more and more reports like the one the CDC released will emerge. It is time to get a grip on this critically important issue - mental health.
Balance.
In my work, there is a fine line and need for balance around challenging the field to move forward and supporting those on the ground who may not be as ready as others to change. This can be a complicated dance.
Take for example the need to screen for mental health conditions in primary care.
A recent article in the Wall Street Journal highlighted the importance of screening for mental health in school based health clinics. No doubt, this is important, yields positive outcomes and is useful and meaningful for the community.
Other studies have shown the significance and importance of screening for mental health conditions, like depression, in primary care.
The problem around most screening is twofold:
1) Positive screens often highlight the lack of immediate mental health treatment for those who may need it at the time of the screening;
2) Paying for screening (and subsequent treatment ESPECIALLY if it is immediate, onsite and integrated) is complicated and often not paid for.
Based on the research, the United States Preventive Services Task Force (USPSTF) recommended that for adults, screening in primary care for depression should really only occur with "staff assisted supports" in place to help treat patients who are identified.
Here is the balancing act.
While wanting to advance mental health in primary care, there needs to be more research and policy work done to change policies that would better support treating mental health in primary care.
Screening is just one example.
So, does the field charge forward making the case that more screening should be done for depression in primary care? Does the field attempt to fix some of the problematic policies that prevent financially sustaining mental health in primary care that often are barriers for robust screening, treatment and healthcare integration?
The needs of the community should be placed first. We should work on doing what is right. Better healthcare integration, including mental health, is complicated and challenging, but does that mean it should not be pursued because policies don't necessarily align properly?
A fine line. A balance.
Being a policy wonk researcher who cares a great deal about primary care and mental health integration, I thought I would take a stab at trying to present some of our work on integration in Austin next year for SXSW.
SXSW is a innovative and exciting "conference" held each year in Austin. Most commonly associated with music, SXSW is so much more. Not familiar - learn more here.
So I decided to take a chance and submit a proposal. Here is the abstract from my 2012 SXSW Abstract:
"The current healthcare system is broken and incapable of meeting the needs of the American public. Fragmentation abounds, costs are soaring and our health is not getting any better. It is time to disrupt; it is time to innovate. Since more mental health is seen in primary care then anywhere else, there appears an opportunity to change the way healthcare is delivered and make it much more comprehensive and patient-centered. By placing mental health providers in primary care, the largest platform of healthcare delivery in the country, we take a step towards disruption and innovation simultaneously in healthcare policy. This presentation will take on of the most significant issues in healthcare, the separation of mental health from the larger healthcare system, describe how disrupting the status quo in healthcare can be as simple as consolidating two separate systems (mental health and physical health) into one, and challenge the community to demand more from healthcare."
Will this make it through to be a presentation at SXSW? I hope so. To help, you can always vote to support this presentation here.
Are there differences in hospital based physicians and primary care providers who follow their patients when they are hospitalized?
A recent article in the Annals of Internal Medicine calls to question the costs of "hospitalists"
The bumper sticker conclusion:
"Decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge."
So while patients may decrease their stay in the hospital, they appear to pop back in to the hospital sooner rather than later.
From Reuters:
"'Hospitalists, who typically are employed or subsidized by hospitals, may be more susceptible to behaviors that promote cost shifting,' they write in the Annals of Internal Medicine.
So far, there is still no solid explanation for the findings.
'Under pressure to shorten length of stay, hospitalists may be willing to discharge sicker patients, leading to increased readmissions,' Dr. Lena Chen and Dr. Sanjay Saint of Ann Arbor Veterans Affairs Medical Center write in an editorial.
But, they add, it's impossible to rule out that unmeasured differences are at play, despite the fact that the study did adjust for various patient and hospital characteristics.
'Kuo and Goodwin's findings remind us that we need more studies that follow our patients wherever they go and help us practice the sort of coordinated care that is most likely to lead to high-quality outcomes,' Chen and Sanjay conclude."
No doubt, healthcare costs will continue to rise. While some of the cost increases and savings from the above study will be argued about for weeks, we must continue to highlight the rising healthcare costs (and eventually do something about it!).
My time with Gregg Masters (@2healthguru) on his ACO watch radio show. Good times!
Studies continue to emerge on the difficulty of accessing mental health treatment.
To clarify, there are really two ways to look at this problem and what is needing to be accessed:
1) acute psychiatric emergencies; and,
2) "traditional" mental health treatment/interventions
For acute psychiatric emergencies, let's look at the state that arguably has the best "healthcare" coverage, Massachusetts. From an excellent WBUR interview:
"The authors of the study, published in the Annals of Emergency Medicine, posed as patients with Blue Cross Blue Shield insurance and called mental health providers in the plan, saying they had been seen in an emergency room and needed a psychiatric appointment within two weeks."
Twenty-three percent of the time the callers were told they needed to have a primary care doctor in the facility and another 23 percent of the time they left two different messages at the facility on the phone several days apart and never heard back.
Said simpler: "In 64 tries just four facilities [mental health] could take a new patient within two weeks. In 15 cases, researchers left a phone message, but never heard back."
While there are limitations to any study, this particular study highlights some of the problems of mental health and the larger fragmentation within healthcare. In the face of a mental health emergency, people often have to jump through multiple hoops just to get the care they need. Considering that when folks are going through an emergency, the last thing they need is another problem to deal with.
It would be one thing if this were only a problem for acute psychiatric emergencies and care.
In a survey of 6,600 primary care physicians, Dr. Peter Cunningham and company found that 2/3 could not access specialty mental health (read outpatient). From the abstract:
"About two-thirds of primary care physicians (PCPs) reported in 2004–05 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care."
There are two things to highlight about this report - 1) they surveyed the front line clinicians who see more mental health than anyone (primary care), and 2) they surveyed on response to the pending federal mental health parity law to see if there would be any change in the ability for providers to access outpatient mental health. You see the answer.
So, are you ready for a revolution?
There is not better place for true innovation to occur than in the mental health sector. Better integration of mental health into primary care is a great place to start, but it doesn't stop there.
Could it be that the better we are at integrating, the fewer studies and stories we hear like those above?
With cuts to Medicare looming, the US government is currently looking for solutions that can solve two problems simultaneously:
1) the increased growth in overall healthcare costs (and impact on economy);
2) the increased growth in overall spending.
Most people I hang around with see these two as interconnected - as inextricably linked. However, it is not clear that the current plan in Washington will address these issues in such a way that we witness true change.
The first response in a time of financial crisis is to usually cut, cut and then cut some more. The problem with programs like Medicare and Medicaid is that cuts disproportionately impact states and certain populations.
Consider Missouri.
"Missouri is home to nearly 1 million Medicare enrollees and 900,000 Medicaid beneficiaries. Medicare provides health insurance primarily to seniors. Medicaid provides or supports health care coverage for children, the disabled, the poor and the blind. In some cases, especially nursing home care, seniors are covered under both programs. And enrollment in both programs is projected to grow."
It is also important to note that Medicare is not "just" Medicare - there are different parts to it: A, B, C and D. Each of these parts have different costs (and cost growths) associated with them.
If healthcare costs continue to grow, and current plans in DC do not address this head on, but rather focus on certain political tactics (and red herrings), we are never going to see a decrease in overall US spending.
Difficult conversations will undoubtedly need to be had for the spending issue to resolve. One thing is clear, it does not appear that certain Medicare plans (read Ryan's proposal) are very popular.
Consider joining Dr. Mark Ryan's tweetchat (#MDchat) tonight on the subject at 7PM EST.
#SaveGME
As I wrote about a few days ago, the Graduate Medical Education program is critically important in not only the provision of healthcare services, but also for the training of the future healthcare workforce. These funds are at risk of being cut. Dr. Pat Jonas described the possible cuts as "another primary care crises."
Dr. Mark Ryan has a strong take on healthcare workforce and GME. He writes:
"Medicare funding pays for majority of physicians' post-medical school training. In other words, medical school graduates who continue their training to specialize in most fields--primary care or superficiality--will be paid for from Medicare funds. So: any cuts to Medicare will reduce our nation's ability to train new physicians, at the very time when we desperately need to train new physicians."
Dr. Kevin Bernstein, on his blog, goes into detail on how major medical societies and associations are working together to fend off some of the GME cuts.This is a great start, but is it enough?
What can be done to help? Who can help?
Dr. Mike Sevilla, offers a few suggestions:
"What can be done? Great question. The first step is to educate our Family Physician friends and colleagues of this potential tragic situation. I admit that I didn't know much about this until some good friends alerted me of the situation. The next step is to contact Congress to let your federal legislator know about our concern and our need to #SaveGME. You may have noticed on twitter the hashtag #SaveGME. This is our way to raise awareness about this legislative issue and the future of Family Medicine. I encourage you not only to spread the word, but also to contact Congress via the AAFP Speak Out website. This is the easiest way to locate and to contact your specific legislator. Another way is to use this link for the House and to use this link for the Senate."
Have your voice heard. Educate someone today on the importance of funds like GME.
After all, we are only talking about training the next generation of healthcare providers. It just might be these providers who are trained to work in the system that we want, not the system we have. It may be these providers who defragment healthcare and offer new and substantial innovation.
#SaveGME
What does the history of the American railroad system and healthcare have in common?
Listening to NPR this morning, I was struck by a story describing the history of the railroad system in the US, and how this system forever shaped the way our economy works. The author of Railroaded: The Transcontinentals and the Making of Modern America was describing how politics and business became intertwined leading to some of the problems we are witnessing today in American politics.
However, it was one point regarding the building and financing of the railroad system that I want to highlight.
The author was describing how the railroad system was being built somewhere between 30 and 40 years before it was really going to be used regularly. Because of this, there was difficulty getting buy in from across the board to fund such an initiative and taxpayer dollars had to subsidize the investment. Now there are a lot more details to speak of here, but I was blown away thinking that a system was built 30 years before it was "really" needed.
Transition point: In the Tour de France, if you are hit by a car, fall, recover and keep riding.
The current healthcare system has evolved over time to become more expensive and inefficient. There have been some excellent pieces written on the history of healthcare - while I will not go into detail on this here, a nice piece in Slate describes some of the humble beginnings of the healthcare system we know today:
"What we recognize as modern medicine, Cohn writes, began in the 1920s. That's when doctors and hospitals, having only during the previous decade learned enough about disease that they could be reliably helpful in treating sick people, began charging more than most individuals could easily pay. To close this gap, which worsened with the advent of the Great Depression, the administrator of Baylor Hospital in Dallas created a system that caught on elsewhere and eventually evolved into Blue Cross. The Blues were essentially nonprofit health insurers who served local community organizations like the Elks. In exchange for a tax break, Blue Cross organizations kept premiums reasonably low."
Bottom line: "Capitalism can't deliver decent health care."
How much did the pioneers of healthcare plan or even think 30 years ahead?
How often did the originators of health insurance think 30 years down the road to consider the impact of their decisions?
Was the healthcare "system" created with the future in mind or simply something that had to be done at the time to "fix" what was broken?
Maybe I am taking this a bit far, but similar to prevention in healthcare, people often don't want to address (read pay for) something that is not going to be immediately beneficial.
At the time, was the railroad system immediately beneficial? According to the story, no. However, without that railroad system decades later, many things would not have been possible.
What can we do to plan 30 years ahead for healthcare? Can we? Is this even possible in the current political system?
Maybe we should do ourselves a favor and consider that the current system is broken, and it may be time to plan ahead for something better.
Funding healthcare education programs are essential to keep providers in the workforce pipeline. However, how well are these education programs currently being funded?
Let's start with Graduate Medical Education (GME) and the importance of this funding.
It might be helpful to know that hospitals in each state receive GME funds to offset costs associated with training medical professionals (mainly physicians). This funding does not pay tuition, but rather offers support to institutions training said healthcare providers. (For the kid folks, pediatric residencies in children’s hospitals receive funding from the Children’s Hospital Graduate Medical Training Program, a different arm)
Additionally, "the Direct GME program uses a funding formula based on expenses, number of Medicare patients at a training hospital and number of resident trainees, all based on 1996 caps."
You can see from this simple explanation of funds that there are several problems here. First, anytime the words "formula" and "based on 1996 caps" are used, you know you are dealing with an antiquated, possibly broken system. Formulas usually have worked at some point in time to be used, but these formulas need to be able to evolve in order to remain working and relevant.
For a basic understanding of this formula and how it can to be, see here. In addition to a formula that may be less than ideal, states are cutting left and right. While Michigan is restoring funds for GME, other states are having to weigh the cost of restoring, sustaining or even cutting these funds.
At the national level, GME funds are looking to be cut due to budget woes and politics. As the New York Times reported, the administration has proposed cutting certain healthcare programs, like GME.
One specific proposal (via NYT): "Reduce Medicare payments to teaching hospitals for the costs of training doctors, caring for sicker patients and providing specialized services like trauma care and organ transplants. Medicare spends $9.5 billion a year for its share of those costs."
What happens when GME funds are cut?
I could go into detail here, but I encourage everyone to read Dr. Mark Ryan's wonderful post on the topic instead: Another reason to preserve Medicare funding: we *NEED* more doctors.
It is important to note that GME funds are important to non-physicians like my profession, psychology. Psychologists became eligible for GME funds in 1997-1998.
Without robust support for efforts like the Graduate Medical Education program, we will be left with a barren healthcare workforce. Continued funding cuts perpetuate the already existent workforce issues seen throughout healthcare. We must speak up and show our support for how important GME funds are for healthcare, and the future of our healthcare workforce.
Is your voice being heard?