Addressing behavioral health to improve all health:
By Steven Ross Johnson
Each year, the nation’s health system spends billions of dollars trying to treat, manage and prevent an array of avoidable conditions that only continue to grow in prevalence.
Nearly two-thirds of all deaths annually are attributable to chronic conditions. Patients with chronic conditions account for 81% of all hospital admissions, 91% of all prescriptions filled and 76% of all physician visits. Roughly 86% of the $2.9 trillion spent on healthcare in 2013 was related to chronic disease.
More than 190 million Americans—58% of the population—have at least one chronic condition, while more than 30 million have three or more. Projections indicate that the number of people living with multiple chronic illnesses will more than double by 2050 to 83 million if current trends continue.
Yet the effort to stem or even reverse the rising numbers of Americans who develop chronic illness has fallen short.
It’s a problem the healthcare system remains mostly unprepared to effectively address. Years of research and initiatives focused on prevention and promoting healthier behaviors have missed the mark because they fail to tackle arguably the single greatest contributor to the chronic disease epidemic—mental illness.
For years, behavioral health was largely ignored when it came to determining the factors involved in physical health. Primary-care physicians traditionally shied away from considering emotional or mental health as a root cause of chronic diseases. Yet, data show that the two are closely linked.
More than one-quarter of adults in the U.S. experience some type of behavioral health disorder in a given year, according to the Centers for Disease Control and Prevention. While 29% of adults with a medical condition also have some type of mental health disorder, close to 70% of behavioral health patients have a medical co-morbidity.
Both conditions often act as a driver for one another, heightening the risk that a person with a chronic disease will develop a mental health disorder and vice versa. The presence of both mental and chronic health conditions in a patient often increase their healthcare costs. Patients with untreated depression and a chronic illness have monthly healthcare costs that average $560 higher than those with just a chronic disease, according to the American Hospital Association.
Other studies have estimated it can cost as much as three times more to treat the physical health of a patient with underlying behavioral health issues than it does to treat the same physical health issues in a patient without a mental health disorder.
“The co-occurrence of chronic illness and depression is really striking,” said Dr. Alexander Blount, professor of clinical psychology at Antioch University New England. “If somebody is diagnosed with a chronic illness, they are twice as likely to have a behavioral health illness. But it’s true the other way around; someone with a mental health diagnosis is more likely to have a chronic illness.”
As healthcare migrates toward a value-based, coordinated-care model, a growing number of providers are trying to address the behavioral health needs of all patients as a means of improving their general health outcomes, albeit with varying degrees of success.
“For the most part, providers do a good job in managing hypertension and diabetes, but they still have patients that show up to emergency room,” said Dr. Will Lopez, senior medical director for insurer Cigna Healthcare’s behavioral health division. “I think providers are at a point where they’re going to have to start addressing the other factors that are affecting their patients’ bid to be successful in treatment, and behavioral health is at the top of that list.”
A mental health crisis
The current trend toward integrating behavioral and physical health is, in many ways, a response to a mental health system that has struggled to meet the demand for such care.
An estimated 44 million adults in the U.S. are living with a mental illness, according to the National Alliance on Mental Illness, a patient advocacy organization, yet nearly 60% of those with a mental health disorder didn’t receive treatment in the previous year. This is despite the fact that spending on mental health hit $221 billion in 2014, making it the single most expensive medical condition in the U.S.
“What we’re seeing now is the culmination of years of neglecting the mental health system,” said Dr. Brian Dixon, an independent pediatric psychiatrist based in Fort Worth, Texas. “If you don’t think very well of yourself because of anxiety or depression, it’s going to be hard for you to be compliant with your medical care—the two are intimately and completely tied together.”
Problems with access to behavioral healthcare services persist despite the considerable attention given to the issue from lawmakers in recent years. Mental health services became part of the Affordable Care Act’s 10 essential health benefits that all health plans are required to cover, while mental health parity rules restrict insurers from placing higher limits on mental health services than ones applied to medical and surgical services.
Still, evidence points to a mental healthcare system that is still offering less access even as the number of people in need of such care is on the rise. A recent study conducted by researchers at NYU Langone Medical Center found that the number of American adults who experience severe distress or feelings of worthlessness and sadness intense enough to negatively impact their physical health increased from 3% of the population in 2006 to 3.5% by 2014, totaling more than 8 million. Of that number, 9.5% in 2014 reported not having sufficient health coverage to access care from a behavioral health specialist, compared with 9% in 2006.
The study also found the number of distressed adults who reported delaying getting treatment because of costs rose to 10.5 % in 2014, compared with 9.5% in 2006. The number of those who reported they could not afford psychiatric medications also increased.
Compounding the problem is a workforce without enough psychiatrists and counselors to fully meet the demand for services.
An analysis from the Kaiser Family Foundation found the U.S. as a whole was only fulfilling around 44% of its total need for mental healthcare professionals and that an additional 3,300 would be needed to eliminate the shortage.
A huge challenge has been the disjointed nature of healthcare. The health system has traditionally reimbursed mental health services separately and at a lower rate, which some say encourages providers to coordinate behavioral and physical health.
“Our payment system has really perpetuated this fragmentation of the mind from the body,” said Mara Laderman, a senior research associate at the Institute for Healthcare Improvement. “It makes it really difficult for healthcare organizations that are paid through fee-for-service to figure out how financially they are going to afford to hire a behavioral health specialist to work in the primary-care practice.”
The road toward integration
Blount estimated that nearly 75% of patients identified as having a behavioral health disorder while in primary care would not accept a referral to see a specialist. Several factors contribute to such a high level of reluctance. At most hospitals, referral systems are still inadequate. Plus, stigma associated with mental illness can deter patients from seeking treatment once they have left the doctor’s office. Without timely access to a behavioral health specialist, it’s more likely a patient will postpone treatment, a 2015 report by the Institute of Medicine concluded.
“They’re going to get their substance abuse treatment or mental health treatment in primary care or nowhere,” Blount said.
Such was the case with Drew, a 43-year-old from Wilmington, Del., who requested his last name not be used. Drew had always led a healthy lifestyle, remaining physically active and had no issues with stress. So, it came as a surprise when in 2016 he suddenly found himself feeling extremely fatigued, sleeping erratically, and experiencing a tightness in his chest.
“All of those things really started to affect my general, overall health,” Drew said. He went to see his primary-care physician, an internal medicine specialist at Christiana Care Health System, a two-hospital, 1,100-bed not-for-profit network based in Wilmington. After a battery of tests to find physical causes turned up negative, Drew’s physician gave him a mental health screening where it was discovered that he was experiencing anxiety. Drew’s doctor then mentioned a behavioral health program offered at Christiana Care.
“When he asked if I would like to speak to one of their behavioral health physicians I immediately said ‘No.’ I just didn’t feel I needed it,” he said.
Since 2014, Christiana Care has embedded behavioral health consultants within at least 11 of its primary-care practices and one specialty-care practice. The program’s focus is on collaboration between patients and providers in real time to avoid the risk that a patient might skip an appointment with a behavioral healthcare specialist. The program has since expanded to integrate behavioral health within Christiana Care’s cancer, cardiac and pediatric programs, as well as its intensive-care unit.
Drew ultimately agreed to see David York, a clinical psychologist at Christiana Care. After a 15-minute session with Drew, York was able to trace the source of his anxiety back to a childhood trauma that he had repressed.
“At the conclusion of that conversation I truly felt like this overwhelming weight had been lifted off my body that I didn’t know had existed,” Drew said. After two weeks, which included a follow-up session with York, Drew’s physical symptoms had subsided.
Had it not been for his meeting with the psychologist during his primary-care visit, Drew is convinced he would have never called to make an appointment.
“If I had left that office and didn’t see Dr. York, I am 150,000% convinced that right now I would be taking whatever was prescribed to me to deal with the symptoms of the anxiety,” Drew said. “Having him be right there and having the trust of my primary-care physician was ultimately for me the most powerful thing.”
Crossing the cultural divide
Successfully integrating behavioral and physical health services requires some cultural shifts; it’s not just a matter of embedding a psychologist or mental health professional within a medical unit.
“When a behavioral health provider comes to a primary-care practice, they are often not practicing in the way in which they were trained,” Laderman said. “It can be difficult for a traditionally trained behavioral health provider to practice in primary care, and on the medical side, a lot of physicians and nurses haven’t necessarily been exposed to a lot of information about behavioral health.”
For integrated programs such as Christiana Care’s, it required some adjustments by embedded behavioral-care specialists to provide shorter-term interventions than the more traditional 45-minute psychotherapy sessions that can go on for months or years.
One size does not fit all
Although a number of health systems have taken steps toward integration, there isn’t a single model that works for every environment. Some approaches call for behavioral healthcare services to be on the same premises as medical care, but mostly separate in terms of practice except when a patient is referred. A second calls for coordination between behavioral and physical health providers that includes a constant exchange of information between the two despite them being in different settings. A third fully integrates mental health as part of a care team that works with a primary-care physician at every point of the patient’s care.
Advocate Health Care targets patients with a medical diagnosis who may also have a behavioral health co-morbidity. Advocate, based in the Chicago suburbs, has embedded a behavioral health specialist at two of its outpatient primary-care practices and plans to expand access through a telemedicine platform.
In 2012, the system found that 26% of its medical inpatients had a behavioral health issue, which amounted to approximately $26 million a year in excess healthcare costs and added to their length of stay by an average of 1.07 days.
Advocate has been conducting mental health screening within its primary-care physician practices as well as screening all emergency department and hospital inpatients over the age of 65. “We did not want to miss the opportunity to screen patients and begin treatment if needed while they were in our EDs and inpatient units,” said Jeannine Herbst, executive director for Advocate’s behavioral health service line.
A role for primary care?
The role of primary care in addressing behavioral health continues to be debated. Some feel the workload of the average primary-care physician is heavy enough without adding the responsibility of being a mental health provider.
There’s also the question of whether a patient can be effectively treated for a behavioral health disorder by a physician who has little time to spend on issues that may go beyond their expertise.
“If a patient is not eager to say I’ve been depressed, I’ve been anxious and I have a backache, it’s not common that the primary-care physician is going to pull that information out of him,” said Catherine Sreckovich, managing director of the healthcare practice for consulting firm Navigant.
But the demands on primary care are constantly evolving to address the public’s health needs. The record number of overdose deaths from prescription opioid painkillers and heroin abuse seen over the past decade has fueled demand for substance abuse treatment. Such care is not as effective without a behavioral healthcare component, which is only going to add to the demand for such services now and in the foreseeable future.
How the nation’s health system ultimately defines mental health’s role as part of the larger healthcare framework will determine the future of not only behavioral health in the U.S., but overall health itself.
By Steven Ross Johnson
It’s a late Thursday morning in April. Angie waits patiently inside a small examination room to finish up a routine visit with her doctor. It’s been a routine of hers since 2001, traveling roughly an hour each way from her south suburban home to the University of Illinois Hospital & Health Sciences System’s Family Medicine Center just near downtown Chicago.
Angie said it’s been the care and rapport that she has developed over the years with her family physician, Dr. Samuel Grief, as well as with rest of her care team of specialists and support staff that has kept her coming back despite the long drive.
“They always ask if you feel worthless, depressed or angry to get a better understanding,” Angie said when asked to describe what happens during a typical visit to the clinic. “So when the doctor comes in, he can go over it with you so you can work out a plan.”
Angie admitted it can be a bit tedious being asked the same questions during every visit, but it’s all part of trying to identify a potential problem early. Each time she visits the clinic a nurse will ask her first a two-question screening tool called a Patient Health Questionnaire, or PHQ-2. If Angie answers “yes” to a question, then she is given a nine-question survey called a PHQ-9.
“You might get up one day and it’s not your day,” Angie said. “So the doctor needs to know that.”
That day came for Angie in June 5, 1998, when she lost her son to asthma. Since then, she has relived that day many times. “You never get over that, and I think about him every day,” Angie said. “You can be having a good time and all of a sudden it will just hit you, and then there it is. The emotions come out and try it to do everything I can to not think about it, but sometimes you just have to let it run its course.”
It is in those moments she said she can turn to her doctor to quickly schedule a session to speak with a psychiatrist. Patients who show signs of having a behavioral health disorder are either seen by an embedded behavioral health specialist or referred to a specialist within UI Heath’s Neuropsychiatric Institute. Ultimately, if falls on the family practitioner to be the point of access for patients in need of behavioral health services. Grief estimated there was a behavioral health component to roughly half of the cases that come into the clinic.
“It behooves the practitioner or physician to identify that behavioral healthcare need,” Grief said. “Part of our practice as family is to talk about behavioral health to almost every single patient,” Grief said. “It’s kind of weaved into the conversation.”
Dr. Samuel Grief, associate professor of clinical family medicine at the University of Illinois Hospital & Health Sciences System, practices at the system’s Family Medicine Center near downtown Chicago. (Photo by Bill Healy)
Angie, of Park Forest, Ill., visits her family physician at the University of Illinois Hospital & Health Sciences System’s Family Medicine Center near downtown Chicago. (Photo by Bill Healy)
Angie credits Dr. Grief’s counsel along with that of her behavioral healthcare specialist for helping her to manage the toll the death of her son has taken on her emotionally over the years.
Other providers have seen some success in incorporating a behavioral health component toward addressing specific medical issues.
In 2013, Signature Medical Group, an independent, multi-specialty physician group based in St. Louis, began a pilot maternity-care program funded through a grant awarded by the CMS that looked to improve child health outcomes by providing behavioral health services to women with high-risk pregnancies. The program uses social workers along with primary-care physicians, dentists and psychiatrists to create a comprehensive care plan that helps to address both a patient’s chronic conditions, as well as mental health issues.
Social workers also identify non-medical factors that could pose a risk to the health of the mother or the child, such as the effects of poverty, food insecurity or housing instability, and help patients connect with community supports. As part of the scope of their work, social workers address issues involving depression, anxiety and substance abuse through trauma counseling.
The program has been credited for helping to reduce the number of the medical group’s pre-term births by 16% since the addition of social workers in 2013, as well as decreases in patient stress and stays within their neonatal intensive-care unit.
“A lot of times this was the first time these women were really interacting in the healthcare system,” said Jennie Oberkrom, clinical program coordinator at Signature. “So we’re uncovering a lot of untreated, undiagnosed mental health issues as well as unaddressed trauma.”
By Steven Ross Johnson
Minnesota’s Arrowhead Region, situated in the northeastern part of the state, encompasses 20,000 square miles of mostly rural communities. The region covers 23% of the state but contains only 6% of its population. Providing regular healthcare services across the vast area is difficult at best; offering adequate mental health services is even more challenging.
Like in many parts of the U.S., Minnesota has a shortage of mental health professionals. The state ranks No. 44 in terms of meeting mental health needs, with just 29% of the need met, well below the national average of 44%, according to the Kaiser Family Foundation.
Recently, the Arrowhead Health Alliance—a collaboration of five county public health and human services departments—assessed how to expand access to behavioral health services across such a wide area with too few providers. With good broadband coverage throughout the region, the answer became obvious.
“The only feasible way for us to extend the scarce resource of mental healthcare is through tele-mental health and engaging the primary-care side to partner in that,” said Dave Lee, director of public health and human services for Carlton County, a partner within the alliance.
The goal of the program, which kicked off in January 2016, has been to link community mental health resources to expand services to schools, jails and Native American Tribal Health and Human Services providers to cover the entire region.
“A lot of what we’ve been doing is focusing on what we call the nontraditional integration of mental health in locations where people are in need of behavioral health services but haven’t been able to receive them—whether it was because of geographic distance, or lack of a provider in that community, or just difficulty in getting (a provider) into that jail as needed,” said Ric Schaefer, director of the Arrowhead Health Alliance.
The alliance partnered with the Minnesota Department of Human Services to use a video system that the agency already had in place to provide telehealth within its hospitals and clinics. The collaboration marks the first time the state agency has linked with a community partner to expand telehealth for behavioral health services. For providers such as Stacy Englund, the use of telehealth has greatly increased her ability to provide mental health counseling to a service area where her clients typically drove nearly two hours for an appointment. Since much of her work is with schoolchildren, getting to an appointment became a logistical challenge.
“A lot of parents would not bring their children to therapy if this were not an option,” said Englund, an outpatient therapist with the Range Mental Health Center in Hibbing. “Students are getting care that they normally would not receive.”
With nearly 1 in 5 U.S. residents living in a rural area, many proponents see telehealth as an effective solution to meet the demand for services within those underserved communities.
“From a sustainability and short-term opportunity perspective, it certainly seems that telehealth offers some effective solutions,” said Katherine Steinberg, vice president in healthcare consulting firm Avalere Health’s Center for Payment and Delivery Innovation, adding that it also allows for providers to conduct therapy during nontraditional hours.
Englund said being able to hold therapy sessions through her laptop has allowed her to almost double her caseload in an average week.
Nonetheless, telehealth continues to face major barriers, not the least of which is reimbursement. Steinberg believes more businesses will adopt the technology as they learn more about its value and ability to actually drive down costs.
“I’m hopeful that because telehealth also offers a lower cost mechanism for providing mental health services that we might see greater expansion of reimbursement,” Steinberg said.
Back in 1991, the Houston Police Department began noticing a problem that continues to plague many law enforcement agencies today.
Beat officers were spending six to eight hours of their shifts working to get a detention order for emergency evaluation if they encountered someone on the street experiencing a psychotic episode.
The process included filling out a seven-page health form and having it signed by a judge and notarized before an officer could take a person to a mental health facility. The only facility available to take in such individuals had just 12 inpatient beds. If all the beds were filled, the officer had to stay with the detainee until one became available.
“Many of those officers had a very difficult time with the process in large part because they saw it as a mental health issue and not a law enforcement issue,” said Rebecca Skillern, a training officer in the Houston Police Department’s Mental Health Division.
So the department began looking into ways to streamline the process of moving people into psychiatric evaluation faster and getting police back to patrolling the streets sooner.
It began by partnering with Harris County’s mental health authority on making the process quicker and expanding the number of available beds. The department also realized that officers needed better training on handling encounters with mentally ill individuals who were causing a disturbance. In 1999, the department launched its crisis intervention team training program, a community policing strategy that focuses on teaching officers techniques designed to de-escalate potentially volatile situations. The crisis intervention team approach was pioneered by the Memphis (Tenn.) Police Department in 1988 as a response to community calls for safer police encounters with those who had severe mental illness.
By 2001, the program had trained more than 200 Houston officers; now it has more than 2,000. The program now includes 40 hours of mandatory crisis intervention training for recruits at the police academy and eight hours of advanced intervention training for all officers, as well as additional opportunities for such education.
In 2005 the state mandated all Texas law enforcement officers to undergo a minimum of 16 hours of crisis intervention training.
Building on this success, the Houston Police Department in 2007 developed a mental health unit, expanding it to a division in 2013, and broadening the scope of work beyond crisis intervention training. The division includes crisis intervention response officers and teams, a homeless outreach team and a chronic consumer stabilization initiative for individuals who are repeatedly in need of police intervention. The division also has officers tasked with enforcing standards for boarding houses, which are often a low-cost housing option for the mentally ill.
In 2010, the Council of State Governments recognized the program as one of six police departments across the country that other police agencies can visit to learn how to improve their response toward individuals with behavioral health disorders.
Skillern said these efforts improve safety for officers and community members by, among other things, reducing the likelihood that encounters involving the mentally ill will end up with police using deadly force.
“This is policing in the 21st century,” Skillern said. “The reality of mental illness is that it’s not going to go away, and especially in today’s world where we’re seeing that it’s becoming much more significant.”
Adults with severe mental illness are involved in 1 in 10 of all police responses and at least 1 in 4 fatal police encounters, according to a 2015 report by the Treatment Advocacy Center.
Fewer than 3,000 of the nation’s 18,000 state and local police departments have crisis intervention training programs, causing advocates to say much more work is needed to expand such programs. A big component among the more successful programs such as Houston’s has been the collaboration between police and community mental health stakeholders.
“Training is great, but over the long term they are not going to have as much success if they go at it alone and don’t coordinate much more closely with our mental health system,” said Laura Usher, senior manager of criminal justice and advocacy for the National Alliance on Mental Illness.
Everyone agrees mental health reform is essential, but will last year’s promises be fulfilled?
By Harris Meyer
Judge Steven Leifman recently had a female defendant in his Miami courtroom who faced a minor criminal charge. He discovered she had experienced sexual trauma as a child and suffered from a schizoaffective mental disorder.
She initially was resistant to participating in the court’s diversion program and getting mental healthcare. Leifman knew if he released her, she would be arrested and jailed again, leading to more trauma—and higher costs for taxpayers and the healthcare system. He talked her into participating in the court’s residential treatment program followed by comprehensive outpatient recovery services.
“We need supportive housing and a case manager who can work with these individuals,” said Leifman, who is nationally recognized for his work in improving Miami-Dade County’s mental health system. “Most of the systematic change has to be done in each community, with the federal government providing the financing. There’s not a silver bullet.”
Policymakers and healthcare providers widely agree that the U.S. has lots of hard work ahead to improve its system for serving the millions of Americans suffering from serious mental illness and substance abuse. They currently are crowding the nation’s streets, jails, prisons and hospital emergency departments, largely going without effective treatment and social services to enable them to live healthier, more productive lives. Research has shown that they die, on average, 25 years younger than other Americans due to untreated chronic medical conditions.
There’s bipartisan support for stepped-up federal coordination and funding. The landmark 21st Century Cures Act, enacted last December, includes a package of reforms and grants. The law also created a first-ever HHS assistant secretary position to quarterback federal programs for mental health and substance abuse treatment. President Donald Trump has nominated Dr. Elinore McCance-Katz, an addiction psychiatrist and former medical director of the Substance Abuse and Mental Health Services Administration, for that position. At deadline, her nomination was awaiting action by the Senate Heath, Education, Labor and Pensions Committee.
In another sign of bipartisan support for expanded mental health programs, congressional leaders in May reached a compromise on a fiscal 2017 appropriations bill, rejecting a number of Trump’s proposed cuts to health and social services programs. The bill, which will fund government operations through September, allocates nearly $800 million to fund a number of programs aimed at curbing the opioid epidemic. The deal also increases funding for mental health block grants by $30 million this year; the president had sought a 20% cut. Ten percent of that block grant is set aside for early intervention programs on serious mental illness. Research has shown that people with serious mental illness fare much better over their lifetime if their disease is detected and treated early.
‘We have to treat it’
Despite the protection of funding for 2017, the outlook for fiscal 2018 is uncertain. There are worries about full funding of the numerous mental health and substance abuse initiatives for which the Cures Act authorized funding, including $500 million for opioid addiction treatment and $51.9 million to promote integration of primary and behavioral healthcare. Beyond that, the Republican drive to repeal and replace the Affordable Care Act could roll back the Medicaid expansion that has enabled millions of low-income people with mental illness and addiction problems to receive treatment.
“If the proposed cuts end up impacting the current funding for mental health, we could be in a situation where there is a sincere intention to give and an equally sincere effort to take away,” said Paul Gionfriddo, CEO of Mental Health America, an advocacy group.
Rep. Tim Murphy (R-Pa.), chief sponsor of the Cures Act’s mental health provisions, vowed to keep up the pressure for full funding. “Mental health and substance abuse are a massive problem and we have to treat it,” he said in an interview. “It will be a challenge because of tight budgets, but we will continue to push hard.”
Experts say even if the Cures Act reforms and grants are fully funded, the negative impact on the mental health system of repealing the ACA would swamp those advances. “It would be one step forward and 10 steps back,” said Ron Honberg, a senior policy adviser at the National Alliance on Mental Illness.
The GOP replacement bill that narrowly passed the House in early May would effectively end the law’s Medicaid expansion to low-income adults, and threaten its mandated benefits and pre-existing condition protections for privately insured people with mental health and substance abuse problems. In addition, state Medicaid managed-care programs would have the option to stop covering treatment for mental health and substance abuse. Those provisions could neuter a separate federal law requiring insurers to cover behavioral care on parity with physical care.
On top of that, the House GOP bill would cut overall Medicaid funding by $839 billion, or about 25%, over 10 years. Medicaid pays for about 25% of all mental healthcare in the U.S.
An estimated 30% of adults who have received coverage under the ACA’s Medicaid expansion have a serious mental illness and/or substance abuse problems, and about 1.3 million people receive treatment for those disorders through that coverage.
Ohio Gov. John Kasich and other Republican governors have stressed that the Medicaid expansion has been key in enabling many people with opioid addiction to receive treatment. Medicaid pays for nearly half of all medication-assisted treatment for opioid addicts in Kentucky, Ohio and West Virginia, and 20% of addiction care nationally.
Murphy, who has faced criticism from mental health advocates for backing the ACA repeal-and-replace legislation, argues the House GOP bill would enhance behavioral care. The GOP bill, he noted, would offer states tens of billions of dollars through 2026 that could be used for mental health and substance abuse treatment. That funding, he said, would do more than Medicaid expansion to encourage states to develop effective systems of care.
Rep. Joe Kennedy (D-Mass.), a strong proponent of improved coverage for mental healthcare, rejected that claim. “The additional funding doesn’t come close to offsetting the damage of repealing the Affordable Care Act,” he said in an interview. “Our (Republican) colleagues have gotten committed to repealing the law without acknowledging the millions of people suffering from mental illness who will be sacrificed.”
Vacancies impeding progress
Besides the funding uncertainties, a major concern for mental health providers and advocates is SAMHSA’s pace in implementing the ambitious mental health agenda laid out by the Cures Act. That implementation has been slowed by the Trump administration’s delay in filling key posts at the agency.
Among other things, the legislation creates a federal inter-agency committee to make recommendations to Congress for better coordination of services for adults and children with a serious mental illness; establishes a National Mental Health and Substance Use Policy Laboratory to promote evidence-based service delivery models; and strengthens federal enforcement of insurers’ compliance with mental health parity rules.
The law also calls for clarifying policy and offering training on when providers may disclose health information related to treatment of an adult with a mental health or substance abuse disorder, a pressing issue for providers. In addition, it establishes a pilot program to award grants for medical residents, fellows, nurse practitioners, psychologists and other professionals to provide mental health and substance abuse services in underserved communities. The shortage of mental health professionals is one of the biggest problems in the field.
Additionally, Trump didn’t nominate McCance-Katz until late April. Her selection received harsh criticism from Murphy. He argued that she is too closely associated with the agency’s previous problems—even though she publicly blasted the agency when she resigned in 2015 for not adequately addressing the treatment needs of people with serious mental illness.
“She was a little too silent when all those problems were occurring,” Murphy said. “That concerns me.”
Leifman, who reportedly was HHS Secretary Tom Price’s top pick for the assistant secretary position, has a different view of McCance-Katz, who’s currently chief medical officer in Rhode Island’s office of behavioral healthcare. “I think it’s a very good pick,” he said. “She’s very smart, she’s very knowledgeable, and she has a really great background on addiction medicine.”
Still, key Cures Act reforms likely will languish until McCance-Katz is confirmed by the Senate and other administrative posts at SAMHSA are filled.
“It’s a little frustrating,” Honberg said. “We have this new law and new opportunities. Some work is beginning on implementation, but creating the interdepartmental coordinating committee and establishing the substance abuse policy laboratory will require someone at the helm in the assistant secretary position.”
SAMHSA says it’s moving forward with the interdepartment coordinating committee. The agency currently is seeking representatives from various federal agencies and setting up a process for nominating public members, said Brian Altman, the acting director of legislation.
Therapy vs. punishment
Another major policy question is whether the Trump administration will focus on a therapeutic or punitive approach toward people with substance abuse problems. So far it’s sent mixed signals.
To head a new President’s Commission on Combating Drug Addiction and the Opioid Crisis, Trump appointed New Jersey Gov. Chris Christie, who has stressed rehabilitation during his governorship. Trump ordered the commission to produce final recommendations by October on improving the federal response to the drug addiction crisis.
Many wonder whether the commission is even necessary. “It seems to be revisiting a lot of territory that’s already been covered by Congress and the previous administration,” said Richard Frank, a professor of health economics at Harvard University who served in a top HHS post in the Obama administration. “The answer is to get money out the door and get programs up and running.”
On the other hand, Attorney General Jeff Sessions has signaled a get-tough approach toward people who use or sell drugs. “We have too much of a tolerance for drug use,” he said in a recent speech. “We need to say, as Nancy Reagan said, ‘Just say no.’ ”
Experts are wary. “I’m hopeful they’ll treat this primarily as a medical issue, which it is,” Leifman said. “For some people, the criminal justice system does play a role to encourage them to get the services they need. However, if you set up systems appropriately, most individuals can and should be treated without ever coming into the criminal justice system.”
Despite these concerns, providers and advocates fervently hope the Trump administration and the new assistant secretary succeed in beginning to transform the nation’s broken system of mental health and addiction care. They hope the Cures Act provisions will be just the first of many reforms and new funding measures.
Kennedy argues Congress needs to boost Medicaid payment rates to persuade more mental health and substance abuse treatment providers to serve Medicaid patients. In addition, he said, lawmakers need to toughen enforcement of insurance parity requirements to ensure adequate coverage of mental and substance abuse disorders.
The end goal, many believe, is to streamline the labyrinth of programs at the federal, state and local levels to provide much easier access to comprehensive treatment and recovery services.
“One of the most important jobs for the new assistant secretary is that when people show up for services, they can get everything they need in one place,” Leifman said. “Otherwise we’re going to waste a lot of money, and people are going to continue to die.”
The number of new psychiatric patients arriving at Mission Health’s six emergency departments each month shot up 31% between 2014 and 2016, from 419 to 547.
Due to a severe shortage of psychiatric inpatient beds in the community, the system’s flagship, Mission Hospital in Asheville, N.C., had to hold many of these patients inside the ED, with the average number of boarded patients at any one time soaring from 15 to 60 during that two-year period. One patient who was particularly difficult to place lived continuously in the ED for 19 months, until he was recently discharged.
The increase in the number of these sometimes-disruptive psychiatric boarding patients was hurting quality of care for all ED patients and putting both patients and staff at risk of injury, Mission Health CEO Dr. Ronald Paulus recently wrote.
An increase in mentally ill patients arriving in hospital EDs is a pressing problem across the country, said Dr. Renee Hsia, a professor of emergency medicine and health policy at the University of California at San Francisco. A study she co-authored in Health Affairs last year found a 55% jump nationally in ED visits related to mental health from 2002 to 2011, from 4.4 million to 6.8 million.
Meanwhile, the number of inpatient psychiatric beds available nationally to serve these patients plummeted nearly 80% from the 1970s to 2010, from about 500,000 to 114,000. In North Carolina, nearly 90% of inpatient beds have closed over the past decade.
The surge in psychiatric patients “is unsafe for everyone in the ED, and not just physically,” Hsia said. She and her colleagues frequently must call police to restrain violent patients before they can chemically sedate them. Those with concurrent substance abuse issues are the most disruptive.
“Because of the crowded conditions and limited resources, even patients with time-sensitive physical illnesses get poorer care,” she said.
To address the problem, Mission Hospital established four special holding areas in the ED for psychiatric patients, with the entire psychiatric staff rounding daily on all those patients to provide active treatment, said Dr. Richard Zenn, Mission Hospital’s medical director for behavioral health. Two are near the hospital’s psychiatric unit, making it easier to share expert staffers.
Patients with mental health issues are moved to the behavioral holding areas—which function like psychiatric units though they aren’t licensed as such—once they’re cleared on medical issues. “It’s safer and more appropriate for them, and then they don’t interfere with the care delivered to other patients,” Zenn said.
The hospital recently hired its first full-time emergency department psychiatrist. Mission Health also created a behavioral emergency response team that can be summoned by any staffer at any time. It’s getting an average of 30 calls a month.
In addition, the system also started providing telepsychiatry coverage to evaluate ED patients at its five regional hospitals.
Beyond that, Mission Hospital partnered with other healthcare organizations and the state to open a comprehensive mental health center across the street that’s open 24/7 and provides a wide range of crisis, outpatient and pharmacy services.
It’s an urgent-care center for mental health, said Sonya Greck, Mission Health’s senior vice president in charge of behavioral health and safety net services. “People can walk in off the street with no conditions attached,” she explained. “They can sit in a living room and talk with peer specialists who have been through this themselves.”
Creating psychiatric holding areas in the ED and hiring an emergency department psychiatrist have led to faster discharge of patients with mental health issues from the ED and improved overall patient throughput, Zenn said. The closely watched “left-without-being-seen” rate for ED patients in March declined to 0.27%, from the mid-single digits. That shows wait times and satisfaction improved for all types of patients.
The opening of the outpatient mental health center across the street from Mission Hospital has started to bear fruit in reducing certain types of behavioral health patients coming to the ED, Zenn added.
Assaults on staff members have fallen, though they still average about 15 per quarter, Paulus wrote.
“All these strategies are chipping away at the problem,” said Zenn, whose system is considering adding new psychiatric beds to its current supply of 33 adult beds. “But we still have a lot of (psychiatric) patients in the ED.”
A major problem in North Carolina, and around the country, is that hospitals don’t get paid for providing behavioral healthcare to patients during psychiatric boarding stays, giving them little incentive to improve care and reduce these patients’ reliance on the ED. Zenn and his colleagues are working to encourage the North Carolina Medicaid program to develop service definitions and pay for this care.
In addition, since many of these patients are uninsured, Zenn wants to see North Carolina expand Medicaid coverage to low-income adults, which the state’s new Democratic governor and several Republican lawmakers have proposed. “That would help with accessing outpatient services and prevent patients from having to come to the ED in the first place,” he said.
Still, hospitals can help solve the psychiatric boarding problem themselves, even in a challenging reimbursement environment, Hsia said. They could do that by collaborating more closely with each other, opening more inpatient psychiatric beds, and launching dedicated psychiatric emergency services.
But first they have to recognize their common interest in better serving these patients, rather than receiving and quickly discharging them from their EDs, or passing the problem off to safety net hospitals like hers.
“When hospitals realize that not having these services can impact their bottom line because (ED) beds are taken up by nonpaying patients, they may understand it makes sense to figure out a solution,” Hsia said. “Because those patients are still coming.”
Cruising bleak downtown St. Louis streets looking for clients, community mental health outreach worker Britney Barbour stops her vehicle and hails a thin bearded man in a poncho who’s standing in the median strip in the cold rain, clutching a plastic cup he’s using for panhandling.
“Hi, Steve, how’s it going?” she asks. “Wanna meet me at the McDonald’s in 15 minutes?”
“I can’t now, I need to make some money,” he replies, scanning the deserted street.
After pulling away, Barbour explains that Steve is a former high school soccer star now in his mid-40s who has a severe substance abuse problem. She’s struck out so far in trying to get him into treatment at her community behavioral health center, Places for People. She’s not giving up.
“The door’s open but he’s not quite ready yet,” said Barbour, who has a master’s in social work and loves doing this gritty street work. “It’s hard for him to think of a life where he doesn’t have to stand in the street and ask for money.”
Barbour is one of six outreach workers who try to lure St. Louisans with mental health and substance abuse problems into Places for People, using a meal, a shower, laundry service, and a bus pass as bait. Once there, clients-many of whom are homeless-receive a wide range of coordinated behavioral and physical health services, along with housing assistance and other social services.
Starting in July, Places for People will reinvent itself as a certified community behavioral health center, or CCBHC, adding new services for children and for substance abuse-only patients. It’s one of dozens of sites in eight states funded by a $1 billion federal demonstration program to test a new, multidisciplinary model for delivering community-based mental health and addiction treatment. All programs offered must be evidence-based, meaning they’ve been proven effective in randomized trials.
Under the Excellence in Mental Health Act of 2014, CCBHCs will receive enhanced, cost-based reimbursement from Medicaid through a global payment per patient model, similar to the way federally qualified health centers get paid. They’ll have to report 22 quality measures, such as follow-up after hospitalization and reconciliation of medications.
For participating centers in Missouri, the demonstration will increase federal matching payments by about 11 percentage points, boosting funding by $25 million to $35 million a year, said Brent McGinty, CEO of the Missouri Coalition for Community Behavioral Health, who worked with Sen. Roy Blunt (R-Mo.) in developing the legislation.
The new model, to be tested over two years, will enable the centers to cover the costs of many support services they already provide, such as outreach, case management, housing, legal and employment services. “The things we do no one pays for,” said Joe Yancey, CEO of Places for People. “Hopefully, the CCBHC model will change that.”
Experts say it’s critical to expand and strengthen community-based behavioral and addiction services as a proactive alternative to the current, woefully inadequate patchwork of treating patients with advanced serious mental illness in hospital emergency departments or warehousing them in jails and prisons. Research has shown that people whose mental illness is detected and treated early can live healthy and productive lives.
“We’re trying to get further upstream to treat people earlier in their illness,” Yancey said. “It’s not OK to wait for Stage 4.”
The CCBHC demonstration is the biggest federal investment in many years in improving community-based mental healthcare. Behavioral health advocates ardently hope the program will deliver improved outcomes and cost savings and that Congress will expand it across the country.
“If we can keep people from the crisis stage by incenting community health centers and behavioral health centers to take care of people better on the front end, that would be amazing,” said Robert Fruend, CEO of the St. Louis Regional Health Commission, an umbrella group for hospitals and other healthcare providers.
Fruend and others say it would help a lot if Republican-led Missouri joined 31 other states in expanding Medicaid coverage to low-income adults, because that would make it easier for behavioral health centers to get their patients into medical, mental health, and substance abuse treatment.
“The CCBHC is an incredible step forward in serving more people, but some sort of additional coverage is a critical component,” McGinty said.
The 315-employee Places for People, which started in the 1970s to provide housing and other services for patients left stranded by the closing of state mental hospitals, uses multidisciplinary teams to address clients’ behavioral and physical health needs.
The agency’s 29 teams provide most of their behavioral and physical health services out in the community-in clients’ homes, city shelters, criminal justice settings and the street. They frequently target people identified as high utilizers of hospital ERs and those referred by law enforcement officials.
The agency collaborates with Family Care Health Center, a federally qualified health center, in delivering medical services on-site, including having an internist hold clinic hours. It also offers an on-premises pharmacy. All these services are coordinated through Missouri’s acclaimed Medicaid health home program, which was launched in 2012 with Affordable Care Act funding.
Recent state statistics show the Medicaid health home program, which served 80,000 Missourians, reduced total Medicaid spending by $35.9 million in 2016, including a $73.3 million reduction in hospital costs, McGinty said. Most of the savings were associated with behavioral healthcare patients.
Dr. Amanda Hilmer, the on-site internist, said before she started doing clinic hours at Places for People, it was hard in a 20-minute visit to understand the whole range of her behavioral patients’ issues, which could include insecure food and housing, and substance abuse. Now she’s able to talk to members of the behavioral health team before seeing the patients.
“I understand what’s going on with patients better, and there’s a lot more trust and honesty,” she said. “It saves a lot of time and I’m so much more useful to patients.”
Under a federal primary behavioral healthcare grant, Places for People has a new focus on working with clients to improve their health through diet and exercise. That includes swimming workouts at a nearby YMCA and sessions with an occupational therapist in the gym. Clients report that eating better, quitting smoking, exercising and losing weight helps a lot with their psychiatric conditions.
“I’m eating better and exercising,” said David Clement, 57, who has suffered from paranoid schizophrenia since he was a teenager and has had long bouts of hospitalization and homelessness. He dropped from 229 pounds to 180 in three months.
Diane McGuire, who directs the agency’s Medicaid health home program, said Clement initially wasn’t cooperative in finding a solution to his homelessness but now is doing very well. Most agencies, she added, stop working with uncooperative clients who miss appointments or engage in substance use. “We don’t have those rules, because recovery works differently for each person,” she said.
Facing a shortage of psychiatrists, psychologists and other highly trained mental health professionals, Places for People deploys so-called peer specialists on its treatment teams. These are people who personally have experienced mental health and/or substance abuse problems in the past, done well in treatment and recovery, and received training and certification in providing services. They use their own experiences to gain clients’ trust and engage them in treatment.
“My story is my greatest tool,” said Steven Spratt, a community support specialist whose mother died of drug addiction and who previously struggled with mental illness, addiction to crack and homelessness. He got clean in 2011 and went back to school. “I tell people they don’t have to feel ashamed. I offer a beacon of hope to them.”
But many clients aren’t ready to fully engage in treatment because, in Spratt’s view, the pain in their life hasn’t gotten bad enough yet. He has one client who winds up in the hospital emergency department every other week or so. Even though the client has refused so far to do what’s necessary to stay healthy, Spratt keeps working with him.
“I can’t lose patience, because his life is at stake,” Spratt said. “People didn’t give up on me.”
Original source: http://www.modernhealthcare.com/reports/behavioral-health/#!/