With the Santa Fe Summit 1997, the American College of Mental Health Administration brought together consumers and other mental health stakeholders with a focus on ensuring accountability in a churning healthcare marketplace. The first summit sparked a remarkably broad effort that has created a set of core indicators for the field, an accountability framework that is at once both focused and doable.
Santa Fe Summit 1998 was organized around the theme of integration of mental health and other services. Presentations and discussions focused on the concept of integration, its history, current experiences and the essential elements necessary to preserve quality, accountability and value as we make decisions about mental healthcare in the context of integration.
Conference content consisted of three main elements. The first was an information session, where presenters focused on the issues of integration as they pertain to mental health mental health and primary care, and issues of integration in the field of children’s mental health. The second part of the conference consisted of presentations of two actual case studies from the field–developing stories of attempts to integrate mental health service and substance abuse services in the public and private sectors. The third aspect was a simulation designed to have participants experience the challenges of incorporating the values and measures developed from Summit 1997 within the context of the current emphasis on integration and the “real world” pressures that exist in the healthcare market today.
From this combination of information and experience, several major themes surfaced:
The rest of this document contains copies of the papers presented, copies of the overheads from the case studies of integration attempts in the public and private sector, the simulation material and a synthesis of the “discussions about learnings” from the six workgroups in the simulation. Within each segment, more detail is presented about the ideas and strategies that emerged.
Presentations on Integration
The first sessions focused on presentations dealing with various aspects of integration. The papers presented and included in this document deal with “Issues of Integration” and “Integrating Primary Care and Mental Health Care”. The key themes and strategies that emerged from these presentations are inherently compatible with the values identified in Summit 1997.
Key Values/Summit 97
Key Values/Summit 97
Key Values/Summit 97
There are no easy answers to questions about when to integrate, with whom to integrate and how to integrate services with mental healthcare Decisions should be guided by desired outcomes and by issues of quality and value for our healthcare dollars.
Two case studies of developing integration models were presented, one from the private sector and one from the public sector. In the former, Delta Airlines is undertaking a major effort to integrate mental health and substance abuse services with physical healthcare for it employees through training and education for supervisors and employees, standardizing delivery of healthcare, destigmatizing mental health issues and empowering consumers. They are doing so because they believe this will result in a healthier workforce, higher quality care, prevention of costly emotional and physical problems and increased safety for the consumer.
The County of San Diego, in California, has been working on a massive redesign of services in both the adult/older adult area and services to children and their families. This was presented as a work in progress, illustrating the complexity of implementing change, and the challenges of developing consumer involved integrated services.
In both situations, those involved are making an investment in the future that they believe will result in a better quality, more cost effective healthcare service delivery system. These are truly developing stories: perhaps worth revisiting after they have been operating long enough to have done some evaluation of their effectiveness.
The simulation exercise was designed to stimulate discussion of issues of values, price and integration in the context of the real world marketplace of mental healthcare. A copy of the material given to workgroup participants is included in this summary. The key learnings from this experience are highlighted below:
The participants in the Santa Fe Summit 1998 on Integration recognized that the concepts of integration and how to preserve quality and incorporate accountability in the “integration movement” are elusive. In the fast changing and highly competitive healthcare marketplace, decisions are made with relatively little information. Clear thinking about functionality, outcomes and the primary interests and concerns of consumers often takes a backseat to decisions about structure, price and the “survival instincts” of purchasers and providers.
The College has developed a set of structure, process and outcome measures that are focused and driven by as set of axiomatic core values for mental health services for adults, children and families. Our challenge is to provide the leadership for incorporating these values into our policy, purchasing, structural, programmatic and fiscal decisions about integrated healthcare service delivery.
Issues of Integration
The Myth of Integration
Both public and private healthcare systems treat integration as a much too simple concept, acting as if it’s self-explanatory and homogeneous–as if one size fits all . Integration is not a single objective: rather, it involves multiple objectives and is multi -dimensional , depending on the population which is served. It is not a single product, but may actually be a product line and definitely requires several product platforms. or delivery systems, for accomplishing the clinical objectives implied by integration.
Current models for integrating health and behavioral health benefits frequently address one or more of the following dimension of integration:
Rarely do they actually engineer a specific clinical strategy to effect integration at the patient and practitioner level.
There also appears to be confusion among three activities: subsuming mental health under health; combining mental health and health: and integrating mental health and health. In public insurance, there’s currently only one model for integration of health and mental health services in which Medicaid purchases management of a single benefit package (in which mental health is included along with medical/surgical benefits). through a single premium, from a single primary contractor or health plan, thereby assuming that singularity equals integration. In almost no case does that commercial health plan deliver the mental health benefit through an integrated approach–most health plans purchase mental health benefits management from a carve out company. Is this integration? Integrated benefits, integrated health plans, integrated financing–none of these automatically guarantees integrated care through collaborative treatment.
While the current attention to integration is laudable, the provision of integrated healthcare may be a second order goal, after the field has developed the clinical and financial technology and approaches for delivering health and mental health services collaboratively. Currently, in both the commercial and public sector. there is no experience base which points to successful models for integrating health and mental healthcare.
Most purchasers treat “buying integrated benefits management from HMOs” the same as buying benefits management which clinically integrates health and mental health services. The two are not one and the same and. it’s possible that achieving integrated clinical care does not require that coverage be provided by integrated health plans. It’s also possible that, although many purchasers have adopted the goal of “integration”. the technology of achieving this goal has yet to be developed.
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Specific Integration/Coordination Objectives
As stated above, there are many ways to operationalize the goal of “integration of health and mental health”. Demonstrating the multidimensional nature of integration, its objectives could include any of the following:
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Development of Integrated Models
If one were developing an integrated model, the sequence of considerations would be as follows:
This is very complicated product development and successful approaches will require adherence to that biological and architectural principle: ” form follows function”. In this case, form (organizational configuration) and financing must follow the clinical objectives, not the other way around.
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Obstacles to Integration
The stigma attached to mental illness, the lack of parity between health and mental health benefits and the current realities of medical practice all present obstacles to integration. Consider just the realities of practice:
Payers’ Opportunities to Facilitate Integration/Collaboration
Payers have opportunities to facilitate collaborative care through their purchasing practices, if they attend specifically to the issue and set expectations for their care management organizations:
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Integrating Primary Care and Behavioral Care
New Models for Integration
If integration is not well-suited to a one-size fits all approach, purchasers must be clearer about the specific clinical objectives they wish to accomplish through integrated benefits management. For example. using the above-described approach for choosing an integrated model (among an integrated product line), the payer could specify the populations for whom it wanted collaborative treatment and the components of the clinical process which were to be delivered in a collaborative manner; it could also identify performance standards and indicators which would demonstrate that this integration occurred. The purchaser could preserve the integrity of a comprehensive mental health benefit package by contracting separately with health plans and with mental health plans, but could withhold a portion of each plans capitation payments as an incentive pool which would be released only if the integration performance indicators were met. This would create a codependence between the health and mental health plans around integrated care since they would need to collaborate in order to receive the incentive payments.
Whatever purchasing strategy they choose, payers can move the field forward on the issue of integration if they adopt two principles: form follows function; measurement, not anecdote.
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H. G. Whittington, M.D.
Last year at the Summit, we found it relatively easy to arrive at a consensus about values. It became clear in the process that many of the desirable outcomes fell beyond the scope of traditional behavioral health services, such as housing, economic security, employment, safety, and general health services. This meeting is the first step at asking how we might, as a concerned subculture of behavioral health policy formulators, pursue the laudable values and beliefs which we all support.
We agreed on the DESIRABILITY of certain outcomes.
Today we begin to discuss the FEASIBILITY of implementing our values in the real world: the task of being PRAGMATIC IDEALISTS: ACHIEVING THE ATTAINABLE WHILE PURSUING THE IDEAL.
FEASIBILITY has several components:
Last year I cited the PARABLE of the Sand Canyon Ruin to demonstrate how beliefs and values, not matter how vigorously pursued, cannot cope with changing circumstances in the absence of effective technology. Last summer in revisiting the ruin, I discovered, nearby, a modem relic: a three-story residence, replete with religious symbolism incorporated in its architecture, standing uncompleted and abandoned. In this instance, the beliefs/values were wedded with advanced technology-and the project still came to naught because the necessary capital was lacking.
We all live hemmed in by this trinity of FAITH/VALUES, TECHNOLOGY, AND CAPITAL/RESOURCES. To ignore the constraints imposed on our attempts to be PRAGMATIC IDEALISTS is to ensure unanticipated and undesirable consequences in our efforts at human betterment (Dorner, 1996). To summarize one component of error in complex organizations, at the onset of a change process there is a balanced mixture of ASSESSMENT, REFLECTION, and ACTION. Over time, as initial apparent successes come unraveled, ACTION steadily increases in frequency, while assessment and reflection decline precipitously. Most of us in this room are action oriented, and will put the Santa Fe Summit recommendations into play. For example, my Managed Behavioral Healthcare Organization, Comprehensive Behavioral Care, has adopted the Summit as the basis for our corporate Quality Management Plan, which will provide an opportunity to assess and reflect if we don’t get too absorbed in acting to observe and think! The Santa Fe Summit, this year and for some years to come, will provide a wonderful opportunity to ASSESS and REFLECT, correcting and refining our initial efforts.
In my presentation today, I will focus on one aspect of the implementation of the value expressed in the Summit Report, the integration of behavioral health and general medical care.
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The integration of behavioral and primary care is not a new idea.
Enough history. My question is this: when an idea that has so much face validity is adopted and implemented by so many bright and idealistic people and yet has apparently not liven up to the self-evident good that seems apparent, why are we once again jumping on the integration bandwagon? Sol Feldman, in his presentation tomorrow, will undoubtedly give us all ample reason to consider carefully the answers.
My job is a bit less prescient that Sol’s, however: to explore why we might want to integrate medical and behavioral health care, how we might go about it, and what the impact on the recipients of our services might be. I will use the over two-decades old trinity of National Health Care reform to organize the remainder of this presentation:
Would integration of behavioral healthcare and medical care increase accessibility, quality, or affordability of behavioral health services?
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The existing system of care appears to perpetuate under-utilization of behavioral health services. Physicians still do not recognize, in about half of their patients, the existence of psychiatric morbidity (Higgins, 1994); chemical dependency is underrecognized as well, and even when identified is not likely to result in an appropriate referral.
As well, there are different cognitive norms between the medical and behavioral health subcultures: physicians do not perceive relationship problems as worthy of professional intervention, while many if not most behavioral health professionals view them as appropriate for treatment services, broadly defined. For example (Kimball and Snowden, 1997), HMO patients with a self-referral option appear to enter mental health treatment because of relationship problems at a higher rate than their physician-referred counterparts. This disparity in world-views (and it appears that patients’ perceptions are closer to the behavioral health subculture’s than the medical) has important, although unanswered, implications:
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Now, could the skill of primary care physicians in the recognition and management of behavioral disorders be enhanced through “integration” of behavioral and medical health services? The efforts to increase physician competency in this area generally have fallen short of true integration, but rather have adopted strategies that incorporate one or more of the following approaches:
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As with accessibility, there are many assertions that integration would improve quality, but few of them are supported by empirical data.
At this point in the presentation, I have just made a transition from one method of value assessmentempirically verified improvements in one or more outcomes-to appraisal of compliance with consensual standards of good and accepted practice. That transition is perilous for the entire process that we are engaged in. The hazard of consensus, of course, is that it is only the codification of the conventional wisdom of the moment, which only occasionally withstands the tests of time, advancing technology, and rigorous assessment of outcomes. For example, a little over ten years ago the Prudential Insurance Company, under Mary Jane England’s leadership spite of my timorous counsel of caution and gradualism–, essentially accepted that then available outcome data did not support the general or predictable superiority of 28-day residential treatment over intensive outpatient for chemical dependency. She was encouraged by a rather eccentric California psychiatrist who shall remain nameless-not out of discretion, but because I don’t remember his name–, who was a strong advocate of intensive outpatient treatment, already in full steam on the west coast. This action in full opposition of the consensus of the experts on chemical dependency treatment-followed by an equally radical re-appraisal of the value of residential treatment for emotionally and behaviorally disturbed adolescents-resulted in the ability to afford a major expansion of outpatient services without crippling co-payments, a significant advance in accessibility.
This is simply another plea that we continue ASSESSMENT and REFLECTION as we go forward with this process. The joy of the scientific endeavor is that proving oneself wrong in initial hypotheses is a victory as much as proving correctness-and the humbling experience contributes to enormous personal growth!
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Since the dollars available for behavioral health services are finite, we must assume a zero sum scenario and ask if any innovation, within a fixed number of dollars, will increase accessibility and/or quality. For this presentation, I believe that we should look at all health-care dollars as the “pot” of money, since the allocation between physical and behavioral health is fungible and ever-shifting. As I suspect Sol will be discussing tomorrow, this area presents the greatest potential hazard to our constituency, as general health care systems may seek reduction of behavioral healthcare costs to “balance the budget on the backs of the mentally ill,” as Mary Jane once so passionately accused an HMO.
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Models for Integration
Perhaps it is time now to ask, what is “integration” anyway? Particularly with such an emotionally charged word, we probably should pay a little attention to what we are undertaking, rather that accepting the unalloyed social good of the abstract concept of integration. Probably the most appropriate definition is, “having all its parts combined into a harmonious whole; coordinating diverse elements.” Using this broader definition, which helps protect us from overly concrete ecumenical enthusiasm, harkens back, of course, to earlier concepts of case management or care coordination. That effort is to various degrees in some disrepair across the country, as the earlier expectations have been dimmed by cost-benefit concerns; as well, case management in the proprietary sector is a code word, often, for utilization management. Yet, at least for high-complexity, high-risk cases, it continues to have an honored place in our armanentarium of care integration.
David Mechanic, who has contributed so richly over the years to the intellectual capital of the behavioral health enterprise, has published a recent article entitled “Approaches for Coordinating Primary and Specialty Care for Persons With Mental Illness” (Mechanic, 1997). He proposes, and reports the limited outcome data, on the following models:
I commend the article to you in its entirety, and will not attempt to parrot it here. Rather, I would like to cite a few words as a segue-way into my long-awaited conclusion:
“The more we learn, the more we appreciate the importance of sensitive management of communication and psychosocial issues across all areas of disease. Patient communication and behavioral health practice is intrinsic to good medicine, more broadly defined, and there is need to integrate such concerns centrally into all aspects of medical education. Managed care and the evaluation of primary care responsibilities may provide the incentives for reappraisal of educational needs.”
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Attempts to assure that all health care is combined into a harmonious whole, and/or all of its diverse parts coordinated, have been numerous, motivated by concerns for patient welfare, and implemented by well-intentioned professionals for three decades without the emergence of a consensually accepted model or strong demonstration of either clinical or social utility. A CULTURAL MATERIALIST might say that is because we lack the TECHNOLOGY to implement our aspirations.
We have focused on structural and process reform WITHIN THE SYSTEM, AS WE DEFINE THE SYSTEM. Conspicuously absent has been attention to factors not entirely inside our community of perceptions and interests:
Although integration is clearly seen as the solution of the moment, the term is used to mean a myriad of different things, we are often not clear on what definition is being used in any particular discussion, more is assumed about the concept than is really known and we do not as yet have any specific models that have emerged to guide us in our thinking and planning.
It is easier to talk about integration than it is to do it. Simply creating integrated administration, financing and/or benefits does not necessarily result in integrated care. Whether we are talking about integrating separate organizational structures, different funding streams, physical and mental health services, or a wide range of health and human services as is often true in the field of children’s mental health, actually implementing a successful integrated system requires consumer involvement at all levels, a clear focus on outcomes, sustained leadership, broad-based commitment, and can be costly, at least during the initial stages.
The integration we are striving for is functional integration; integration in practice so that the service delivery system appears seamless to the consumer. Creating a common language for practice guidelines and outcome measurement can help move us in this direction. Financial incentives to work together have proven successful in the past, New knowledge that links mental health and physical health may create even stronger technological and professional incentives for integrating care.
The current competitive healthcare marketplace frequently does not allow the careful reflection and the focus on integration and the values and outcomes that were identified in Summit 1997. As conference participants tried to apply these principles during the simulation, they found themselves focusing more on producing a product for the purchaser that would be acceptable, with greater emphasis on price than on consumer involvement and issues of integration, access and accountability.
Consumers and families are at the core of performance measurement
Consumers/customer choice must be a driving value for all systems of care, including their design, delivery, evaluation and accreditation.
Sustained models start with the consumer, empower consumers and/or are consumer driven
The term “integration” is used in many different ways. Presenters discussed the various definitions and the need to define integration from the client/service perspective.
No matter how integration is defined or implemented, it is valuable only if it adds value to the healthcare equation and produces a seamless service system for the consumer.
Access to mental health and substance abuse services must be quick, easy and convenient, and outreach and follow-up must be seen as part of the access continuum
Issues of ethnicity, race, age and developmental status, gender and language. culture, spirituality and/or disability are consciously addressed in assuring access and availability of services.
Successful integrated systems incorporate the “three A’s” of good service delivery-Affability, Accessibility, Ability
Mental health and substance abuse delivery systems must be accountable to both internal and external stakeholders for meeting the mental health needs of the people they serve in ways that are effective and efficient, and that accountability must be based on reliable, comparable data.
A true public health vision of community health must drive outcome measurement, which means that universal access and integrated primary and mental health and substance abuse care are the ultimate goal of effective systems.
Desired outcomes should drive the change process.
In thinking about integration, form should follow function; integration should occur functionally and in practice, structure becomes less important
There has been a long history of attempts to integrate all health care, and health and human services, without the emergence of a consensually accepted model or documented successful outcomes.
Integrated administration, integrated financing and integrated benefits do not necessarily result in integrated care
Capable, sustained leadership is key to successful integration
Implementing and sustaining successful integration requires careful planning and continuous assessment and reflection avoiding -‘the logic of failure”– when things start to falter action increases, while assessment and reflection decrease
Under the pressure of trying to develop a presentation with very little time and information, values, integration issues and outcome measures took a backseat to developing a product at a competitive price
Different stakeholders emphasize different values Consumers took for choice and seamless services; clinicians stress quality treatment and service, purchasers focus upon price and cost effectiveness, providers need to maintain a viable business The key values identified in Summit 97 need to be operationalized for all stakeholders.
Price forced a discussion of balancing reality and values Responses to the competitive process need to be structured in such a way that it will be possible to incorporate and operationalize key values. If not, one should be willing to walk away from the business
In the marketplace it is important for both purchasers and providers to be clear about integration expectations. There is a difference between buying an integrated benefits system and buying a benefits system that integrates services.
It was difficult to focus on the concept of integration in the competitive procurement process. Incorporating key values, integrated outcome measurements and consumer input are ways of encouraging functional integration to occur following a successful contract procurement.
identification of clinical risk factors which trigger the need for a psychiatric assessment
identification of medical use patterns or physical conditions which can serve as “warning signals” for the need for psychiatric intervention
appropriate identification of the mental health needs of HMO members
appropriate treatment of persons with psychiatric disorders by primary care practitioners
appropriate referrals of persons with more extensive psychiatric needs to specialty mental health practitioners
appropriate levels and types of consultation across primary and specialty care (e.g. mental health)
for whom is care to be integrated?
Specify the population(s)
what part of the care delivery process is to be integrated? (screening, intake, diagnosis, treatment, referral?)
Identify the clinical functions to be impacted what strategies will be employed to do this?
Describe the clinical interventions
what delivery system will yield the greatest likelihood of successfully implementing these strategies?
Construct the product platform
what financing method(s) will incentivize clinical practice in the desired directions?
Choose a financing method
what organizational configuration will best support and facilitate all of the above?
Develop an organizational framework to support the integrated functions
Very few primary or specialty medical care practitioners have any training in/exposure to mental health problems or psychiatric conditions
Very few primary care practitioners spend extensive time with their patients (or look for issues that the patient doesn’t specifically present)
Very few primary care practitioners conduct wholistic/comprehensive assessments on their patients, unless there’s a specific reason for doing so
Patient consent is required for any collaborative activities. Health plan members may not want their HMO communicating with their mental health providers; MBHO members may not want their mental health provider communicating with their health plan
All mental health services are not offered at the same level of complexity and intensity. It may be true that HMOs can successfully provide “primary mental health services”. but that only MBHOs can provide both primary and specialty mental healthcare.
Establish specific “bridge” protocols for provider-level collaboration across the health/mental health boundary
Establish mental health-specific performance standards and measures which are consistently applied to both HMOs and MBHOs
Establish targeted “integration/collaboration” objectives which are then operationalized through specific performance indicators. Move beyond our current reliance on anecdotes to chronicle efforts at integration since “the plural of anecdote is not data”.
Is the technology available to attain the goal?
Do the resources exist to capitalize the necessary processes?
Is there reasonable evidence that achievement of a goal would yield empirically demonstrated benefits?
If so, what is the value of the benefit, computed as the outcome enhancement expressed quantitatively divided into the cost? For example, if intervention A results in a 20% increase in interpersonal contacts over a base period, and the cost is $500 a month, might that money be better spent in increasing the proportion of pre-school children receiving a full schedule of immunizations?
Would the implementation process be socially acceptable in the present economic and political milieu? For example, when I published the first medical necessity rating scale in 1966, it was met with thundering indifference; it is now occasionally cited as a forerunner of our present system of rationing care.
On February 5, 1963, John F. Kennedy delivered a message to Congress which said, ” I propose a national mental health program to assist in the inauguration of a wholly new emphasis and approach to care for the mentally ill … We need a new type of health facility, one which will return mental health care to the mainstream of American medicine ….
This proposed a structural approach: build a facility with an open medical staff and they will come. We did not, in general, have open medical staffs; and private practitioners did not come.
Interestingly, psychiatrists have rejoined, perhaps unfortunately, the mainstream of American medicine to a considerable extent-with, some of us feel, a consequent loss of many of the attributes that made psychiatry particularly useful to society! Capitalism is indeed wondrous in its workings
Over the years, national policy had been directed toward the “psychitriatizing” of medicine, with generous federal grants:
General practitioners were subsidized to enter psychiatric residencies; they came out as psychiatrists, however, and rarely combined family and psychiatric medicine in their practices.
Training opportunities were developed for practicing physicians, ranging from didactic to sensitivity groups, to increase their sensitivity to, and comfort in dealing with, psychiatric problems.
We subsidized the development of psychosocial training in family practice residencies, utilizing predominately clinical psychologists as faculty, with more success. While Family Practitioners have not notably expanded their scope or expertise in the management of behavioral health problems, they may be marginally better gatekeepers, and more sophisticated brokers for behavioral health services on behalf of their patients.
Most recently, the Depression, Assessment, Recognition, and Treatment project has developed good training materials for non-psychiatric practitioners, as well as useful treatment guidelines for practitioners.
And, independent of national policy or financial incentives, non-psychiatric physicians continue routinely to prescribe over 70% of all psychoactive medications dispensed (if antipsychotics are excluded, the proportion of antidepressant and anti-anxiety agents is even higher). And, the National Comorbidity Study ( Kessler et al, 1994) shows that while only half of the one-fifth (20%) of the community population having a mental disorder in a 12 month period sought any form of professional service, only half received care from the behavioral health specialty sector, with most of the remaining receiving their care exclusively from primary care physicians. In this context, then, behavioral healthcare is significantly integrated into general medical practice.
In 1966, as Director of Psychiatry for the City and County of Denver, I located mental health teams in each of the Neighborhood Health Centers in the Denver General Hospital’s catchment area. In addition to the usual suspectspsychiatrists, psychologists, and social workers-masters prepared psychiatric nurses and indigenous non-professionals were charged with a sub-area of about 40,000 population, and encouraged to work closely with the physicians and other health workers in the Neighborhood Health Centers. This consanguinity model did not produce uniformly stellar results-just as marriages and other relationships do not necessarily prosper with consanguinity! Admittedly, there was some improved communication: but the reality was that, in general, the mental health types and the medical types did not particularly like each other, or feel greatly compelled to relate differently than they had before collocation.
The first generation of federally approved HMOs were all integrated models, with employed staff-model mental health professionals. While a few large HMOs, such as Kaiser, Harvard Community Health Plan, and Puget Sound, have “kept the faith,” most have “carved back out’ the behavioral health components.
Does the extension of psychosocial services-as opposed to pharmacological intervention for the symptoms of situational disturbance, such as insomnia or anxiety, which can be rendered by general physiciansresult predictably in the prevention of more serious mental health disorders (Mrazek and Haggerty, 1994)? If so, intervention can be seen as having a preventive effect, a desirable social goal.
If, on the other hand, the psychosocial services only offer palliation-relief of tension-which is no more effective than medication, and do not prevent the development of more serious disorders, then affording such services is a waste of the health care dollar.
There is, of course, considerable evidence that early intervention does result in a decrease in absenteeism and an increase in work productivity; this would suggest that such a benefit should properly be funded by employers under an employee assistance benefit.
Continuing Medical Education utilizes a cognitive model which has Questionable efficacy in modifying physician behavior (Stoudmire, 1996).
The development of integrated training and clinical guidelines, such as the publication of the Quick Reference Guide for Clinicians entitled Depression in Primary Care.- Detection, Diagnosis, and Treatment (Agency for Health Care Policy and Research, 1993) clearly has face validity, and has been perceived as useful by primary care physicians.
The use of patient-report screening instruments has been proposed for many years, and research confirms that they would increase recognition of mental disorders in the physician’s office. While research continues to show their usefulness, and even that while increasing primary care visits they do not increase the use of psychotrophic medications or rate of hospitalization (Mazonson et al, 1996), such instruments are little utilized in routine medical practice. Chemical dependency instruments, which exist in great variety, are also not routinely utilized, even in settings, such as the offices of obstetricians, where there is considerable preventive potential.
There is limited research indicating some enhancement of outcomes through collaboration:
One study of collaboration between the primary care and behavioral health provider on the outcomes of treatment of depression (Katon et al, 1995) showed, when compared with patients treated without such collaboration, improved rates of compliance (75.5 % Vs 50.0%), more patients helped by antidepressants (88.1% Vs 63.3%), and a greater likelihood of rating the quality of care as good to excellent (93.0 % Vs 75.0%). However, no differences were noted with “minor depression.”
While other authors believe that the PCP may be able to enhance medication compliance (Lin et al, 1995; Faloon et al, 1996), data is impressionistic and far from convincing.
Certainly, we all have experienced the untoward effects of the primary care physician’s and the psychiatrists prescribing medication in ignorance of what the other is doing. Because of this, the state of Texas, in its Medicaid reform, has mandated communication between the behavioral health provider and the primary care physician concerning diagnosis, medication, and treatment planning and results (although, not mandating reciprocal communication from the PCP to the BHP). As a subcontractor for HMOs in San Antonio, Fort Worth, Austin, Lubbock, and the Houston metropolitan area, CompCare has achieved modest success in increasing written communication between the BHP and the PCP. The value of this process, however, has not been demonstrated; but it is clear that the costs of care administration have been increased-since these dollars can only come out of the amount used to purchase behavioral health services, the cost-benefit ratio is critical to determine before we blindly perpetuate superstitious, bureaucratic behavior forever.
Enhanced early recognition and referral for appropriate treatment of major mental disorders would certainly be a strong reason for integrating services. The NIMH Epidemiologic Catchment Area Study, Four Sites, demonstrated that the lag between age of onset and first diagnosis of major depression ranges from 6.7 to 13.5 years, depending upon age of onset. Yet, we cannot empirically demonstrate that this creature called ‘integration” would measurably shorten that interval.
The dearth of hard data, however, has not deterred NCQA from codifying some elements of integration in their Standards for the Accreditation of Managed Behavioral Healthcare Organizations. Ql 7.2, “Collaboration with medical providers,” mandates consultation with PCPs, other healthcare practitioners, and relevant medical delivery systems in the selection of clinical issues to study and analyze. Ql 1.5 directs that the Ql committee include structured input from representatives of relevant medical delivery systems or other health care practitioners. Ql 6.2 requires that the BHO has mechanisms to inform primary care physicians about the diagnosis, treatment, and referral of behavioral health disorders commonly seen in primary care. Again, this has implications for the costs of health care delivery. Indeed, our own Summit last year affirmed, in the statement of values, that integration of behavioral healthcare and medical care adds value.
Use of the PCP as gatekeeper was designed to prevent the unnecessary or frivolous utilization of behavioral health services. By now the literature is replete with data that such a strategy may reduce access to outpatient services by behavioral health professionals, the patients did not go away, and often received unnecessary inpatient services or over-utilized general medical services as a consequence. Whenever the PCP operates with a global capitation, so that any specialty services are deducted from his monthly payments per enrolled member, the disincentives for early and appropriate referral increase prohibitively.
The “medical offset” hypothesis, postulated on two decades of research-which is often imperfectly understood and applied-has never, in my experience, been a convincing argument for a non-psychiatric medical professional: our colleagues simply have not observed, in their experience as practitioners or administrators, that improved access to behavioral health services reduces general medical care costs. And, indeed, there is no empirical data from a naturalistic practice environment that supports this hypothesis; moderate effects noted in atypical or specialized environments, or with special populations such as somatizing or system-abusing patients, simply have not held up in the ebb and flow of every-day clinical life. (Shulberg, 1997) The clearest yield, actually, was overlooked by many in the reading of the classical McDonald-Douglas study of integrated EAP and behavioral health services: immediately following the identification and referral to treatment of a chemically-dependent employee, the general medical costs of the spouse and dependent children declined precipitously.
The utilization of PCPs as primary providers of behavioral health services, including such approaches as guideline-directed treatment of major depression, has been research extensively (Nazareth et al, 1996; King, 1996; Schuylberg, 1996; Katon et al, 1996; Brody et al, 1997). Efficacy has been variable, and no data was presented on cost comparisons with utilization of the behavioral health provider.
Long-term cost reductions from improved early recognition and referral for appropriate treatment, since almost all behavioral health problems first present in the PCP’s office, represent a theoretical yield that would, unfortunately, be obscured by the rapid movement of members from one organized system to another, as well as the movement of providers in and out of care management systems due to network restriction, exclusion based on provider profiling, and provider resignations based on fee or contract disputes.
The liaison/collaboration model
New practitioner models
Functionally integrated carveouts
Extended care models
The CONSUMER is, after all, the one most concerned with having the diverse parts of the system coordinated into a harmonious whole.
The PURCHASER, broadly defined, controls decisions about allocation of resources that results in incentives and disincentives for the coordination of the system of care into a harmonious whole.
We might well focus our future efforts, then, on the following endeavors:
But we must also, in a society that does not like boundaries, work on defining much more precisely the components of “behavioral health,” and delineating the implications of service system design and payment mechanisms. We have pretended too long, for obvious reasons, that the worried well-the common cold of behavioral health-are entitled to a disproportionately large share of the health care dollar, to purchase a “store-boughtened friend” with whom to discuss their emotional distress over life’s unavoidable unpleasantness. Nor can we any longer pretend that every one who chooses to get drunk or stoned is the victim of an illness. Nor that everyone who is sad is “depressed.” Nor that intra-species aggression and predation is always the result of a brain disorder. This lumping together of all human misery under the illness rubric demeans and erodes our public image and credibility. The imprecision of our diagnostic categories evokes memories of the humors and the wandering womb. Our psychotherapies and counseling are so imprecise and rendered so promiscuously for all human distress, as to remind us of the panaceas of the last century, bleeding and purging. Nor should we forget the admonition of Action of Mental Health (Joint Commission, 1961) that the major unfinished business of our activities is effective treatment and rehabilitation of major mental illness. As is true for individual adolescents, our adolescent field must decide what we cannot do, in order to devote our full energy and resources to that which only we can do well. As the father of seven adolescents over four decades, and as one who had an inordinately prolonged adolescence myself, I am painfully aware of the anger and pain that such an acceptance of limits entails. But not to do so engenders an eternity of unrealized promise. But for today, let’s focus on one aspect of improvement, the reform of the competitive environment.
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Reform of the Competitive Environment
Managed care companies compete on the basis of price. As this competition continues to erode margins-indeed, no un-subsidized behavioral health managed care company has yet demonstrated a capacity to yield a sustained profit in excess of that yielded by many less risky investments-managed care companies have limited ways to remain viable:
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WITH THE HEAVY DEBT BURDEN OF THE NEW MANAGED BEHAVIORAL HEALTHCARE MONOLITHS, THESE PRESSURES HAVE INCREASED EXPONENTIALLY: ESTIMATES OF THE MONTHLY COSTS OF DEBT SERVICE ALONE RANGE FROM $0.15 PER MEMBER PER MONTH TO $0.48 PMPM.
Clearly, it does not require a clairvoyant to predict the turmoil of these next few years, which will have a disastrous effect on consumers when, not if, the next economic downturn occurs. When a labor surplus again develops, companies will be less impelled to compete for employees on the basis of benefits, and usually mental health benefits are the most vulnerable to cost-saving measures (with the exception of the larger companies with highly professional human resource departments).
IT IS TIME NOW, THEN, FOR US TO DEVELOP A CONSENSUS ABOUT THE STANDARD BENEFIT PACKAGE TO BE OFFERED AS A MINIMUM BY ALL MANAGED CARE COMPANIES. SUPPLEMENTS WOULD STILL BE OFFERED FORPURCHASE,BUTWITHINDEFINEDBENEFITMENUS-MUCHASNOW EXISTS FOR MEDICARE SUPPLEMENTAL PLANS.
Managed care companies would then compete on price and service, with regulatory oversight to guard against fraud and abuse.
Undoubtedly, any uniform national benefit design would be lower that our hopes and expectations. But, I believe it is a better platform to build from than the present PARITY platform, which is more form than substance.
Unless the initiative is national, as states have found however when they have acted independently, the usual competitive forces will be inhibited since the “playing field” is not level.
Another state approach is to define certain diagnoses as “like any other illness.” This sound like good social policy, since it should promote private sector services for major mental illnesses that otherwise would be a public sector responsibility. It is, however, vulnerable to manipulation because psychiatric diagnoses are so fungible. NO PLAN BASED ON DIAGNOSTIC CATEGORIES CAN BE FAIRLY ADMINISTERED AT THIS TIME IN HISTORY: we lack the technology to substantiate psychiatric diagnoses. With the advance of the neurosciences and genetic research, we undoubtedly will have such capability in the future-which will raise many ethical and social justice issues.
I hope that these observations and thoughts will contribute to the reflective process of this and future Santa Fe Summits, and look forward to the vigorous debate that will ensue. I will be really disappointed if we go home this time with so much agreement-it will suggest to me that we have dodged the big issues upon which the future of the mental health venture, a component of the centuries-old human betterment movement, will hinge.
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Agency for Health Care Policy and Research. Depression in Primary Care: Detection, Diagnosis, and Treatment. U.S. Government Printing Office, Washington, DC, 1993.
Brody DS, Khallq AA, Thompson TL. Patients’ perspectives on the management of emotional distress in primary care settings. J Gen Intern Ed 12:403-406) 1997.
Dorner, Dietrich: The Logic of Failure. Addison-Wesley, Reading, Massachusetts, 1996.
Fraser J Scott. Prof Psychol 27:335, 1996,
Higgins ES. A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course. Arch Fam Med 3:908-917@ 1994.
Joint Commission on Mental Illness and Health: Action for Mental Health. Basic Books, New York, 1961.
Katon W et al: Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 273: 1026-1031, 1995.
Katon W et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 53:924-932, 1996.
Kessler RC, McGonagle KA, Zhao S, et al. Arch Genl Psychiatry 51:8-19, 1994.
Kimball JM, Snowden LR. Problem type and referral to HMO mental health treatment. Adm Policy Ment Health 24:399-409, 1997.
King M, Nazareth I. Community care of patients with schizophrenia: the role of the primary health care team. Br J Gen Pract 46:231-237, 1996.
Lin EH et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care 33:67-74, 1995.
Mazonson PD et al.- J Am Board Fam Pract 9:336-345,1996.
Mechanic D: Approached for coordinating primary and specialty care for persons with mental illness. Genl Hosp Psychiat 19:395-402, 1997.
Mrazek PJ, Haggerty RJ, Eds. Reducing Risks for Mental Disorders. Frontiers for Preventive Intervention Research. National Academy Press, Washington, D.C., 1994.
Nazareth I. King M, Tai SS. Monitoring psychosis in general practice: a controlled trial. Br J Psychiatry 169:475-482, 1996.
Nickels MW, McIntyre JS: Psychaitr Serv 47:522-526, 1996. “The integration of mental health care and primary medical care enhances the quality of patient care and may improve the overall cost-effectiveness of a health care system.” Not data provided to support this assertion.
Penner N. Group Health Cooperative of Puget Sound: toward integrated care, a pioneering provider’s first steps in integrating medical and behavioral health services. Behav Hlth Mgt 16:24, 1996.
Schulberg HC et. al. All that glitters is not always gold: medical offset effects and managed behavioral health care. Arch Fam Med Jul-Aug:334339 1997.
Schulberg HC et al. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry 53:913-919,1996.
Stoudemire A. Psychosomatics 37:502-508, 1996. “…evidence indicates that not only are psychiatric disorders underrecognized in primary care settings, but also that treatment is often inadequate and accompanied by less than optimal outcomes…Strategies for the develoment and implementation of these educational training modules will also be discussed [in Part II].”
Tews J et al. Improving the management of patients with schizophrenia in primary care: assessing learning needs as a first step. Can J Psychiatry 41:617-622, 1996. From southern Alberta.
Tiemens BG. Ormel J, Simon GE: Occurrence, recognition, and outcome of psychological disorders in primary care. AM J Psychiatry 153:636-644, 1996. From Netherlands. “Recognition of psychological disorders was not associatedwith better outcome. Recognition is a necessary but not a sufficient condition for delivery of treatment according to clinical guidelines. Increasing recognition is likely to improve outcomes only if general practitioners have the skills and resources to deliver adequate interventions.”
Voelker R. Quality standards intend to bring psychiatry, primary care into closer collaboration. JAMA 277:366, 1997. Discusses NCQA standards.
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Stoudemire A- Psychosomatics 37:502-508, 1996 “…evidence indicates that not only are psychiatric disorders underrecognized in primary care settings, but also that treat3nent is often inadequate and accompanied by less than optimal outcomes … Strategies for the development and implementation of these educational training modules will also be discussed [in Part III].”
Tews J et al. improving the management of patients with schizophrenia in primary care: assessing learning needs as a first step. Can J Psychiatry 41:617-622, 1996. From southern Alberta.
Nichels MW, McIntyre JS: Psychiatr Serv 47:522-526, 1996. “The integration of mental health care and primary medical care enhances the quality of patient care and may improve the overall cost-effectiveness of health care system.” Not data provided to support this assertion.
Penner N. Group Health Cooperative of Puget Sound: toward integrated rare, a pioneering provider’s first steps in integrating medical and behavioral health services. Behav Hlth Mgt 16.-24, 1986.
Tiemens BG, Ormel J, Simon GE.- Occurrence, recognition and outcome of psychological disorders in primary care. Am J Psychiatry 152:636-644, 1996. From Netherlands. “Recognition of psychological disorders was not associated with better outcome. Recognition is a necessary but not a sufficient condition for delivery of treatment according to clinical guidelines. Increasing recognition is likely to improve outcomes only if general practitioners have the skills and resources to deliver adequate interventions.”
EDUCATION AND EMPOWERMENT OF THE CONSUMER. In somewhat belated recognition of this self-evident truth, the College just last year began to reach out actively for consumer involvement, believing that it is time to move beyond the adversarial relationship that has so often characterized cross-cultural exchanges, to a true partnership and community of interest. We have a great deal to learn about how to work together effectively. I have no doubt that future Santa Fe Summits will focus on this vitally important area.
REFORM OF THE COMPETITIVE ENVIRONMENT in order to enhance coordination between various components of the healthcare system to produce an harmonious whole. I would like to end with a few thoughts about how an organization such as ours, acting as a public trust, could promote a national debate-not only by our pronouncements, but by emboldening the key opinion-setters in this room to end our attempts to accommodate to a system that is corrupt at its core.
They can restrict benefits such as exclusions by diagnosis, chronicity, or annual or lifetime benefit maximums
They can reduce utilization by increasing co-payment levels
They can reduce provider reimbursements still further
They can utilize ever-less well-trained, and hence less pricey, providers
They can become more efficient in the provision of the non-clinical aspects of their operations: information and referral, utilization review, provider services, claims payment.
They can reduce their sales commissions. In years past, 3% of premium was a not unusual commission, even higher when brokers were involved. The company that I work with, focusing heavily in the private sector, HAS discontinued commissions for sales personnel, considered a departure bordering on sacrilege by many!