A recent post on the Huffington Post titled The Costs of Not Caring: How to Fix Our Broken Mental Health Care System highlights the significant reductions to state mental health budgets over the past years and the subsequent impact to people with various mental health conditions.
The blog builds a compelling case outlining the rationale and history of mental health services from institutionalization to deinstitutionalization, the mental and physical health disconnect, and the key challenges we face. Beyond that, we also know there are both personal and institutional barriers that prevent persons from receiving the care they need, when they need it, where they need it, how they need it, in the language they need it, and so forth.
First off, there is no easy or singular solution. Mental health and substance abuse services are financed through multiple sources: states and counties, the federal-state Medicaid program, the federal Medicare program, private insurance coverage, patients’ out-of-pocket expenditures, and a host of smaller public and private programs. This forms a complex patchwork of funding streams to finance programs. Adding to the complexity, each funding stream has particular eligibility rules and benefits packages. This poses one of the biggest challenges to policymakers to undertake reform, particularly finance reform, in mental health and substance use policy.
But the good news is that there is a national movement afoot and we are making some progress in several fronts. Increased funding to support mental health initiatives, bundled payment models being tested, integrated health care being adopted and scaled more widely, and certifications established to ensure organizations are meeting quality care metrics, are just some examples of steps being taken to improve our health care system.
Although money is a major factor, money alone will not solve fixing our broken health care system. Other reforms are required to ensure that our health care system is responsive to the whole health needs of our nation! Here are some considerations:
Funding. Our system remains fragmented, in large part due to how we finance health care (as noted above). Bundled payment pilot demonstration projects are currently being implemented; this is a promising effort to use a single payment approach to address whole health, versus separating mental health from physical health. And last but not least, completely moving away from fee-for-service to a “value-based” financing where there is shared risk but also shared rewards for successfully managing patients with complex health care conditions.
Integrating mental health and physical health. Collaborative care (an integrated health care model) is an effective model with a strong evidence base. Providers must conceptually shift their thinking in terms of whole health, and redesign their care delivery systems to incorporate core components of integrations or implement models of care. New workflows, instituting team-based care, training, and tracking of health care outcomes, are just some of the transformations that must take place to move delivery systems to the next level. Payors have a stake in this as well.
Policies, rules and regulations. Local, state-wide, and national policies drive the activities of providers. Having managed large provider contracts in a former life, I know that providers will “do what they get paid for.” Providers have limited capacity and are often “hand-cuffed” by antiquated policies, rules and regulations of how care is designed, delivered and reimbursed.
Reducing burdens. Providers and health care systems want to deliver good care. But competing priorities to satisfy program, reimbursement, data & other reporting requirements results in undue burden and subsequently takes away precious and valuable time from patient care. Carefully examining what you really need as a payor to determine if you are getting your ROI and eliminating the excessive and perhaps traditional reporting will lesson this burden. What data elements or metrics are you requiring providers to submit? Are we using those data or metrics to make informed decisions about the program being implemented?
Outcomes versus outputs. Reporting on how many clients or patients were seen (encounters) in a given quarter in a clinic site is important…but the real question should be “Of the 1,500 persons you saw at your clinic, how many of them demonstrated improved health outcomes? What metrics are you collecting to look at health outcomes?”
Incentivize or reward good quality care. Its time we reward and place value on health outcomes and quality care. It’s a shared ownership and responsibility on the part of the provider and patient. Both want the same result. For patients, if you are sick, you want to get well. For providers, you want to treat and facilitate health and wellness to your patients. Enough said.
Agreement on what constitutes best/promising practices. A shared decision making process between payors and providers on what constitutes best/promising practices and allow for flexibility to implement small, demonstration pilot programs can result in more effective and efficient ways of delivering care. Having a strong evaluation component will support payors and providers to try methods that are “outside the box” (e.g., use of peers; care coordination; prevention efforts; complimentary alternative approaches). We must support providers in their engagement with patients “What works (or helps) you feel better?” and make that part of the treatment plan.
Culture eats strategy. Check out my blog post on December 1, 2015 about organizational culture.
Shift in mindset. Lastly, it will require a paradigm shift in our thinking. It’s time we reconnect the head to the body versus separating these out. This will require the political will of all involved: policy makers, payors, health systems, providers, and last but not least, the main driver: people. We must demand whole health be the standard of care, not separation and continued fragmentation. We the people must demand it be designed and delivered in this way. Consumers must harness their collective voice to convince policy makers and payors that the current system is unacceptable and demand the changes that will move us towards the Triple Aim: improved population health, patient activation and ownership in their care, and care delivered at less costs.