New Programs Show Value of Health and Behavioral Health Integration

A Kaiser Health News sampling of the latest headlines about Obamacare reflects our continuing anxiety over the law just months before it is fully implemented.

The most interesting to me was this one.  According to a new CNN poll, only 43 percent of the public favors Obamacare.  But of those who oppose it, only 35 percent do so because it is too liberal.  Sixteen percent say that it is not liberal enough!

No matter how you feel about Obamacare, one of the most significant changes it facilitates will be the integration of health and behavioral health care – meaning that care for both physical and mental illnesses will soon be delivered together.

This only makes sense.  People with cancer, for example, often develop depression or anxiety that complicates their care.  And people with mental illness often develop physical conditions – sometimes as a side effect from the medications they take – that can cut twenty-five years from their lives.

Integrating health and behavioral health care has not been the norm over the past century. 

In a nutshell, this is because regular health care evolved from an acute care model – the idea that we could cure disease with aggressive, short-term interventions.  Mental health care evolved from a chronic care model – that mental illnesses could be managed, but not prevented or cured.

What we have learned in the last 20 to 30 years shows that both models can be useful in treating all diseases.

So we began to manage some diseases that we could not cure using a newer chronic disease model.  HIV/AIDS treatment is an example, but so are today’s treatments for many chronic conditions, including cancers, heart diseases, diabetes, and hypertension.  And we began to use an acute care model to treat mental illness, offering short-term stabilization in addition to longer-term therapies.

With diseases co-occurring and treatments often intersecting, care integration was the logical next step.

In its 2010 document, Evolving Models of Behavioral Health Integration in Primary Care, the Milbank Memorial Fund offered numerous examples of the care integration approaches that have evolved over the past twenty years. 

And while care integration has been slow to gain traction, that is about to change as a result of the Affordable Care Act.

Access to insurance despite pre-existing conditions, prohibitions on rescinding coverage after a person gets a chronic disease, and greater parity in health and behavioral health benefits are three reasons why, from a consumer perspective. 

More billing options and better reimbursement rates for primary care providers offering behavioral health screening and support services are two reasons why, from a provider perspective.

And the call for early intervention to prevent future tragedies is one big reason why, from a purely political perspective.

This week and next, I have the good fortune of being witness to two cutting-edge integration initiatives that reflect our changing environment. 

I serve on the Board of Directors of the Jerome Golden Center for Behavioral Health, and this week attended the grand opening of its new primary care clinic.

For the first time in its forty year existence, this safety net community mental health center will offer formal primary care services in the same location in which it offers behavioral health services.  Patients will benefit from one-stop shopping, and receive monitoring and treatment for health conditions as they are treated for behavioral illnesses. 

Integrating health services into behavioral health services in this way is a far less common approach to integration than doing it the other way around.  HRSA, for example, notes that 70 percent of community health centers offer at least some mental health services.  But some people – especially those with serious mental illnesses – often access only behavioral health providers, because they are reluctant or unable to seek out care in multiple locations.

And in the coming week, I’ll be at the annual meeting of Mental Health America for a presentation by the Mental Health Association of Palm Beach County about its Be Merge initiative.  Through Be Merge and related initiatives, MHAPBC is training primary care and mental health providers to work together in any model to integrate health and behavioral health services.

The initiative has won Mental Health America’s 2013 Innovation in Programming Award, and is clearly ready for prime time.  MHAPBC has made the training and toolkit available online through the University of South Florida, for use by agencies and providers throughout the nation.

As these two initiatives show, integration has finally arrived.  Better late than never.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Veterans and Mental Illness: A 2013 Update

Fifty-four percent of Iraq and Afghanistan war veterans who have sought treatment in the VA system since 2001 have been treated for mental disorders.

This is the second most-frequent diagnosis among these veterans.  It is an indicator of the profound effect recent war service is having on the mental health and well-being of our veterans.

The data come from a March, 2013, report entitled Analysis of VA Healthcare Utilization Among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) Veterans.  

Here are some numbers that reflect how extensive the use of VA services has been during the last decade.

As of the end of 2012, 2.5 million troops had served since the beginning of the Iraq and Afghanistan wars.  Just over 1.6 million had become eligible for VA healthcare.  Of that group, almost 900,000 had used VA healthcare services by the end of 2012.

These 900,000 veterans most often sought treatment in VA centers in the south or in the west.  More than 85,000 sought treatment in the VA South Central Healthcare Network, while more than 80,000 sought treatment in the VA Desert Pacific Healthcare Network.  By contrast, less than 39,000 sought treatment in the VA New England Healthcare System.

Of those seeking treatment, 88 percent were male, and 12 percent were female.  93 percent had been seen on an outpatient basis only, while 7 percent had been hospitalized in a VA hospital on at least one occasion. 

Almost half were under the age of 30.

And the 550,000 who accessed care during 2012 alone represented 9 percent of the total number of veterans receiving VA care during the 2012 fiscal year.

And while – as might be expected – musculoskeletal system conditions were the most frequent diagnosis (58 percent) over the entire decade, nearly as many veterans (54 percent, or over 486,000) were diagnosed with mental disorders.

Many had two or more disorders.

Post-traumatic Stress Disorder, or PTSD, was the most frequent mental disorder treated in VA settings.  Over a quarter million OEF/OIF/OND veterans were treated for PTSD by the end of 2012.  But depressive disorders were nearly as prevalent, with more than 200,000 veterans being diagnosed with those.  Also, nearly 200,000 veterans were treated for neurotic disorders.

Together, these numbers provide strong statistical evidence that repeated exposure to environmental risk factors, including violence, are factors in multiple mental health conditions.

On the other hand, only 59,000 were diagnosed with alcohol dependence and only 32,000 with drug dependence.  These numbers suggest just as strongly that the mental disorders among returning veterans were not caused by risk factors within the control of the veterans themselves.

On Memorial Day, all of these data should give us pause to think about the inadequate federal and services and systems to which our OEF/OIF/OND veterans are returning. 

While the VA has taken steps in recent years to extend additional services to returning veterans, including allowing veterans to enroll in VA health services for up to five years after service and waiving co-pays for health problems related to military service, a significant number of veterans have not yet entered – or will never enter – the VA system.  

In addition, as a number of news outlets, including the Daily Beast, reported in March 2013, 245,000 veterans had been waiting for more than a year for disability benefits as of December 2012.  The average wait time for Iraq and Afghanistan veterans was between 316 and 327 days.

The federal government could be doing more for these men and women, but so could our states.

Funding for mental health services were cut by $4.6 billion by states between 2009 and 2012, and the unwillingness of many states to expand Medicaid benefits this year is certain to take a toll on many of our returning veterans and their families.   

We all know that this is no way to treat our returning veterans.

So as we raise our flags on another Memorial Day, we should never forget that our responsibility to those who serve our country extends over 365 days. 

Now is the time to pay back those for the sacrifices they have made.  Or are we so cold as to expect these mostly young veterans to have made this sacrifice – along with the toll it took on their health and mental health – all by themselves?   

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The Stories Behind the Headlines: Is This the Best We Can Do?

Health policy has often been in the news headlines this month.  

To cite three examples, CDC released a new report about causes of death.  CMS published data showing wide variations in hospital charges for common procedures.  And, in the context of a newly-reported Oregon Medicaid expansion study, states have been making decisions about Medicaid expansion.

Let's look at the mental health policy stories behind the headlines.

Suicide on the Rise

The CDC reported this month that as of 2009, there were more deaths from suicide in the United States than there were from motor vehicle accidents.

Suicide rates increased by over 28 percent among men and women aged 35-64 from 1999 to 2010.  While men were three times more likely to commit suicide, the rate increased more for women (32 percent) than for men (27 percent).

Suicide rates are highest in the west, but they are increasing in 39 states.

Men are most likely to commit suicide with firearms, women with poison.  The most rapidly growing cause is suffocation.

During the same period, results were down slightly among elders, and up slightly among youth.  CDC speculated that the bad economy could be affecting rates.  It also noted that baby boomers have had elevated suicide rates throughout their lives.

So what are we doing about this?  The recent Medicaid and Medicare debates suggest a whole lot less than we should be.

Oregon Study Links Medicaid Expansion to Reductions in Mental Illness

By now, everyone knows that the Florida legislature decided not to expand Medicaid to over 1 million residents.

Florida isn’t alone – it looks like elected officials in approximately half the states will turn down Medicaid expansion for at least this year, and forfeit billions of dollars that could be used for patient care.

Many expansion opponents latched onto a study published this month in the New England Journal of Medicine to support the case against expansion.  The study analyzed the results of an Oregon Medicaid expansion program over a two-year period.  It concluded that the Oregon expansion had no effect “on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions.”

Expansion proponents looked for a silver lining, arguing that the study also showed that Oregon’s expansion improved access to care and increased the use of preventive services.

But both seemed to overlook the study’s most definitive conclusion – diagnoses of depression went down by 30 percent among those covered by the Medicaid expansion. 

Mental Health America notes that depression has been estimated to cost $77 billion annually.  So how many billions could we save by cutting depression rates by 30 percent?

And why isn’t this garnering all the headlines?

New CMS Data Show Wide Variations in Payments for Psychosis Care

This past week, the Centers for Medicare and Medicaid Services (CMS) released data on charges for hospitals throughout the country.  The release attracted plenty of attention, because there were wide variations in what different hospitals charged for the “same level of care.”

CMS wants high-charging hospitals to lower their charges.

Those charges, however, may not be the most important numbers in the data.  The real headline is in what Medicare actually pays for the “same level care” throughout the country.

If you suffer from psychosis, you’re better off being hospitalized in Maryland – where Medicare pays an average of $11,277 per discharge, twice as much as it does in a half dozen other states – than in any other place in the country.

The variation in payments in states – even within geographic regions – was astonishing.   I put a table with the numbers for all the states on my State Rankingspage, but here are just a few examples.    Alabama hospitals were paid only $5,256 per discharge, while those in Florida were paid $7,006 and those in Georgia $6,605.  Connecticut hospitals were paid $8,239 (note: the overall number of discharges was very small for Connecticut), while those in Massachusetts were paid $7,494.  North Carolina hospitals were paid $6,188; those in Virginia were paid $5,851 and those in the District of Columbia were paid $9,444.  California and Oregon hospitals were paid $8,916 and $8,816, respectively, but Washington hospitals were paid only $6,504.

You can see information for all the states here.

When we look at the three reports together, they certainly beg at least this question.  Is this really the best we can do?

Paul Gionfriddo will be speaking at the breakfast meeting of the Middlesex (CT) County Coalition on Housing and Homelessness on Friday, May 17, at 8 a.m.  It is open to the public; RSVP to ann@anendinten.org. 

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The People on the Plaza

On a recent bright and sunny Monday afternoon, I took the sixteen-minute BART ride from Oakland – where I was doing some work – into downtown San Francisco.  I went to several places where people who are homeless tend to congregate. 

What I saw made me wonder.  Do we realize that if we do nothing, up to half of the people who are chronically homeless are likely to die in the next ten years?

I exited the BART train at the Civic Center/UN Plaza station.  When I arrived above ground, I saw more than a hundred homeless people in the vicinity of the station.  They were sitting or resting on the plaza, pretty much keeping to themselves.

Scores of tourists, business people, and shoppers hurried about their business.  There was no interaction between the two groups.  It reminded me of the way old-time cartoons had the action layered on top of a static backdrop – a crowd bustling with activity set against the backdrop of stationary homeless people.

I witnessed something similar in at least three other settings that afternoon.

I walked into Buena Vista Park, a beautiful, wooded park on a hill along Haight Street with awesome, expansive views of San Francisco.  As I climbed its paths, I passed by several people out walking their dogs.  They barely noticed the homeless people sleeping or sitting on the grassy lawn nearby. 

In the nearby panhandle of Golden Gate Park, a few joggers and sunbathers also ignored the small groups of homeless people sitting together under the trees.

And at the Powell Street station later on that afternoon, hundreds of shoppers passed by scores of homeless people without paying them the least bit of attention.

At first, I didn’t see what was wrong with this picture.  I was impressed with the live-and-let-live spirit of the community, where no one hassled anyone else. 

But then I looked more closely.  The people passing through the plaza were so accustomed to the homeless people on the plaza that they were not moved – either to anger or to sympathy – by seeing them.

San Francisco has an estimated 24,000 people who are homeless.  Its governmental agencies and nonprofit community do far more for them than most. 

According to a recent article in the San Francisco Chronicle, the city has moved 8,000 people off the streets since 2004, and has 1,155 emergency shelter beds.  A new homeless health care clinic will open this summer with the capacity to accommodate 50,000 visits per year.  And because the homeless population is aging, 77 new apartments are opening for homeless seniors.

But that doesn’t mean that chronic homelessness isn’t a problem anymore.

The National Alliance to End Homelessness released a new report last month that documented some improvements in the prevalence rates of both overall homelessness and chronic homelessness in the United States over the past ten years. 

But the same report shows that the numbers of homeless people have remained steady during the last four years, in spite of an improving economy.  (Perhaps cutbacks in mental health funding are a reason.) One person in every five hundred is homeless. And out of every ten thousand veterans, 29 are homeless.

Here's something to think about.

The Chronicle article also noted that the mean age of the homeless population increased from 34 to 53 between 1990 and 2010, and that the life expectancy of a person on the streets is 64.  It is possible that chronic homelessness is decreasing because of better services.  But it is also possible that it is decreasing because chronically homeless people are dying off.  In the next ten years, half could be dead.

The NAEH report makes it clear that the problem of homelessness is not limited to warm weather and service-rich communities like San Francisco. 

In fact, Colorado, Oregon, Washington, Wyoming, and Alaska are among the eleven states with the highest rates of homelessness in the country. 

There is a clear connection between behavioral illnesses and chronic homelessness.  I plan to talk about this in a presentation I will be making at a breakfast open to the public sponsored by the Middlesex County Coalition on Housing and Homelessness in Haddam, Connecticut on Friday, May 17.

My goal in that talk will be simple – to remind people that no matter where you fall on the philosophical spectrum, doing nothing about homelessness is not an option. 

You may be able to walk right by the people on the plaza without them saying a word, but this doesn’t mean that they shouldn’t command your attention.

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/