Suicide and Obamacare

In 2009, there were 36,891 suicides in the United States, according to the CDC.  This translates to a rate of 11.9 for every 100,000 people.

And rates among certain groups were even higher.  For example, the suicide rate among veterans, according to the Veterans Administration, was three times higher – or 35.9 per 100,000 veterans.

Suicide is a problem that ought to command our attention.

And it does.  For many years we have used suicide data as surrogates for documenting the consequences of serious mental illness.  We all know that the “danger to self” standard we use for determining when people with mental illness qualify for emergency care is, in effect, a “suicide may be imminent” standard.

As a result, for many years community mental health organizations have also been asked to track suicides as a measure of the effectiveness of their programming. 

But there are reasons why focusing on suicide rates too closely leads to inadequate public policy.

Suicides are just the tip of the iceberg.

Many more people consider or attempt suicide than die from it.  If you really want to be staggered by a national statistic, CDC reported that in 2011 7.8 percent of the teenage population had attempted suicide.  That is one thousand times as many as had died from it.

Also, the overwhelming majority of people with serious mental illness who die early do so not because of suicide, but because they are undertreated for other chronic conditions (such nicotine addiction, diabetes, and cardiovascular problems).  Some of these are linked to treatments they receive for their mental illnesses.

Finally, at the community level the number of suicides is usually so small that it is nearly impossible for any single organization to affect the rate more than anecdotally.  The agency may be able to point to individual cases where its intervention made a difference, but it will probably never be able to move the rate on its own.

And when the suicide rates don’t move, policy makers use this to justify decisions to reduce or eliminate program funding. 

So what does Obamacare have to do with suicide?

Many other provisions of the law have been lost in the din surrounding the most visible parts of the Affordable Care Act.

One of these was a mandate that the Department of Health and Human Services focus on the quality of our health care.  Since 2012, it has been doing this, along with a number of agencies in the Department, including the Substance Abuse and Mental Health Services Administration (SAMHSA). 

SAMHSA has just invested over two years in developing a National Behavioral Health Quality Framework (NBHQF). 

When the NBHQF is finalized, it will open the door to the use of new standard outcome indicators in determining the effectiveness of health and behavioral healthcare in our communities. 

We will be able to add these indicators to suicide rates, giving state and local officials much more powerful tools in judging the effectiveness of community mental health programs.

For example, suicide risk assessments (NQF #0104) will become a standard diagnostic tool in provider settings.  Providers will also be expected to use depression screening tools such as the PHQ-9 at six and twelve month intervals to monitor patients consistently over time (NQF #0710-0712).  And risky behavior assessment and counseling for children under the age of 13 will become a standard of practice (NQF #1406), as will diagnostic evaluation of children with major depressive disorder (NQF #1364-1365).

These all focus our attention on the 999 in every 1000 who consider and attempt suicide in addition to the one who tragically commits it.

We can also expect the integration of health and behavioral healthcare to become more systematic. 

Cardiovascular and diabetes monitoring of people who are prescribed antipsychotics (NQF #1933-1934) will become a standard of practice, as will management of ADHD in children in primary care settings (NQF #0107-0108). 

These indicators focus our attention on some of the other reasons people with mental illness die so young.

We all have an opportunity to say how we feel about these indicators. 

SAMHSA has released the NBHQFin draft form, and is accepting public comments on it until September 17, 2013.  Comments can be submitted using an online form, and don’t have to be formal or comprehensive.

The NBHQF will be finalized after the public comment period.  Then it will begin to guide the funding and delivery of mental health services. 

But for the next week, we all can say how we think the government should measure the quality of our behavioral healthcare services.

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/ 

Veterans Dazed, Not Dazzled, By Mental Health Care

Nearly 2.1 million veterans received mental health care from the Veterans Administration between 2006 and 2010.  According to a Government Accountability Office report released in October, 1.2 million veterans received mental health treatment in 2010 alone.

Almost 30% of the 7.2 million veterans who received treatment from the VA received mental health treatment.  So did 38% of Iraq and Afghanistan (“OEF/OIF”) veterans.  Many more probably needed it. 

The GAO report shows how pervasive mental illness is among veterans, and how co-occurring mental illnesses overwhelm both veterans and their service delivery system.

Younger veterans and reservists are especially affected.

We now have over 22 million living American veterans, but only 4 million served during World War II or the Korean War.  Seven million served during the Vietnam War, and almost 6 million are OEF/OIF veterans. 

OEF/OIF veterans accounted for 12% of all those receiving VA mental health services in 2010, a three-fold increase in just five years.  The GAO said this was expected “because of the nature of OEF/OIF veterans’ military service – veterans of this era typically had intense and frequent deployments.” 

Another October 2011 report entitled Losing the Battle: The Challenge of Military Suicide quantifies the tragic effect of this.  We lost 33 active and reserve duty Army personnel to suicide in July 2011 alone, and veterans – less than 10% of our population – account for 20% of all suicides in America.

There are three reasons why we lose so many veterans to suicide.  They are

• Traumatic brain injury, resulting in disability;
• Chronic pain from bodily injury; and
• Post Traumatic Stress Disorder (PTSD).

PTSD is far and away the most significant of these reasons.  I wrote about this in an earlier column.  As both the GAO report and the chart accompanying this column show, nearly half of the veterans receiving VA mental health care in 2010 had PTSD.  Most had at least one other mental health diagnosis, too.

It is a national failure that we don’t do a better job of identifying suicide risk factors and intervening earlier.

VA screening protocols may be part of the reason.  The authors of Losing the Battle report that returning veterans have historically been discouraged from admitting to mental health problems as they fill out their post-deployment screening forms.  As a result, the GAO reports the VA now “requires veterans treated in primary care settings to be screened for mental health conditions such as PTSD, depression, substance abuse disorders, as well as a history of military sexual trauma.”

And it turns out that veterans are more dazed than dazzled by the mental health care they are offered.

They avoid it, the VA told the GAO, because of stigma, lack of understanding about available services, logistical challenges accessing health services, and concerns about the quality of VA care.

• Mental illnesses are stigmatizing largely because many people still believe that they are “behavioral” weaknesses, not serious and life-threatening diseases that can shorten life expectancy by 25 years.
• Many also believe that services are only for people who are severely mentally ill.  They avoid seeking care for fear they will be labeled “whiners” and “psychosomatics.”
• Veterans, reservists, and non-veterans have logistical challenges in accessing services.  The VA does not have a full complement of mental health providers.  At least those they have get paid.  Major insurance companies are cutting reimbursements to community mental health providers, so patients who find providers outside of the VA often can no longer afford the out-of-pocket cost.
• It is impossible to have a quality mental health care system unless non-mental health professionals don’t just screen for – but are trained in managing – mental illnesses.

A 2009 SAMSHA reportfound similar reasons given by the 5.1 million civilians who also reported unmet mental health needs.

We can begin to fix this if we do four things:

1. Commit a fraction of the resources we committed to the wars to fight the mental illnesses they have caused – in the VA and in the community, wherever veterans, reservists, and non-veterans receive services.
2. Increase training of primary and specialty care providers so they recognize, diagnose, manage, and refer patients with mental illnesses.
3. Make periodic mental health screening a part of wellness exams for everyone, starting with young children.
4. Insist that insurers honor the mental health parity mandate.

We remember the sacrifices of our veterans when we fly our flag.  We honor those sacrifices when we take care of the men and women who made them.

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