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MOVING UNDER THE HEALTHCARE TENT

March 1, 2006
by LINDA ROSENBERG
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Providers should take advantage of society's and general healthcare's greater recognition of behavioral health disorders

There has been substantial progress in the public's understanding that behavioral health disorders can be treated effectively, and that improving the nation's health means improving the nation's mental health and reducing substance use.

The past year has had many significant landmarks for our field:

  • Mental health professionals were on the ground with our troops in Iraq.

  • Health and Human Services Secretary Mike Leavitt launched a campaign to encourage those affected by Hurricane Katrina to access behavioral healthcare services.

  • The most recent Institute of Medicine (IOM) report in the Crossing the Quality Chasm series confirmed the views of the Surgeon General's report that behavioral health is an integral part of general health and that effective treatments for mental illnesses and substance use are available.

  • The National Business Group on Health's report, An Employer's Guide to Behavioral Health Services, acknowledged the high cost to businesses of untreated and poorly treated mental illnesses and encouraged employers to give equal attention to general and behavioral health.

Behavioral healthcare is being accepted as part of general healthcare, and we need to leverage the opportunities gained from moving under the healthcare tent: opportunities to reframe and address the inadequacy and misalignment of behavioral healthcare financing, and opportunities to invest in organizational supports that accelerate the pace of behavioral healthcare service improvements.

We can begin by viewing the costs and reimbursements for mental health and substance abuse treatments in the same context as other medical specialties—cardiology, oncology, etc. We must have standards of treatment and salaries commensurate with the skills needed to meet the standards. The growing demand for behavioral healthcare services and the available workforce's limitations make improving salaries a priority. To solve the workforce crisis, behavioral healthcare (a healthcare specialty) must pay staff more, not less, than primary care. And better salaries will require reimbursements based on the costs of delivering effective services.

Nowhere is the gap between service costs and reimbursement more dramatic than Medicare's discriminatory copay and inadequate mental health outpatient benefit. This growing barrier to access results in the shift of our aging population and the large numbers of individuals with mental illnesses on the Social Security disability rolls to very costly inpatient hospitalizations, which have a more robust Medicare benefit. As all of healthcare commits to avoiding unnecessary hospitalizations, this is an issue whose time has come.

The healthcare tent offers an opportunity to shift to the persuasive language of healthcare, particularly as we advocate for increased funding. This means talking about our progress and our successes while acknowledging current limitations to produce positive treatment results for all individuals. It means asking for additional funding not because we are in disarray, but because we want to take advantage of new knowledge and technology that will improve outcomes.

Behavioral healthcare increasingly is interested in general healthcare's disease-management model for long-term medical illnesses, such as diabetes, cardiac conditions, and asthma. We understand and embrace disease management's components: care or case management, consumer and family education and illness self-management, and treatments based on the most effective practices.

We need, however, to become more comfortable with healthcare, addressing more fully mind-body connections. Given the costs of service duplication, the data on primary care's inability to diagnose and adequately follow up, and the paucity of trained behavioral healthcare staff, this comfort level is critical as referrals, collaborations, and contracting increase between primary care and behavioral healthcare.

The Centers for Medicare & Medicaid Services’ (CMS) Quality Improvement Roadmap, the IOM report, and the report by the President's New Freedom Commission agree that excellent behavioral healthcare requires the acceleration of research findings to practice. And we are beginning to understand that the adoption of new practices is fundamentally a systems management function. Success depends on building and organizing systems capable of integrating an internal feedback loop: provider organizations and their practitioners systematically collecting and analyzing the outcomes for their programs and the individuals they treat.

The first federal project to fund organizational improvement, the Health Disparities Collaboratives, supports community health centers’ capacity to determine which patients have an illness, ensure that they receive evidence-based care, and help them manage their own treatment. Federal investment is also helping substance abuse provider organizations improve care delivery. The Network for the Improvement of Addiction Treatment (NIATx) guides providers through the change process, providing measures for improvement and offering tools for gathering data, working in groups, and documenting improvement.

The IOM recommends increased funding for provider organizations’ implementation of an electronic health record (EHR). The EHR offers critical support to the service-improvement process: promoting the application of protocols and guidelines, and helping to maintain contact as individuals move through a complex system, are hospitalized in local or state hospitals, lose stable housing, or become entangled in the criminal justice system. The EHR holds the promise of helping to reduce the enormous financial burden of paperwork and reporting duplication.

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