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Rethinking federal BH agencies

November 25, 2008
by Doug Edwards
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President-Elect Obama says he will examine the federal budget line by line to reduce waste and inefficiency. As part of that process, I hope someone in his administration seriously considers realigning the federal government’s agencies related to behavioral healthcare.

I've written about this before, and now seems like a good time to bring this idea up again.

Do we really need separate national institutes of mental health, addiction, and alcoholism, especially as we learn how prevalent co-occurring disorders are? Would we be able to close the science-to-service gap if we folded SAMHSA's grant-making authority into one behavioral health research institute? Couldn't ONDCP and CSAT better coordinate their prevention messages?

Most importantly, could the federal government do more for citizens with mental health and substance use problems at current funding levels (we're not likely to see more in this economy) by streamlining operations?

I hope someone in D.C. is thinking about these questions.



Ann, you raise a great point regarding HRSA. To the average citizen it probably makes no sense to have community health centers and community mental health centers often serving the same people, especially as public discourse on wellness grows.

Charles, thanks for bringing up all of those very important points. I do consider you an expert in this area! :) As a taxpayer, I expect and demand a more efficiently operating federal government, and I am not a fan of unnecessary bureaucracy. But as a behavioral healthcare supporter, I see your point that consolidation could have negative consequences.

I agree that there ought to be a review of all government agencies and consolidate wherever possible. In fact, I think this type of efficiency can be realized by all types of organizations.

Many organizations, similar in nature and mission, replicate their principles in the delivery of their services. This replication is wasteful, in both resource conservation and advocacy effort.

However, I think there ought to be hesitation in the conclusory statement regarding the prevalence of dual-diagnosis. There is widespread disparity, not only in the prevalence itself, but also, and more importantly, in the severity. These disparities affect both funding and treatment, and might warrant further consideration before proceeding forward.

Doug, I've asked the same question myself over the years. I'd be interested in reading Charles Curie's views on the matter. But there's another issue that's even bigger and II have to admit that it's pretty troubling to me. If I were in Washington, I'd be asking why the federal behavioral health agencies couldn't be merged into the Health Resources and Services Administration. Wouldn't delivering community mental health services through the local health centers be the best way to finally integrate behavioral health and primary care? Wouldn't it be more efficient and less costly? Wouldn't it be better for our citizens to have "one-stop shopping?" As much as I would grieve the loss, I think it's a question that we should be anticipating.

Ann, I do have thoughts on both the restructuring of the federal bureaucracy and on the opportunities in the first year of a new administration. First, we need to consider the risks of restructuring and combining federal agencies. What could we gain and what could we lose? Right now, we have three agencies (NIDA, NIMH & NIAAA) in NIH with clear research substance use and mental health missions and we have three centers (CSAT, CMHS & CSAP) within SAMHSA with clear services policy, funding and evaluation missions. A distinction was made years ago in creating SAMHSA so that there would be a clear focus on services administration and accountability. The head of SAMHSA is also a Presidential Appointee who is Senate confirmed, who reports directly to the Secretary of HHS and has access to the White House offices (DPC, OMB, ONDCP, etc.) and gives the fields of substance use treatment and prevention and mental health services a higher profile than if SAMHSA was combined with another agency. It was easier for SAMHSA to get budgetary attention and to garner support from the Secretary and the White House for priorities such as the establishing the New Freedom commission on Mental Health, addressing co-occurring disorders, shaping Access to Recovery, influencing SBIRT development, establishing the Strategic Prevention Framework, and addressing the integration of behavioral health and physical health services (to name a few priorities) because of the Administrator's position within the bureaucratic and political structure of HHS and the federal government. A combining of agencies could lower the profile of behavioral health. Also, just because agencies combine, does not mean integrated or collaborative efforts will take place. Effective efforts are usually the result of the right people leading and managing the right way.
Form should follow function, when we try to use form to force function much energy is expended in the restructuring both in attaining it and resisting it. I would be very concerned that precious time of the first two years of a first term could be spent on a restructuring agenda instead of pursuing clear goals around the services administration and research agendas. I am convinced that political will, effective leadership and expert management are the elements necessary to maximize integrated and collaborative efforts and make progress on critical agendas. As Secretary, Tommy Thompson expected HHS to function as "one HHS" and operating divisions responded by working together in unprecedented ways. We managed by the principle of "one SAMHSA", used a "matrix management" approach and the Center Directors and staffs demonstrated ever increasing collaboration in virtually all SAMHSA services and programs. The first year of a first term should be spent on establishing agreement on the vision, mission and priorities of a new administration and everyone needs to "hit the ground running" that first year around key priorities. You really have only the first two and one half years of that first term to establish and implement initiatives before the fourth year election cycle hits. So the time will be very precious from January of 2009 until late 2011. If programs are not underway by then, it can be very difficult to get any attention back on moving those programs until after the next election. So we need to be very careful when proposing restructuring as a solution to attaining collaboration and integration. It is best to lead and manage in such a manner as to realize those outcomes of collaboration and integration and then consider restructuring as a means for strengthening those efforts.

The expert comments above are most reassuring. The topic has come up from time to time in various national forums, and my fear has been that a blending of all those federal agencies could result in our nation losing both the baby and the bath water. Hopefully, if such discussions surface in the new administration, there will be a thoughtful and deliberate approach to reorganization. My guess is an initiative of this sort will not be among the immediate priorities. Long term at best.

Ann When I first came to Washington there was something called the Health Services and Mental Health Administration, of which the NIMH (then including all research, training, services, and prevention for mental health, alcoholism and drug abuse). Both then and through the many reshufflings that have occurred since, collaboration and coordination has been difficult to maintain as advocates and interest groups sought to advantage their own priorities. Most of the current programs resulted because their advocates felt they were getting short shrift within the then-existing structure. I agree with Charley that a lot of time could be wasted during the next couple of years if we focus on these organizational issues and stir up turf battles among the constituency groups. However, it is not a bad idea for smart people to put some energy into imagining the most effective structure. If health reform does come, there will clearly be an interest in restructuring the federal agencies to fit the new direction (and get out of the way of its development). And if we are serious about integration of behavioral health and the rest of health, this will be an important element for which to be prepared with ideas at the right time.

Doug Edwards

Vice President and Managing Director

Doug Edwards

Doug Edwards is Vice President and Managing Director of Vendome Healthcare Media’s Mental Health...

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