Supporting your desire to live free from self-destructive behavior as you embark on a life long journey of recovery.

Category Archives: Value Based Medicine

SCH participates in a visit to Congressman Roskam’s office to discuss the value of mental health.

On April 10, SCH was proud to send a representative to Congressman Peter Roskam’s office (US House of Representatives, Illinois’s 6th district) to discuss the value (financially, morally and otherwise) of providing people with mental health treatment.   This topic is of particular importance in today’s political environment given the movement to overturn The Affordable Care Act and more specifically the discussion around eliminating what is referred to as “Essential Health Benefits” in some insurance policies.  The discussion was initiated by Nancy Meier Brown, President of Meier Clinics Foundation, and we were joined by representatives from Timberline Knolls Residential Treatment Center, NAMI DuPage, Northwest Community Healthcare and Linden Oaks.

What we all know is that healthcare today in this country is a complete mess.  With total spend at nearly 20% of our GDP and with a system that is fragmented, unorganized and full of waste, what we have today is unsustainable and we all deserve better.  A system that is more fully integrated, more organized and measured based on its results is what we believe is the long term solution.  What many don’t know, apparently, is that some don’t feel like mental health deserves the same treatment as other illnesses and diseases, as if disease of the brain somehow isn’t on the same level as disease, for example, of the heart.  Though we all know someone who has been touched with one form of mental illness or another (from depression to substance use disorder), the fact of the matter is many still don’t feel these diseases deserve the same level of compassion and treatment that other diseases have received for decades.  Maybe it is because of stigma or maybe it is because of the ignorant belief that mental illness is often a “poor choice” rather than an unavoidable disease.  For those of us in the room with Congressman Roskam last week, frankly we simply do not understand why or how we are even discussing eliminating mental health benefits given what we know and see every day, and what the data and literature all support.   Yet the conversation is happening, and that is why we were there last week.  To plead a case that needs to be plead.

Hopefully in an attempt to support our case, we were asked at the meeting to present the Congressman with some facts as to why it makes sense to continue to fund mental illness treatment.  Though to us this is intuitive and we don’t see cardiologists being asked to make the case for why heart disease treatment should be covered by benefits, the data he asks for exists, and we will of course oblige him with his request.  That said, this is yet another wake up call for all of us that our world of caring about those who struggle with behavioral health issues is under utter attack at the moment.  The parity law is great, but there is no parity, and things appear to be getting even worse.

Some of the data we will be presenting is as follows.

First of all, proper treatment works.  For major depression, panic disorder and obsessive compulsive disorder rates (of improvement) are about 70%.  This is comparable to rates of improvement for people who suffer from physical disorders, including diabetes and asthma at 70-80%, cardiovascular disease from 60-70% and heart disease at 41-52% (12). 

The National Institute on Drug Abuse estimates that every dollar invested in addiction treatment programs yields a return of between $4 and 7$ in reduced drug related crime, criminal justice costs and theft.  When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1! (13).

The US Department of Health and Human Services estimates that for every $100,000 invested in treatment for substance abuse (measured in California, New York and Washington), there are savings of $484,000 in health care costs and $700,000 of crime costs were shown to be avoided.  (14)  In a comparison of medical expenses of Medicaid clients who received treatment, the following savings were noted (measured in Washington):  $170.00/month for patients receiving inpatient; $215/month for those in outpatient treatment, and $230/month for those receiving medication assisted therapy (specifically methadone).  In California treated patients have been shown to reduce ER visits by 39%, hospital stays by 35% and total medical costs by 26% (14).

Just by integrating medical and behavioral services, The National Council for Behavioral Health estimates that between $26-$48 billion can potentially be saved!

Thanks to Nancy Meier Brown for including us in this discussion, and thanks to the Congressman for taking the time to meet with us.  Clearly there is a lot of work to be done, and it will be done.  We have no choice.   Our patients and their families deserve every ounce of time we can devote to advocating on their behalf.  Please join us in the fight.

The customer is always right

The customer is always right…
By: David Newton, Director of Operations

“The customer is always right” is a slogan by which most successful businesses live and die.  We learn early in our careers that we must listen to “the voice of the customer.” “No” is a word we don’t use when talking with customers, and a disappointed customer is one who will likely not be around for very long.  Solving problems and providing solutions for customers is what lies at the essence of all successful business, and as we do so we want a happy customer whose interests are aligned with ours and who feels taken care of and listened to.  Business people have entire departments (sales) dedicated to making sure that the customer is not only “always right” but also that they are never told “No” and that  ultimately, they are happy.  Success is optimized when there is alignment and a “Win-Win” dynamic in place. In this respect, medicine is not unlike any other business.  We are solving problems by saving lives. We want positive outcomes for our patients and we do well if they do well.  We too want happy patients, but not at the expense of quality of care, and this is where things differ.

As stewards of knowledge that our patients may not have and having taken the oath to place others interests above our own, we simply cannot make every patient happy all of the time.  We want them happy, if for no other reason than a happy patient is one who is more likely to stay committed to long-term recovery.  However, it’s not that simple. 

In treating those who struggle with addiction and other behavioral health issues, we find ourselves at this crossroads nearly every day; patients who want medications that we know aren’t good for them and patients who need more care than what we might be able to provide are two issues which come up regularly.   Another is optimal group size for treatment.  Deciding what to recommend to a patient becomes even more challenging when there is not necessarily a correct and incorrect answer.  For instance, what exactly is the optimal group size for treating complex co-occurring eating and substance use disorders?   Is it 6, 8 or maybe 10?  The answer, it depends….  Deciding whether a patient needs IOP, PHP or Residential is another one where there is not always a black or white answer.   ASAM has specific criteria for determining the appropriate level of care, but anyone in this field knows there is always some subjectivity as to what is best for the patient and that can easily lean either way depending on who is doing the analysis.  Is it always the right decision to deny prescribing a stimulant such as Adderall to an addict?  The answer is generally yes, as this medication is addictive in and of itself and it further dissociates people from their insides- all bad for the addict.  However, it could be helping with ones ADHD, in which case there could be an argument made to keep the person on it.

At SCH we have disappointed several patients because Dr. Kim would not prescribe a medication which she believed would be harmful to the patient.  We have disappointed several because they wanted very badly to join our IOP but our clinical team felt it was best to say no either because our group size was already too big to provide optimal treatment, or because we felt a HLOC (higher level of care) was more appropriate for the patient.  These decisions have in all cases lead to “unhappy” customers, yet any good clinician who puts their patient’s interests above those of themself would have made the same decision.  Making such decisions to say “No” to patients is one that is never easy, as we all want to help everyone, nobody really wants to turn anyone away and we are all human- it is hard to say “No”.  However, good clinical care in this field requires “No’s” all the time, and with good clinical care comes good long term business.

Medicine is unlike any other business.  It requires us to say “No” all the time because that is what is in the best interest of our patients.  Of course we want happy customers!  More importantly, we want healthy customers who can recover from these deadly diseases.  In time and with recovery, our hope is that these patients will look back and be grateful for the course on which we helped them stay.  For the team at SCH and because of Dr. Kim’s unwavering commitment to always doing what is best for her patients, we know nothing else. 

What Does Repeal and Replace Mean for Mental Health Treatment in America?

Despite all of the politicians involved, this really is not a political issue. It will be resolved through legislation and a lot of politicking, but at the end of the day this issue affects every single one of us, directly or indirectly. We all care about people who struggle with these diseases. We all have family members and friends who struggle with these diseases. Mental illness does not discriminate based on one’s political beliefs, religion, gender, class, ethnicity, or the color of one’s skin. It affects every single one of us, it can be deadly, and we all care, regardless of our political beliefs.

We don’t really know how this will end. However, the reality of the proposed legislation is that if the roll-back begins on “essential health benefits”, we are all at risk. It is the ignorant and misinformed mindset that somehow coverage for mental health is not “essential” that we need to be most concerned about. Those who think they know this to be true are wrong and those who feel this way simply do not have the facts. Ensuring mental health coverage for everyone, or at the very least ensuring that mental health is treated on par with other illnesses, is the right thing to do and it adds value to society in just about every way imaginable.

It will likely take months, maybe years, for a true “repeal and replace” to come to fruition. One can hope that when it does happen, mental health remains a priority, or at least on par with other medical conditions. What has been proposed thus far is indeed extremely concerning, yet we must remember this is just an initial proposal. This is a negotiation. We must keep this in mind and we have plenty of time and opportunity to make our case.

At the core we need to remain focused on key issues, such as increased access to care, real parity, de-stigmatization of these diseases, and ultimately integrated, increased access to treatment for all human beings. This work is truly meaningful. Our patients need us to advocate for them. They deserve it. We can reach out to our congressmen and congresswomen, write about and speak about the issues at every opportunity, and support groups like The Kennedy Forum, who will undoubtedly be continuing to take a leading role in the fight against this misguided mindset and peacefully fight for justice at every corner. 

We also believe this is the perfect opportunity for all of us to work together to show the true value of prevention, early detection, and treatment for those who suffer from these diseases. Although is not about money at all for those who genuinely care about the individuals needing their help, if new legislation listens to one thing rational, it is cost. Most of us know that the treatment we provide and the time and money spent on prevention ultimately saves our patients (and society) money. This shows itself in direct costs, such as reduced medical co-morbidity costs, and indirect costs, such as reduced workplace absenteeism and increased productivity. It also makes people healthier, happier, and more productive members of society. We improve medical outcomes that matter to our patients and we do so in a way that saves money for all of us! In other words, we provide value to our patients, their payers, their employers, their families and ultimately to society and government. As we show the world the data that supports these facts (much of which is already well publicized), we will be in a stronger position to protect those who need our help the most at this critical time.

At SunCloud, we understand very well just how difficult it is to quantify the value we as treatment providers are creating for our patients and their families. Unfortunately, most don’t care and few want to listen. Today can mark the beginning of a new day for all of us. By working together to prove to the world just how important it is to support people with mental illness, we can protect the interests of our patients and ensure the best possible outcome for them at this precarious time in history. By focusing on our patients and what matters to them, and by working together to continue to do what we know is right and worthwhile, we will not lose this battle. We can’t lose this battle. Prevention and treatment does in fact create value and we have come too far to settle when this much is at stake.

Prevention and Early Childhood Trauma-from a dad who could have done better

Solving the addiction crisis in America is arguably one of the most challenging crises we have ever faced, particularly in recent decades.  It is not the only one, but it is serious and wide spread.  Like many other complex problems, we face as humans, we will likely never eradicate the world of addiction.  There are cultural, biological, social, and genetic components to it which are all intertwined and which we are just now beginning to really understand.  

Yet as the problem has reached the “epidemic” proportion, it seems that there is far more focus on treating the disease and not nearly enough on prevention. One area of prevention in particular, which we do not talk a lot about, starts at home with healthy, present parents.

Treating the disease of addition, no matter how it manifests itself, is incredibly important.  Saving lives is ultimately the only thing that matters and effective, evidence-based treatment is capable of achieving amazing and proven results.  Integrated treatment centers, programs such as “A Way Out” and “Text a Tip” in Illinois, helpful medications, and drugs like Naloxone are all incredibly useful. Without effective treatment, we would undoubtedly be far worse off than we are today.  Further, evidence-based prevention programs such as “Botvin Life Skills” in schools, talks with our wiser elders, and reminders throughout our lives to avoid certain self- destructive behaviors are all incredibly helpful.

The one piece we seem to be missing is the fact that many of these issues, which come up later in life, start early on with our children as their brains are developing, particularly as they deal with loss and trauma.  The data and literature show a direct link between early childhood trauma and addiction.   Though I am not a therapist, I have zero clinical training, and have done no research myself on the effect that early childhood trauma can have on children as they grow older, I am a believer.  Many minds far more brilliant than mine have published many compelling studies on the direct correlation, and I shall leave it to them to defend their thesis in the event anyone out there does not believe it.  D.W. Winnicott (the late British child psychiatrist) defined trauma in early childhood as, “two things that can go wrong in childhood: things that happen that shouldn’t happen — that’s trauma — and things that should happen that don’t happen.” Early childhood loss is the essence of what trauma really is and when we recognize and admit that to ourselves, we realize there is so much more we can be doing (or not doing) as we raise our young children. 

For me, I never thought of my children’s early experiences as being anything close to “traumatic”.   There were no murders, no suicides, and no rapes.  We did deal with one natural disaster, but we were able to escape before it hit and fortunately nobody was injured.  My kids went to a good school when they were young, my family was always around, my kids played all sorts of extracurricular sports, had friends, we took vacations, etc.

Looking back, however, we had all sorts of trauma in our household as my two older kids were young. Some of it was avoidable and undoubtedly causing problems today, which is what keeps me awake at night on occasion and motivates me to share like I am doing today. For instance, I was, and still am in many ways, addicted to work. When I was home, much of the time I was not emotionally present for my kids.  I was on my phone, checking emails, or just generally distracted living mostly a fear based life. I was in a horrible marriage. When we were together as a family I was anything but present and the tension in the home was palpable I am an anxious person and have been for a long time – worried about work, worried about making money to feed my family, worried about just about everything.  Most people can’t see it, but my kids know it and it affected them – it still does.  My ex-wife and I had a cantankerous divorce.  We both played very aggressively, fighting for just about everything, and the kids got mixed up in it in ways that were both avoidable and unnecessary.  Their mother struggled with substance use and, for several years, she was essentially gone.  This was a huge loss to my kids and one that, to this day, they have not quite gotten ahold of.  Looking back there was lots and lots of trauma for my two older kids and today one of them is showing concerning signs which the data very clearly could have predicted.

My advice to future parents, parents of young children, and the all of us who are concerned about this epidemic of addiction:

 Be aware of the fact that early childhood trauma can increase one’s chances of becoming addicted to some form of self-destructive behavior as they get older.

Trauma is not only defined by life’s horrible events such as rape, murder, war or natural disasters.  It is much more broad that that and includes things such as unavailable, distracted, or stressed parents and events such as divorce.  In our society where many of us are stressed to the core, we have got to know that this takes us away from our kids and as they see this as a loss, therein lies a form of trauma.

What we can avoid and do better with as parents, we should. It starts with being aware of the long term consequences of our behavior. Yes, this is much easier said than done, particularly in today’s high stress, fast paced dog eat dog world.  However, the importance of creating a nurturing, safe, and stable environment where we are present and available while our kids grow and their brains develop cannot be understated.

For me, the silver lining is that Kim and I are raising our 2 ½ year old son with this awareness.  Though nothing is ever perfect, both of us do what we can to provide him with the loving and nurturing environment he and his brain need and deserve right now. Life will throw curve balls and we will inevitably have a child at some point who blames all of his troubles on his parents. Yet our hope is that we are currently living a life that is conducive to the state he needs us to be in, and we can try and live this way because we are aware. Living a trauma informed life is something we should all aspire to.  Knowing what can constitute trauma to our child’s brain is crucial if this is something we want to try to avoid.  There is currently so much focus on treating addiction once our kids get older and they find themselves addicted or in some form of self-destructive behavior pattern.  Starting earlier, I believe, is critical.  For those of us fortunate to be able to do so, we owe it to our kids to do nothing less.

SINGLE CASE AGREEMENTS, SELECTIVE CONTRACTING AND DOING WHAT IS RIGHT FOR THE PATIENT

Having spent nearly 25 years in a business completely unrelated to healthcare before studying under some brilliant minds at Kellogg Northwestern and Harvard Business School as I was earning my MBA, I feel I bring a fresh, albeit sometimes naïve, perspective to the business of healthcare.  Wherever possible, I try to use this to our patient’s advantage. Our patients need and deserve as much advocacy as possible, to include from those who come from other industries and see best practices not being performed in healthcare. A few of the things in our area of behavioral healthcare that are exceptionally bothersome to me include:

Lack of transparency on prices and quality

Lack of meaningful and universally accepted outcome measurements that patients and payers need in order to know who does what and how well they do it

Lack of meaningful accountability on all ends

The fee for service model

The damage caused to patients by care that can sometimes be so incredibly fragmented, unintegrated, and poorly aligned.  

Recently I had to deal with something that simply did not sit well, and what unfolded so negatively impacts our patients that it is worthy of discussion. Several weeks ago, we received a call from a person who wanted to learn more about SunCloud Health (SCH).  It turns out the individual had seen Dr. Kim, Founder and Medical Director at SCH, when they were at Timberline Knolls (TK), then under Dr. Kim’s leadership, a few years ago. She had developed a great relationship with Dr. Kim while in treatment at Timberline Knolls and wanted to learn more about what Dr. Kim is now doing at SCH. At the end of the initial evaluation, it was determined that this person was an ideal fit for the services provided at SCH, not to mention the fact that the person had a previous therapeutic relationship with Dr. Kim which, at the time, resulted in a dramatic improvement in the individual’s life.  Research in the mental health and addiction field supports the notion that an individual’s relationship with their therapist is a key and integral factor in treatment.  

The woman mentioned above was ready to start treatment at SCH the next day. The only problem with beginning treatment was that we were not in-network with her insurance company…YET.  In fact, as of the time of this situation, we had been in the process of negotiations for months with this insurance company and had been told that we were close to finalizing a deal to go in-network with them. Thus, they know who we are and that we have all of the quality credentialing they need to feel confident in the care we provide. In addition, they know of Dr. Kim through her experience as CEO and Medical Director at TK.  That said, at this time we were not officially in-network and this patient needed to use their insurance to pay for services. As a result, we did the only thing we could do under these circumstances and applied for a single case agreement that would provide an exception to allow us to treat this particular patient at rates at or near those that would apply if we were in-network.

With this patient, we felt our case for the exception was pretty rock solid. As a part of our proposal, we also made an offer to the insurance company that, to the rest of the world, would seem “impossible to pass up”.  Our case to the insurance company included the fact that the patient had had a good therapeutic experience with Dr. Kim in the past which resulted in positive outcomes, she was committed to working with Dr. Kim and the treatment team at SCH, and we at SCH felt that we could provide her with what she needs at this point in her life. Medical necessity was clear according to American Society of Addiction Medicine (ASAM) criteria AND we offered to provide service at WHATEVER PRICE the insurance company was willing to pay us.  We made it clear we would literally do it for any amount of money.  One would think all of this would have been enough.

Despite all of this, the decision was unfortunately as feared – DENIED.  It was denied on the basis that, according to this insurance company, there are other treatment centers in our surrounding area who are in-network with this insurance company and can provide similar services. Therefore, the member should go to one of these other “comparable” facilities.  They did not care that we were willing to provide treatment at whatever price they wanted, and they apparently did not care that the member had a good relationship with Dr. Kim and felt if anyone could help her, she and the team at SCH could. Thus, if this woman wanted to receive treatment at SCH, she would need to pay for it herself with her “out-of-network” benefits, which means no discount from the insurance company and self-pay. Although we proceeded with this woman, we were left dumbfounded as to why this case was denied.

First, it is not true that there are other outpatient treatment centers in our area providing similar or comparable care.  What we do here with co-occurring disorders and how we do it is relatively unique.  Most in our area treat one symptom or the other and they do so by tracking people based on their “primary” symptom. Rarely do they treat more than one symptom in one facility and, even more rarely, do they spend as much time getting to the underlying cause of the self-destructive behavior as they do on the symptoms.  And even if I am dead wrong about this and there are dozens who do exactly what we do within 2 miles of our location with equal or better outcomes, how would anyone know? We don’t measure or compare standardized outcomes in this field! This drives us crazy here at SCH. We are advocating every day for the inherent value of outcomes and the shift from fee for service to value based reimbursement, but for today, it’s not happening.  Thus, none of us really know what is true and what is not true with regard to who does what and how well they do it.  To deny based on what is really nothing more than a guestimate is just plain ignorant and wrong.

Second, treating a person with depression or an eating disorder or some form of deep trauma is not the same as replacing a knee or fixing a broken wrist.  Yes, we all need to feel comfortable with the doctor from whom we seek treatment for any ailment, but WAY more so in this field than in any other. There has to be a high level of trust and an unwavering sense of safety in the Doctor/Patient relationship when treating these illnesses. The data shows this is a critical piece of treatment which leads to improved outcomes and it should be weighed heavily when considering whether or not to support a patient in getting help from someone with whom they feel safe and have a good and healthy relationship.  This was the case here and yet it did not make enough of a difference.  In our opinion, this alone should have been basis to approve the single case agreement.

Third, we literally offered to treat this person for essentially any amount the payer wanted to pay us.  At first, this really got me that this went in one ear and out the other.  After all, we are on the verge of entering in to an in-network agreement with this insurance company and never before have I had such a good product or service and offered it at “any price”.  After all, we meet all of this insurance company’s quality criteria for such agreements.  They know us, they know our Medical Director and CEO, and they know that she has an exceptional reputation in this field. If they didn’t know all of this, I would expect a denial.  It wasn’t as if we were approaching this insurance company and asking for $1,000.00 per day for treatment when their contracted rates with their in-network providers is $250.00 per day! If this were the case, I would expect a denial.  In any other business, the buyer would have accepted our offer 10 times out of 10, yet not here. 

I was so bothered by this denial that I reached out to one of my former business professors who is now teaching business strategy in healthcare at Harvard Business School. Admittedly, she was able to help me at least think through it a bit. Her response, from an economic perspective, was that economists believe “selective contracting” is necessary for lower negotiated rates and therefore this was likely the basis of the denial.  Part of the in-network process includes negotiating highly discounted rates for insurance companies and their members from a select group of providers in exchange for volume. She also noted that if the insurance company agreed to pay for this woman to be treated at a facility not currently in-network it could potentially upset some other provider in the network. Needless to say, neither reason seems anywhere close to enough basis to deny care in this case.  Illinois does have an “any willing provider” statute, but it does not apply to this case unfortunately.

In thinking through the concept of selective contracting, I, of course, understand the concept of having networks with a select group of suppliers who provide similar products and driving cost down from them in exchange for volume.  In my experience, I have found this negotiating technique to be most useful when demand is greater than supply, and in general, the technique can be useful with many businesses and maybe even some areas in healthcare- BUT NOT OUR’S!  A patient’s interests should come before the interests of the network, especially if it is a case such as this one.

Further, we currently do not have the means by which to evaluate or compare “precise products” in this field.  Thus, how can an insurance company select whom they will contract with and whom they will not contract with (and at what price) if they don’t even know who really does what and more importantly what they do and do not do well?  Second, even if we ignore this and were to concede the value of selective contracting in our field, is this really a legitimate and moral basis for denying a patient the care that they want and need? I would argue someone’s life is far more valuable than upsetting the apple cart with the “network”, especially if it can be done at a lower cost and at least as well as others.  Third, in the outpatient treatment of co-occurring disorders, demand is far greater than actual supply. Good providers are needed and patients are suffering as a result of care that often does not meet their needs! Many say they can treat what we treat at SCH, but the reality is few actually can.  In fact, this is one of the reasons Dr. Kim started SCH.  In her role at the residential level at TK, where they do treat co-occurring disorders, she and her medical team would often struggle to find patients an outpatient treatment center that was capable of continuing with the relatively sophisticated level of treatment that their patients would receive while in residential.  The reason for the struggle is that not many exist.  This would often lead to relapses and re-admissions and is one of the reasons why Dr. Kim is so interested in providing this quality of care at the outpatient level – she knows there is a high level of need!  When demand for a product or service exceeds supply, selective contracting can be useful as a means to offset some of the supplier’s “power”.  However, when a supplier is willing to provide a product or service at “any price”, negotiating is simply not necessary.

Our patients face so many obstacles and barriers in getting the right treatment at the right time for their specific needs.  From stigma to not knowing where to go and why, patients often rely on their insurance companies to help them make the right decisions. In this case, the right decision was to grant this single case agreement exception that we filed on behalf of the patient. There was no economic, moral, or medical reason to deny it and lots of rational and compelling reasons to grant it.  Our hope is that nobody has to experience what this patient went through with this case.  Our patients deserve more and better care from all of us.  Allowing a provider like us to treat this particular case was the right decision for this patient.  All of us benefit when patients heal.  Our interests should be aligned.  One day they will be.  I believe that. 

 

How Do We Make Decisions On Where To Go For Help When There Is No Reliable Data? OUTCOMES!

I read an article over the weekend which focused on helping the consumer find the right provider for mental health services when they may need it.  Given the myriad of treatment options out there today, the unethical behavior by a few, the immense amount of marketing dollars spent on appealing to a sometimes naïve and desperate consumer with pictures of swimming pools and mountains, I found the article to be refreshing and very insightful. It was clearly written by someone who has been around long enough to understand the pitfalls one can easily fall in to when faced with a mental health crisis and someone who clearly cares about patients and their families.  The author lists the following criteria that one should ask a provider when seeking or considering treatment options. Many of these are good to know, a few (I think) are not overly helpful and many probably mean a lot more to professionals than to a consumer. The last one, however, is critical to all of us. It is written as, “How does the treatment provider measure success?” and it deserves recognition and further conversation.

· How is your program licensed? (Residential, IOP/ PHP or ?)

· What is the length of the program?

· What do you do for detox if needed?

· Where are your services provided?

· What is a typical day in your program?

· What is your relapse policy?

· What is your maximum patient capacity?

· How do you work with co-occurring issues?

· How many on your treatment team have Masters Level or above educations?

· Are there medical personnel on-site 24/7?

· What does insurance cover?

· What is your cash pay cost?

· If a client leaves treatment early, is there a refund for unused amount

· What age group/gender do you serve?

· How many one-on-one sessions does a client have with Master’s Level or above clinician per week?

· Is the client expected to prepare their own meals (sober living level) while in treatment?

· How often do you drug test?

· Are phones and computers allowed?

· Is there a family program? If so, please explain.

· Do you have an MFT on staff (Marriage and Family Therapist)

· Is there an aftercare program?

· How does the treatment provider measure “success”?

As with any purchase, the right choice for a buyer is subjective. People make decisions based on what matters to them and what value they may place on something (referred to sometimes as a consumer’s “reservation price”). Some place price above all else whereas others include additional criteria such as quality, convenience, turnaround and durability in their decision making process. Some people buy from a brand or a particular company regardless of cost whereas others shop around and compare products as they make their decision. What is common is that most rational people who are spending their own money like to have some reliable and relevant information on the products or services they intend to purchase prior to making their decision. In most cases people tend to use that information to compare products and services across multiple sellers; for example- if I can buy an 8 ½ x 11 piece of white paper for 2 pennies from a seller 5 minutes away and I can buy the exact same piece of paper for 1 penny from another seller 5 minutes away (the other way), all other things equal I am going to buy from the 1 penny seller. If my intention is to print on that piece of paper I would want to know that the print-ability of the two papers is comparable. 

In this simple example if I am unable to ascertain whether or not the two papers are of similar quality, it would be very difficult for me to make a rational decision on which paper to purchase. In fact, I probably wouldn’t buy either! It could be that the 1 penny paper is completely ragged and will not run through my printer. If my goal is to run the paper through my printer for a wedding invitation, this paper could cost nothing and I still wouldn’t want it. Looking at it another way and assuming now that the 2 penny paper is a much nicer shade of white than the 1 penny paper, if I can afford the 2 penny paper and a nice shade is something that matters to me, then I would likely buy the 2 penny paper. 

Having this information is not only helpful as we make an assessment on who to buy from but it is also helpful for both sides (the buyer and the seller) as to what the agreed price is and in exchange for that price what the buyer should expect to receive in return (the bargain). For instance, if I agree to buy a sheet of paper from either seller which is supposed to measure 8 1/2 x 11 yet when it arrives at my office it measures 8 ½ x 5 ½, then I know I have not received what I bargained for. Maybe the seller made a mistake, maybe there was a problem in production or maybe I ordered the wrong size. Assuming I did not make the mistake, having had this information up front enables me to hold the seller accountable for what she agreed to sell me in the first place. In this instance I have the option of sending the wrong size back or possibly I bargain for a reduction in cost given the smaller size of the paper I received. If it was unclear what size I was going to receive when I agreed to make the purchase, I would have an impossible time holding the seller accountable for what to me is nothing short of an error.  

The point is we need information in order to make decisions and yet in healthcare, particularly in mental health, this information does not readily exist for the consumer. This makes the decision on who to see, where to go and when to go nearly impossible.  In mental health we currently rely on word of mouth, referrals and marketing materials.  This works for some but not optimally for many. Fortunately, this is changing as the focus is turning to having reliable and relevant data from providers which measure outcomes (results) and value, just as we had in my simple example of the paper. That said, the reason we are living in the dark ages at the moment is not necessarily because providers are inherently not interested in providing data for consumers. Rather, it is because there is currently very little in terms of universally accepted outcome measurements that the field agrees are relevant, it is extremely difficult to measure these outcomes with our patient population and it is even more difficult to risk adjust- which is critical if we are to use outcomes to make decisions.

Some providers are tracking functional outcomes such as follow up visits made and medication adherence. Some are tracking re-admissions and relapses. Others are tracking using tools such as Beck Depression Index, PHQ-9 and the Addiction Severity Index. While all of these measurements provide valuable data for both patient and provider, unless we all agree on universally standardized outcome measurements for the diseases we are treating, we simply cannot compare one provider to the next. Esteemed groups such as ICHOM have recently established a standard set of measurements for depression that the world is being encouraged to use. However, to date there is nothing for substance use disorder nor eating disorders, and this is troubling.

To make matters more complicated, risk adjusting our patient population is extremely difficult to do and yet it is a critical piece of data one must have when evaluating outcomes. For instance, if you have two providers who treat eating disorders and one sees only patients who have been hospitalized at least three times whereas the other sees patients who have never been hospitalized and whose disease is generally caught early, looking at an outcome such as readmission rates in a comparison between these two providers will tell us nothing. Of course the provider who sees the higher risk patients is likely to have a significantly higher relapse rate that the provider who sees the lower risk patients. Does that mean the former is not as good of a provider? Absolutely not. Only once risk adjusted do outcomes in this field mean anything when comparing providers.

When one is measuring a patient reported outcome measurement such as level of happiness or self- content on a given day, in this field we all know our patient population’s answer can sometimes be subject to the effects of the very illness we are trying to treat. Relying on an important outcome such as this can therefore be potentially misleading.  Yet this is the type of outcome that matters most to our patients and capturing the accurate answer when we want to know it can be incredibly powerful.

Comparing results across multiple providers is what is ultimately most important to a consumer as they attempt to make a rational decision for themselves and their healthcare, given their specific situation. In mental health we want to know what a provider is particularly good at, and what they may not be so good at. If our goal is to truly live free from the disease of addiction, then we probably do not want to work with an eating disorder provider who focuses mostly if not exclusively on achieving a certain weight for a patient. It would be similar to going to Burger King for a 5 dollar meal if what you really wanted was a 50 dollar steak from Morton’s. Yet we know not to go to Burger King for a really good steak because we have visibility in to what each provider really specializes in.

If our goal is to get back to work and live free from our active addiction, and we are able to compare three providers against one another and all three show relevant outcomes that are more or less comparable and yet one is 10% less expensive, then we want to know that. If a provider advertises that they are experts in treating co-occurring disorders, then we want to be able to see what happens 3 and 5 years out for their discharged patients…. How do we know if a provider is truly an expert in treating the more complex co-occurring cases? We would know if that provider and others who claim to do the same are tracking and measuring relevant outcomes that matter to the patient who suffers from a co-occurring illness. If someone says they specialize in co-occurring disorders and yet the data shows that the majority of their patients post treatment over a 5 year period re-admit to different specialists in eating disorders and anxiety, then maybe that provider really doesn’t specialize in treating co-occurring cases but rather what they really do well is treat people with less complex substance use disorder cases. 

Once we have outcomes and results available to consumers, we can begin to rely on those results as we make decisions and we can hold our providers accountable for delivering those results to me. Let’s say in a perfect world (the future) I am a consumer and I present with a risk adjusted case of substance abuse category “A”. I am able to pull up data on three providers who specialize in treating what I have. The reported outcomes that matter to me are all essentially the same. However, two of the three quote a price of 20 and estimate the time I will be in treatment and away from work at 5 days. The third provider quotes a price of 30 but estimates the time I will be in treatment and away from work at 3 days. If I have the means and if getting back to work is very important to me, I may choose the third provider. Granted I am paying a little more but in exchange I am getting something that is of value to me. Let’s say, however, that for reasons that don’t have to do with me interfering with my treatment (KEY AND NOT SIMPLE), I choose the third provider and yet after all is said and done I am in treatment for 6 days. First of all, having had the information I had before making my decision on where to go I am in a much better position to hold my provider accountable for the extra 3 days I was in treatment. In other words, when they come to me and ask for another 30 because of the extra 3 days, I don’t fork over the money without a thorough analysis of what went “wrong” and who should be held accountable for the extra 3 days’ worth of treatment….. There is a measure of accountability that comes with having data prior to making a decision. Patients can hold their providers accountable for their side of the bargain. One may think this is horrible for providers, yet it is not at all. This type of risk sharing inherently incentivizes providers to be more efficient and effective with everything they do from diagnosis to treatment to follow up. And it goes both ways. In this example if I chose the 30-dollar provider and they treated me in 2 days, conceivably there is a savings of 10. If the provider gets to share in that savings, there is incentive, motivation and an inherent alignment of goals. Risk sharing can’t go just one way. That’s not fair to providers and it will never work.

If we are all measuring ourselves against one another using standardized outcomes, then we know what we are good at and we know what we may not be so good at. With this information, we can choose to focus on improving where we need to and can improve or possibly get out of the business of what we may not do so well and focus on what we do exceptionally well. This would be good for all providers and all patients. We can’t all be good at everything, yet what we are really good at is where we should be focusing our time and energy. This makes good business sense, and it is good for patients.

The outcomes that we are measuring must be standardized and relevant, and they must be results that matter to patients. Without this, a consumer can look at the best data in the world and have no basis with which to compare providers against one another in an effort to find what works for them. This is how markets work. It is normal, and this is where healthcare is headed. Getting there with mental health is anything but easy.  However, as providers and payers work together to establish mutually agreeable standardized outcome measurements, we will get there. And when we do, our patients will be ecstatic as the quality of care will naturally increase and no longer will patients be forced to live in the dark ages as they make decisions at an incredibly vulnerable time in their lives.

A Disturbing Conversation with my 14 Year Old Son…

This is a kid who painfully and with a tremendous amount of sadness watched for years as his mom suffered/suffers from a major substance use problem, whose father was hospitalized for an eating disorder when he was a teen and whose step mother is arguably one of the nation’s most well respected psychiatrists in the field of treating substance abuse and eating disorders. This is a kid who has spent countless hours talking with his dad (and his step mom) about why he needs to be very careful with the choices he makes given his specific genetic predispositions for addiction as well as his the environmental and social factors he is faced with as he grows up on the Northshore of Chicago, a relatively affluent part of the city where much of the culture is ok with “some” use (of illegal and illicit substances) amongst teens so long as it is not “excessive”…  Nearly every member on his maternal side of the family has a substance abuse and or fairly significant mental health issue and many on his paternal side have much of the same.  He himself already shows signs of obsessive thinking and addictive behavior with relatively harmless behaviors such as his phone use, girls and food.

Four years ago before we moved out of the city this kid swore up and down, left and right that never would he even be interested in trying “drugs or alcohol”.  He watched as his mom would simply not show up for visitation and would then disappear for days with no contact, he would get in to the car as it wreaked of booze and cigarettes, he was the victim of wild mood swings that we would later attribute most likely to substance use (or withdrawal).  He was vocally angry and disgusted.  He understood.  We talked about it.  There is no doubt that this kid knows first-hand just how powerful these substances can be, how addiction can take over and ruin one’s life as they may know it today and that he needs to be very careful about the choices he makes as he enters that period in life where this stuff is going to be available almost everywhere he turns.

AND YET, the conversation last night was around how “most parents” of his peers don’t have a problem with their kid (he’s 14!) drinking a little or experimenting with what they now call “weed”, and that his step mom and I are anti-drug “Nazis” because of our zero tolerance policy around using anything that is considered illegal or illicit.  He now seems utterly shocked that we would expect him to abstain from alcohol until at least the age of 21, and he was just letting me know that it was “kind of a bummer” that he and I would not be able to have a “beer” together because he would not feel comfortable drinking around me knowing how I feel and what our rules are.  He says we are the only ones who actually call other parents on a Friday or Saturday night before we let him go out to make sure they will be home and that they know our boy is headed over there, and he can’t stand it.  He says his friends and even some of the parents think we are nuts.  I believe some of this, as a few times the parents have outright lied to us.  And many times the kids try to lie, but we catch that before it goes too far.

It was like talking to an alien last night!  This was not my kid from just a few years ago who sat with me crying in front of our house when he was 8 waiting for his mom to never show up because she was out all night getting completely wasted.  This is not the kid who I have spent countless hours talking to about him and what he needs to be careful with, because of who he is and where he comes from.  This is not the kid who was disgusted by even the thought of drinking and smoking, just a few short years ago!   I attribute some of these dramatic changes in him to being a teenager and a lot of it to living in a culture where there is in fact an implicit message being sent by many parents that “some” use is acceptable, that “weed” isn’t that bad and that if the kids are going to drink then they should stay at home and drink as opposed to going out…  Kids pick up on this, they use it to their advantage and they run with it.  It’s a terrible message and it has got to stop.

I recall last October picking up my daughter at a party (she was a sophomore then) and not only were many of the kids drinking but the mom approached me in the parking lot defensively and completely wasted.  This was the same mom we had called earlier in the evening to first ensure that they (the parents) were going to be home and second that the Halloween party was going to be supervised and drug and alcohol free.  Clearly she lied.  Why wouldn’t these kids feel free to get wasted with her???

My son tells me there is drinking going on at nearly every party every weekend amongst his peer group.  When I ask where the parents are, I am told they are “out”.  Several times my kid has tried to get over to one of these parties yet if the parents won’t confirm they will be home, he doesn’t get to go.  Do the parents really not know this is happening in their home?????   I find this nearly impossible to believe.

I have tried on several occasions to talk with fellow parents whose kids are friends with mine and who are apparently using, in an effort to possibly work together to talk with our kids together.  It is all denial.   Nobody wants to believe their kid is using and even if they believe it, so long as it’s not that bad, it’s not a problem….

I will leave the data and the statistics to another day (and to my wife) but I think we all know very few who ultimately die of an overdose of an opiate do so without first trying and starting with alcohol or “weed”.  Addiction is a progressive disease.  Some of it is genetic/biological and some of it is environmental.  When one is genetically predisposed to addiction, the family and that individual have to be extra cautious.  Yet when living in a culture where society condones the use of some substances, I can speak from personal experience that the battle can start to feel completely futile.  How can I as a parent of my 14 year old, knowing what I know and having seen what I have seen, compete with my parenting standards against what my boy sees and lives the 10 or so hours a day that he is out of the house.  I cannot.  I need help.  We all need to help one another with this epidemic because if we think it’s going away or that it won’t affect nor touch us for whatever reason, we are wrong.

Allowing a 14 or 15 or even 16 year old to think that some moderate use of alcohol or “weed” is somehow ok (because it is not excessive or because it is not something worse like cocaine or heroin) is categorically and unequivocally wrong, and it is the wrong message to send to our kids.  The data and all of the literature supports this.  Trust me.   Throwing a party until 2 am (even if it is a Bar Mitzvah!) and allowing our 13 year olds to watch as most of the adults up that late get completely smashed is just plain bad for our kids.  Throwing a party in one’s basement so that their kid doesn’t have to drive to another basement to drink or use drugs is terrible.  Why would anyone think that is a good idea?  If a parent knows the kid is using and spending time with others who are using, put an end to it.

Having watched my son take such a dramatic turn in the last year or so I have become acutely aware of the power of his environment.  All parents who love their kids get it- It is this terrifying reality we face as we pray every day that our kids don’t make the wrong choice and end up beginning what can easily turn out to be the beginning of the end as we know it today.  At the very least we as parents need to do our part.  We can only control so much but what we can control, we should control and do it right.

A Little Bit of Clarification On What We Mean When We Use the Word, “Value”.

Three months in and one thing we have seen is that some of our peers in the field of addiction either don’t understand what we are talking about when we use the word, “value” or they feel threatened by it because somehow they think it equates to less care or lower quality of care for our patients.  In fact this couldn’t be further from the truth.  We are huge advocates for both increased access and more care for mental health.  By shifting and re-framing the conversation from the “price” of siloed mental health care to one of total value delivered to the patient by providing integrated care, we feel we can realign the interests of payers, patients and providers in a way that ultimately results in higher quality of care at a lower TOTAL cost to the payer.

The notion of applying value in behavioral health for me began years ago when my wife would come home day after day feeling beaten down by payers who continually challenged the “medical necessity” of the care that she knew her patients needed.  This would often result in a patient’s coverage being denied, despite Kim’s best efforts to advocate for her patient, and despite the data that shows the inherent long term value of proper treatment of these deadly and incredibly costly diseases that only get worse, both “mentally” and emotionally” if not treated properly.  When treated properly, however, so many far more costly medical co-morbidities are potentially avoided, people can return to their lives and remain productive workers, families and marriages can be saved, relapses and re admissions go down, quality of life gets better for our patients, etc.  Treating someone’s addiction is not only the right thing to do but it is also something that can save society and payers an incredible amount of money.  If money is what drives these decisions, then as providers let’s show them the value (or money they can save by investing in what we do!) by spending a few more dollars in a relatively inexpensive way.  By working to peel the data back and show the naysayers just how valuable and relatively inexpensive this treatment can be, we get our patients the treatment they deserve.

People ask… What do you mean by saying you track “outcomes” and want to improve “value” and that there should be “risk sharing”?  In mental health we have all seen and continue to see pressure from payers to cut back on treatment.  This, despite so called parity and the press the opiate crisis has created. Average length of stays at the residential level are down dramatically in recent years, reimbursement rates continue to race to the bottom even in outpatient settings and in many cases quality of care is suffering as a result.  This is worst case scenario for our patients and their families and yet we believe there is a solution that creates value rather so we don’t have to watch it get destroyed even more. The conversation between payer and provider is currently all about “price” when in fact it should be all about the long term value that proper integrated and evidence based treatment provides to our patients.  We all know that proper treatment saves lives and we also know that it can also save billions in healthcare dollars.  Some statistics backing this up; Researchers have noted that, “the vast majority of individuals with mental illness who receive appropriate treatment improve….. For major depression, panic disorder and obsessive compulsive disorder rates (of improvement) are about 70%.  This is comparable to rates of improvement for people who suffer from physical disorders, including diabetes and asthma at 70-80%, cardiovascular disease from 60-70% and heart disease at 41-52%.  The National Institute on Drug Abuse estimates that every dollar invested in addiction treatment programs yields a return of between $4 and 7$ in reduced drug related crime, criminal justice costs and theft.  When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1!  Just by integrating medical and behavioral services, The National Council for Behavioral Health estimates that between $26- $48 billion can potentially be saved.

When we look at the data, this is what we see.  We see the VALUE in treating these diseases where value is measured by outcomes that matter to patients per dollar spent.  Patients want to improve, they want to see their total health to get better, they want integrated treatment of both the emotional and the physical, they want the society in which they live to have less crime and as more and more of the costs of healthcare shift from traditional insurance products to patients they will want to know they are spending their money wisely and receiving the best possible care in the process.

Outcomes help us quantity and qualify the success that we as providers are having with our patients.  They show us what we are good at, where we could do better and where maybe we should not be.  This we can share with our patients and their payers in an effort to justify the value of the cost of our provision of care. They enable patients to have data from which to make informed choices about where to go for treatment and why.  They enable payers to reward those of us who are truly increasing value for our patients and they hold us all accountable for our provision of care that we agree to provide.   If our patients do well, we do well.  If they do not do as well, we do not do as well.  Of course we aren’t on the hook for a patient who leaves treatment and heads straight to the bar.  That’s not value and no provider in their right mind would agree to share in that risk.  However, we may be on the hook to some degree if we treat a patient diagnosed with a co-occurring case of substance use disorder and depression, for example, if we only treat the substance use and not the underlying depression.  In this case we know if the depression is left untreated the chances of a relapse and subsequently more medical and behavioral problems are significantly higher both in the short run and long run.  In other words, if we treat a patient with sub optimal care based on their diagnosis and they don’t do well, maybe we should share in some of that risk.  And even if we don’t agree that a provider should share in any of the risk surely we all agree that the provider in this case who successfully diagnosis and treats the co-occurring depression and substance use disorder with medication assisted therapy and other modalities aimed at the depression should get paid more than the provider who only treats the substance use disorder- and not just because their costs of treatment may be higher.  In this case the latter provider is much more likely to achieve better outcomes for the patient, which means their treatment is more valuable to the patient and the payer; thus, their service is more valuable and they should be rewarded accordingly.  Better alignment and real integrated coordination creates an environment where we are all working together to optimize results for our patients, and where our patients have the highest chances of success.  It is really that simple.

Our conversation about value is based on our recognition that the current fee for service model is fragmented and broken and whether its capitation or some form of value based reimbursement, SCH wants to be a part of the conversation and what we see is a solution for our patients.  Once this value is recognized by all, our patients will be in a much better position from which to receive the care they both need and deserve. 

A Case is Made for Integration and Coordination of Care

When asked (almost every day) how behavioral health will ever be able to make the switch from volume based reimbursement to a more value based model, I often times find my head spinning with all sorts of unanswered questions; 1) How will we ever be able to properly risk adjust for this inherently unpredictable patient population who often present with what may look like one primary yet in reality have complex co-occurring diseases, and if we can’t properly risk adjust we can’t shift any of the risk to providers? 2) How will we be able to define an episode of care when many times these illnesses are life-long chronic diseases (meaning the “episode” is their entire lives)?  3) How can we as providers agree to share in the risk with these patients who, unlike many patient populations, do have more power to “cause” a relapse despite the best efforts of even a coordinated and highly integrated care team?….  I begin to try and answer some of this, and then I am reminded of just how complicated this journey is.  Some days the path seems clear.  Other days, however, I am tempted to pick up the phone and call Professor Porter and Dr. Lee and ask them how in the world we are going to make this happen….

Yet the next thought in my head, and it happens each and every time, is my own personal experience; I believe in many ways I was the victim of a fragmented care team and subsequently I often contemplate what could have happened differently had the system been set up differently.  In thinking through this the path becomes clearer and I am reminded of why we need to make this change and why it makes sense for all of us.  Getting there, of course, is much more difficult.

Without going in to too much detail I have struggled with depression and generalized anxiety disorder for much of my life.  I had a major eating disorder when I was a teen, and these days my Achilles heel is arguably my (over) dependence on running.  That said I am incredibly fortunate that not since I was a teen has any of this really gotten in the way of my life, at least not on the surface….

Six years ago and only by pure luck, I was diagnosed with stage one esophageal cancer.  In an application for life insurance I was asked whether or not I had not followed up with a Dr. on any recommended follow ups in the past year…  In fact, about one year earlier I had a scope as a result of some bleeding and was told there was inflammation in my esophagus and that I should come back in six months for a follow up.  I did not follow that recommendation so when the application asked the question, I had to answer and deal with it honestly. This lead to going in for the follow up.  It turns out the tumor was extremely small and I had cancer.  Further and as I was told, had I gone back six months earlier like I had been told to do, they would likely have been able to take it out without gutting me like a fish and removing my entire esophagus and half my stomach.  I say probably because nobody really knows for sure, but probably…

During this time in my life I was under the care of my psychiatrist, my primary care doc who referred me to the GI doc and of course the GI doc who did the initial scope, recommended I come back in six months and then took me back in one year later and made the diagnosis of cancer.  During this time in my life I was under a tremendous amount of stress as I was finalizing a divorce, fighting for my kids, watching my business change and struggling to stay in a relationship with my now amazing and wonderful wife.  I was depressed and very anxious and my eating habits were anything but normal. I was running a lot and I was taking prescribed medication to include a lot of Zantac.  The Zantac was taken to help me with heartburn and reflux that I had since I was a teen.

Hindsight is always 20-20 but bear with me….  First of all, as a man with a history of ED, reflux and heartburn under the weekly care of a Psychiatrist and annual care of a primary care doc, and knowing that there is some connection between ED and esophageal cancer (or at least Barrett’s esophagus, which can lead to cancer), why in the world was I not put on some annual protocol to preventatively check for abnormalities of my esophagus in the first place?  Second, as a man with a history of ED, reflux and heartburn under the weekly care of a Psychiatrist for depression and generalized anxiety disorder, under the annual care of a primary care doc and now diagnosed with a suspicious and inflamed area in my esophagus, why in the world did these three doctors leave it up to ME to follow up in “six months” without any (and I mean any) phone calls, text message, emails, pushing or prodding?  No doubt it was my responsibility to either go or not go (nobody could have forced me) but I don’t even know if my primary care doc or even my psychiatrist knew that I was supposed to go back in after six months.  We know people who suffer from depression are less likely to practice self-care.  Of course we are.  Therein lies the essence of depression.  This is not an excuse but rather a statement of medical fact.  I can’t help but think that if my Psychiatrist, my primary care Doc and this GI doc all spent five minutes on the phone together maybe 2 weeks after I did not show for my six month follow up, somehow someway this very likely would have resulted in me going in there shortly thereafter.  And had I gone in, the chances that I could have walked away from this far less affected than I am today increase dramatically.  They could have caught it before it turned in to cancer, I would not have needed the surgery and today I would be able to eat and live far more normally than I am currently able.

Yet this didn’t happen and it brings up a few relevant hypotheticals.  First of all, if the GI doc was measured and reimbursed by the value (results) he delivered to his patients and not per procedure per hour, I have got to believe he would have maybe had his secretary pick up the phone a few times when I missed the six month follow up (or maybe I never made it in the first place) to urge and implore me to come in…  After all, he finds an area of concern and he knows it needs to be looked at again in 6 months and he knows my medical history (more likely to get this cancer and more likely to not show up for the follow up) yet because his mind is on the next procedure because he makes his money per patient per procedure, he is probably not spending too much time thinking about me in between visits or really once I leave his office that first time.  If he is being measured based on results and outcomes, however, the best possible outcome in this case would have been identifying this cancer of mine before it turned in to cancer.  Imagine if he actually shared in some of the savings that could likely have been realized if this cancer was caught earlier (before it turned in to cancer) and didn’t require the surgery I had?  Risk sharing goes both ways…

In as much as Doctors are generally good people in the field of medicine because they want to help people and save lives, they too are humans.  They don’t know everything about every one of their patients and frankly they are busier today than ever before trying to make back the money they seem to be losing in the race to the bottom fueled by a fee for service reimbursement model.   The case for coordination and integration is made with my experience.  Take, for example, a value based model where the “team” is organized around my condition and where the “team” is working together to ensure optimal efficiency, reduced redundancy and the best possible outcomes for me, their patient.  In a hypothetical model where my psychiatrist was the leader of my care team, for instance, first of all for certain he would have known that I had the six month follow up and second of all, he would have done everything possible to support me in going to that appointment (and it would not have taken much).  He would have done so because he cares and also because if his performance on some level is being measured by my total health and not just whether or not I am feeling depressed or anxious, he is financially incentivized to do everything in his power to ensure I am doing something as simple as a follow up with an appointment that I should have never missed.  If he did his job here, he would have likely saved me from a horrendous and incredibly costly surgery and he would have helped stop my cancer from living inside me for an additional six months.  And in a model where he is the leader of the team and he knows about this and he does nothing about it, he is held accountable financially because the value provided to me as measured by outcome/$ spent goes way down as a result of what ultimately happened to me.  In a world where these three doctors were probably not even talking to one another, nobody can blame anyone but me.

The blame game…. So many people then begin to say to me that it was my responsibility and my responsibility alone to go to that six month appointment.  Ultimately, I do not disagree.  Value is not designed to shift the risk from the patient doing stupid things to a Doctor who can’t control their patient’s sometimes insane and unexplainable decisions. Nobody could have forced me to that appointment.  I know that.  In my case and in this hypothetical I see the my providers responsibility going as far as this care team (with my Psychiatrist as the lead) urging me to go back to this follow up, and working together to do so.  This would have been something discussed in my therapy sessions.  My psychiatrist, because he knows me the best of all three and was seeing me weekly throughout this time, could have communicated with my GI doc to let him know I was struggling to come back in.  They could have used scare tactics, they could have gotten on the phone together and called me or maybe they could have asked for the support of my family.  I don’t know what they could have done but I know they could have done more than they did, which was nothing.  And as long as they could show they were working as a team, that they all understood the importance of me, their patient, following up with this appointment and that they had communicated all of this to me, they did their job and from a risk sharing standpoint they are off the hook.  They did as much as they could have been expected to do and if I still choose not to go, they don’t get penalized.  I do.

Another way to look at this that provides value of an alternative model.  Say, for example, I am choosing not to go in for this follow up because I am super anxious about it (I don’t really want to find out at this point in my life that I have something else wrong with me), I am depressed and just overwhelmed getting through life at the time (all true).  Say my Psychiatrist suggests at this time that I see him twice weekly instead of once weekly in order to discuss and address some of this because if I can’t manage to get myself in for a follow up visit with a GI doc (given my medical history), then something is obviously not right.  Say this costs an extra 600.00/month for a few months in additional therapy visits.  Or say months or even years earlier my Psychiatrist believes I should be coming in more than once weekly because of what I am struggling with, yet I choose not to because its expensive and insurance covers none of it (true again).  Say had I done this it would have cost maybe an extra 10k annually for a few years yet because of the extra work and time I had put in to therapy I am not struggling as much and I have no trouble making it in to this six month appointment…  Do we think an extra 20 or 30k invested in my mental health would have had a positive ROI if it helped avoid a surgery that cost hundreds of thousands of direct dollars, many more than that in indirect costs as a result of the lost revenue because I could no longer optimally run my business and almost my life???  Of course it would have!

The following conclusions are clear when I use my own example.

  1. When talking about shared risk particularly with mental health, the conversation is far more complicated than when we are talking about someone with a broken hip or even cancer.  Though mental illness is not a choice by any means, there is more a patient can sometimes do or not do to effect outcomes than with some of these other diseases which makes the risk sharing conversation more tricky.
  2. The current state of fragmented care delivery, which is particularly evident between mental health providers and medical providers, can and does have devastating consequences on patients, their families and their payers.
  3. Doctors are good people and they would not be hurt by being financially incentivized to work outside their individual silos in aligned teams designed around their patient’s needs and conditions.
  4. Bundling one’s service and sharing in some of the risk does not necessarily mean that a provider is on the hook for a patient’s bad decision.  There can and should be parameters and stop gaps put around how far a provider can be held accountable because it is true particularly in mental health that we are dealing with patients who have extraordinary powers to derail their own recovery, even if not by choice.
  5. The links between mental illness and medical illnesses are documented and supported by data.  This means mental health providers and medical providers must work together to serve their patients best interests and overall health.
  6. The data shows investing in one’s mental health is a wise investment, both financially and otherwise.  My experience validates this data.
  7. Risk sharing probably should extend beyond just payer and provider and on to the patient, and risk sharing goes both ways.  When a team works together to save cost or avoid a co-morbidity because of their alignment and skill, they should be rewarded.  Yet when they aren’t working together as they should and something bad happens as a result, they should be held accountable.

So while I don’t quite know how exactly to move the needle away from the current model, I do know we will all benefit once the transition happens.   At SCH we are thrilled to be a part of this conversation and this movement.  We believe it is absolutely the right direction for our patients and their families, which ultimately means it will be best for us as well.

Redesigning Behavioral Healthcare and Improving Outcomes, Reducing Total Cost

David Newton, Director of Operations and Marketing, SunCloud Health

 

 SunCloud Health Outpatient Treatment Center - Substance Abuse, Drug Addiction, Eating Disorder

REDESIGNING BEHAVIORAL HEALTHCARE DELIVERY IN THE FACE OF OBSTACLES- IMPROVING OUTCOMES WHILE REDUCING TOTAL COST.

THE SCOPE OF THE PROBLEM:  In 2013, it is estimated that Americans spent over $200 Billion treating Mental Health conditions, more than on any other medical condition including heart conditions, trauma, cancer and diabetes. (1) This does not include an additional $193.2 billion in lost earnings per year caused by those with serious mental illness (2).  Approximately 1 in 5 adults in the US experiences mental illness in a given year (3), and approximately 1 in 25 adults in the US experiences a serious mental illness in a given year that substantially interferes  with or limits one or more major life activities (4).  Behavioral health disorders are the leading cause of disability in the US and Canada (7) Individuals living with serious mental illness face an increased risk of having medical conditions (5), and adults living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions (6).

IT IS AN INTERNATIONAL PROBLEM:  The problem is not just related to the United States.  According to the World Health Organization, depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease.  More than 350 million people are estimated to suffer from depression worldwide and as the WHO clearly and properly states, “Especially when long lasting and with moderate or severe intensity, depression may become a serious health condition.  It can cause the affected person to suffer greatly and function poorly at work, at school and in the family…” (9)

MENTAL AND MEDICAL CO-MORBITIES:  The connections, both medically and financially, between “mental” illness and “medical” illnesses are well established.  Logically, people with mental illness are more likely to have additional medical complications, and people with medical illnesses are more likely to have mental health complications.  According to the National Council for Behavioral Health, medical costs for treating those patients with chronic medical and comorbid mental health/substance use disorder (MH/SUD) conditions can be 2-3 times as high as those who don’t have the MH/SUD conditions.  The additional healthcare costs incurred by people with behavioral comorbidities were estimated to be $293 billion in 2012 across commercially insured, Medicaid and Medicare beneficiaries in the United States.  (8)  In a study examining 150,000 Medicaid claims for beneficiaries in six states, authors determined that people with substance abuse disorders had significantly higher expenditures for health problems compared to others.  (15).

AGAIN, THIS IS INTERNATIONAL: As the Canadian Mental Health Association clearly states in its 2008 report titled, “The Relationship between Mental Health, Mental Illness and Chronic Physical Conditions”, “Mental health and physical health are fundamentally linked”. People living with a serious mental illness are at higher risk of experiencing a wide range of chronic physical conditions.  Conversely, people living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population.  Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes”.  (16).  Diabetes rates are significantly higher among people with mental illness, obesity rates are up to 3.5 times higher in people with mental illness in comparison to the general population, people with mental illnesses often experience high blood pressure and elevated levels of stress hormones and adrenaline which increase the heart rate, which significantly elevates the risk of heart disease.  In Canada, women with depression are 80% more likely to experience heart disease than women without depression.  Similarly, people with mental illness have up to three times greater likelihood of having a stroke.  (17)  The relative risk of people with a mental illness developing specified chronic physical conditions is as follows:  Diabetes:  1.6 for people with depression; Heart Disease:  1.6 for people with depression; Stroke: 3.1 for people with depression.  Conversely, there are significantly elevated risks of depression among people with heart disease, elevated rates of anxiety and depression among people living with chronic respiratory diseases and highly elevated rates of substance abuse and eating disorders among people with a history of trauma.  (all Canadian article and facts we know to be true)

INTUITION AND MORE CONNECTIONS BETWEEN MENTAL AND MEDICAL: We know that a person suffering from depression or anxiety is less likely to routinely go to their annual primary care doc visits.  We know that a person with bulimia nervosa is causing massive damage to their GI system.  We know that a person suffering with alcoholism is causing massive damage to their liver.  We know that tobacco smoke causes cancer of the mouth, throat, larynx, blood, lungs, stomach, pancreas, kidney, bladder, and cervix.  We know that injection of drugs such as heroin, cocaine, and methamphetamine currently accounts for about 12 percent of new AIDS cases.  (18)  And we know that people suffering from anorexia nervosa are at increased risk of the following medical comorbidities:  Thinning of the bones (osteopenia or osteoporosis), mild anemia and muscle wasting and weakness, brittle hair and nails, severe constipation, low blood pressure, slowed breathing and pulse, damage to the structure and function of the heart, brain damage and multi organ failure.

SO MUCH GOES UNTREATED:  Yet as the WHO also notes, although there are known effective treatments for depression, “fewer than half of those affected in the world receive such treatments”.  The National Council for Behavioral Health notes that more than one in three adults with serious impairment received no mental health treatment during the past year, with less than one third of adults with mental health disorders who do get treatment and receive care considered to be minimally adequate.  (10)  According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health, 23.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol abuse problem in 2009 (9.3 percent of persons aged 12 or older). Of these, only 2.6 million—11.2 percent of those who needed treatment—received it at a specialty facility. (11)

LACK OF PARITY: Despite the growing costs of mental health care, these illnesses do not get the same level of research funding as heart disease, diabetes or cancer.  The National Institute of Health estimates it will spend $396 million on serious mental illness in 2016, whereas heart disease, cancer and diabetes will receive $1.3, $5.7 and $1 billion in funding respectively.  Anxiety disorders and depression, the most common mental health conditions, will receive much less- $163 and $406 million (19)!  Further and as noted above, despite the enormity of the problem less than half (41%) of adults in the US with a mental health condition received mental health services in the past year.

PROPER TREATMENT WORKS, AND IT’S “WORTH IT”:  The case for duly treating mental health as vigorously as we treat “medical” health could not be any more substantiated.  Proper treatment saves lives and it can save billions in healthcare dollars.  Researchers have noted that, “the vast majority of individuals with mental illness who receive appropriate treatment improve….. For major depression, panic disorder and obsessive compulsive disorder rates (of improvement) are about 70%.  This is comparable to rates of improvement for people who suffer from physical disorders, including diabetes and asthma at 70-80%, cardiovascular disease from 60-70% and heart disease at 41-52% (12).  The National Institute on Drug Abuse estimates that every dollar invested in addiction treatment programs yields a return of between $4 and 7$ in reduced drug related crime, criminal justice costs and theft.  When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1! (13). The US Department of Health and Human Services estimates that for every $100,000 invested in treatment for substance abuse (measured in California, New York and Washington), there are savings of $484,000 in health care costs and $700,000 of crime costs were shown to be avoided.  (14)  In a comparison of medical expenses of Medicaid clients who received treatment, the following savings were noted (measured in Washington):  $170.00/month for patients receiving inpatient; $215/month for those in outpatient treatment, and $230/month for those receiving medication assisted therapy (specifically methadone).  In California treated patients have been shown to reduce ER visits by 39%, hospital stays by 35% and total medical costs by 26% (14).

Just by integrating medical and behavioral services, The National Council for Behavioral Health estimates that between $26- $48 billion can potentially be saved!

If we are to make real progress, we need to increase access to care and we need to address the current state of fragmentation both between mental and medical health as well as within mental health itself.  We must adapt universally accepted outcome measurements (leading to greater cost transparency) that can be used by providers, patients and payers alike to make informed decisions and to hold one another accountable for their part of treatment and recovery.  If we can make headway in these three key areas, more people will seek and receive treatment for their mental health issues, patients will become more healthy both “mentally” and “physically”, and total healthcare dollars will be saved as a result.

BARRIERS TO PROGRESS:  STIGMA AND SHAME:  Many still living in the dark ages believe addiction is a choice.  At SCH we believe addiction is a disease, just like diabetes or cancer.  We know from science that an addicted person’s brain has a disrupted choice mechanism.  As The National Institute on Drug Abuse says, “However much we may wish that a person’s choices were free in all instances, it is simply a fact that an addicted person’s failures in the realm of choice are the product of a brain that has become greatly compromised—it is readily apparent when we scan their brains…”  The whole concept of anonymity in Alcoholics Anonymous or any of the other twelve step programs is telling. When people go to physical rehab for a broken and healing bone, is there an oath of secrecy associated with the patient’s visit?  There is nothing to be ashamed of by attending a recovery meeting for addiction, and yet this persists. At (SCH), we support the de-stigmatization of these diseases that has occurred over the years. We teach our patients that what they are suffering from is a disease, just like diabetes or cancer. We don’t believe people choose to ruin their lives and families when they become addicted to opiates. The activity in the brain that occurs when an addict is sick is nothing she can control.  We are working with EAP programs and Human Resource Executives at major companies trying to educate them on how to help their employees feel more comfortable asking for help.   We learned recently and were abhorred to hear that one EAP program actually tells first time callers that their calls are being recorded!!!!  As more and more people begin to understand that these are real medical diseases that manifest themselves similarly to other disorders around which the patient has little control, more people will seek help earlier and recover quicker, which will also result in diminished disease burden and need for long-term health resources. Most importantly, fewer people will die because they were ashamed to ask for help.

BARRIERS TO PROGRESS, LACK OF PARITY:  Why has mental health been separated or carved out from mainstream health care delivery?  Why do mental health providers spend so much of their time arguing with payers over authorization and medical necessity of their services when this rarely happens with medical conditions? Why is there a special (and additional) deductible for “mental health” with many insurers?  Despite the federal “parity” law enacted in 2010 (Mental Health Parity and the Patient Protection and Affordable Care Act of 2010), “discrimination still exists toward mental health and substance use conditions”, according to NAMI Executive Director Mary Gilberti.  She goes on to say in an April 1, 2015 report published by NAMI, “Progress is being made, but there is still a long road ahead.  The act contains a number of provisions that generally combine to extend the reach of existing federal mental health parity requirements, and is a response to the disparity in insurance coverage between mental illness and other physical illnesses.  According to the Congressional Research Service report dated 12/28/2011, “…parity generally refers to the concept that health insurance coverage for mental health services should be offered on par with covered medical and surgical benefits”.  (31) Yet in the NAMI report dated April, 2015, NAMI identifies areas, “where insurance companies need to improve and greater scrutiny is needed.”  This report specifically cites some following conclusions:  1) a lack of mental health providers is a serious problem in health insurance networks. 2) Nearly a third of survey respondents reported insurance company denials of authorization for mental health and substance abuse care.   For ACA plans, denials were nearly twice the rate for other medical care.  3) High co-pays, deductible and co-insurance rates create further barriers to treatment and 4) there is a serious lack of information about mental health coverage to enable consumers to make informed decisions in choosing care”.  (30)  At SCH we make the case every day with patients, their families, their payers and their employers that mental health benefits should at the very least be treated equally with other physical illnesses.  We do this as we have utilization review calls with payers, we do this when talking with EAP’s and Human Resource and Benefits groups at major employers in the Chicago area and we blog about it on our website, on twitter, on LinkedIn and at every chance we can.  We believe the cost benefit analysis speaks for itself; Investing in mental health treatment saves lives and it saves dollars.  Further, discriminating against those with mental illness by not reimbursing or covering it like other illnesses perpetuates the myth that addiction, for instance, is a choice which feeds in to the shame stigma and ultimately gets in the way of treating these illnesses as illnesses just as we do with other illnesses- early, often and as aggressively as we can because we know our outcomes are better when we do this and because it is the right thing to do.

BARRIERS TO PROGRESS, FRAGMENTATION BETWEEN MENTAL AND MEDICAL.  In the United States health care system, there is massive fragmentation between medical and mental health provision of care. Most payers and providers alike behave as if medical health and mental health have little to do with one another. As noted above, many studies have substantiated the costly impact of untreated or under treated mental health conditions (for example depression) on a person’s medical health. Despite this, many physicians know little to nothing about diagnosing mental illness and they know even less about addiction.  Training of mental health is minimal at many medical schools and it is even less with other specialties such as Dentists.  Intuitively we know that a patient with untreated or inappropriately treated mental illness, whether that be depression, bipolar disorder, addiction, PTSD, or an eating disorder, is ill-equipped to take care of herself medically. People with active addiction or depression are less likely to see a doctor for an annual physical exam where they may receive screening for a preventable illness.  As noted by the Canadian Mental health Association’s report of 2008, people with serious mental illness who have access to primary health care are less likely to receive preventive health checks.   They also have decreased access to specialist care and lower rates of surgical treatments following diagnosis of a chronic physical condition.    ‎Mental illness, at its root, affects a person’s thinking, planning, and motivation to care for self and warps their beliefs about what they deserve and are capable of accomplishing.

Another example tells the story….  A 45 year old female with cocaine dependence, BED, bipolar disorder, opioid dependence and history of developmental trauma presents.   She came to us seeking a psychiatrist for buprenorphine. Many addiction psychiatrists would likely see her for utox and sub Oxone med management monthly.  They may see her for 15 minutes every other week, they won’t coordinate care with her primary care doc or any of her other docs and as a result they may prescribe her medicine that might very well be harmful to her given her overall health history.

At SCH, she receives a thorough bio-psycho-social-spiritual evaluation. Her former prescriber is contacted for information sharing. It turns out she has no PCP, has never had a mammogram, she does not get pap smears because she is ashamed of her body. She sees a GI doc for reflux. At SCH she gets a PCP who works with the psychiatrist to manage this patient long-term both medically and psychiatric ally. If medical recommendations are not being followed, this becomes a therapeutic issue addressed by the psychiatric team in weekly individual session and group sessions. Further, at SCH mental health care is integrated. The whole patient is addressed, not parsed out by disease treated sequentially or in parallel using fundamentally different modalities. We even go so far as to regularly check the new prescription monitoring program where we are able to see what medications our patients may be getting from other doctors.  We had a case recently where a woman who suffers from cocaine addiction was being prescribed Adderall by one of her other (ignorant) MD’s.  We learned of this by using the PMS, we confronted the patient and we coordinated her care so as to ensure this wouldn’t continue to happen.

BARRIERS TO PROGRESS, SILOS WITHIN BEHAVIORAL HEALTHCARE:  The system today is incredibly siloed and often results in a game of “whack a mole” as one “primary” symptom is addressed yet because the underlying cause was not or the “secondary” diagnosis was not made nor addressed, another symptom pops up and the patient relapses in to a similar yet on the surface different type of addiction.  Many of the most well esteemed hospital systems and providers in the country have separate tracks, for instance, for eating disorders, substance abuse disorder and trauma.  This, despite the following according to NEDA:  Research suggests that nearly 50% of individuals with an eating disorder (ED) are also abusing drugs and/or alcohol, a rate 5 times greater than what is seen in the general population. The co-occurrence of these disorders affects both men and women with up to 57% of males with BED experiencing lifelong substance abuse problems. Eating disorders and substance abuse are independently correlated with higher than expected rates of death both from medical complications as well as suicide. An example- A patient presents with what is diagnosed as binge eating disorder and they get put on the “eating disorder” track where hopefully they learn to control (and reduce) their intake of food to a moderate amount and then they are discharged.  On the other end of the hall are patients who present with, say, an addiction to drugs.  These patients will hopefully learn to eliminate their consumption of drugs through maybe medication assisted therapy, behavior therapy, family therapy and other forms of therapy.  Both populations are suffering from addictive behaviors yet they are placed on separate tracks.  What gets missed in this approach is the many commonalities each of these populations share to include the fact that some form of trauma or depression or other mood disorder is likely at the root of the primary symptom.  Thus, when the food addict is able to manage their food intake and yet the underlying cause was never addressed nor did they learn the tools needed to fight imminent future urges for other substances, the next major stressor in their life could lead them to now find themselves addicted to alcohol or some other substance.  At SCH we do not put patients on separate tracks, as we use an integrated approach where we are not only integrating medical with behavioral but we are assessing and integrating our patients overall mental health.  We seek to treat the symptom and its underlying cause, giving our patients the tools they need to be free and healthy from all addiction.  Not all providers are capable of seeing the patient in this light and the literature supports the fact that co-occurring disorders can be difficult to diagnose due to the complexity of symptoms…. And inadequate provider training or screening, an overlap of symptoms, or other health issues that need to be addressed first.  Hiring the right therapists is critical to maintaining this integrated approach, and then ensuring we do not fall in to the easy trap of segmentation, treating the one symptom without regard for others that may be going on at the same time- which all too often leads to relapse.  Supported by a 2014 SAMHSA report, we know that people with co-occurring disorders are best served through integrated treatment.  This often leads to better health outcomes and lower healthcare costs.  (32)

Yet this same SAMHSA article sheds light on an inherent major problem that is not only a major barrier to treatment but one that also forces some providers to game the system in order to treat their patients.  The report states the following:  People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder.  According to the National Institute on Drug Abuse, drug addiction is a mental illness.  An addiction changes the brain in fundamental ways, disturbing a person’s normal hierarchy of needs and desires and substituting new priorities connected with procuring and using the drug. The resulting compulsive behaviors that override the ability to control impulses despite the consequences are similar to hallmarks of other mental illnesses.  Insurance companies do the same.  When applying for in network status, SCH was asked by all whether we provide “mental health” OR “substance abuse treatment” Our answer- they are the same and so we provide both.  From a patients perspective this separation can prove fatal and sometimes leads to good intentioned providers gaming the system in order to get their patients the treatment they need.  For example, not all patients have residential coverage for all of their mental health conditions, despite ACA and Parity. Commonly, a patient with an acute substance use disorder as well as an eating disorder will have RTC (residential treatment) benefit for mental health (ED) but not substance use disorder, or vice versa.  It is possible then that this patient would not receive authorization for treatment of their substance use disorder because somehow the payer sees substance as different from mental health, and visa versa.  For people who do have benefits for both MH and SUD, most often if they have co-occuring disorders only the identified “primary” disorder is authorized for treatment.  At SCH we are being very transparent with payers that our integrated approach may lead to us not being able to provide them with a “primary” diagnosis particularly when the patient presents with co-occurring diagnosis.  From our perspective, it does not matter what the primary is and we do not and will not just treat the primary.  We will treat the person.  When one of our clinicians was asked in an interview what they would treat first, a substance abuse diagnosis or a depression diagnosis, the answer was literally, “it doesn’t matter…”  We will of course treat any acute aspect first and foremost but after that we are treating the whole person, meeting them where they are at and getting to the root cause(s), or as close as possible. We won’t and don’t game the system like some providers do and it is too early to tell how payers will respond to our steadfast approach to integrated treatment.

BARRIERS TO PROGRESS, REACTIVE (and more fragmented) CARE. The Current models of delivery of mental health are reactive instead of preventative. Care is episodic and fragmented, rather than a longitudinal provision of care for people with chronic illnesses (many of whom achieve full remission…AND do best with ongoing preventative care in an outpatient setting). One example illustrates the issue- The person who has been to rehab 5 times for polysubstance dependence. They have been sober for 4 years, they are attending AA, and they now need a dental surgery, or an appendectomy. They end up being prescribed post-op narcotic pain meds prescribed by a provider who has had little to no addiction training, the sober patient is not fully aware of the support warranted to take these meds as they are prescribed and decides she can do it on her own.  After all she’s been sober 4 years.  That said, she takes the medication without any support and relapses once her prescription runs out. At SCH as that patient’s outpatient provider, or monthly addiction psychiatrist, we would collaborate with the surgical team and patient’s support system to facilitate the following plan: the patient never touches the prescription, her designated loved one fills it, and the loved one hands out the med as prescribed to patient in recovery from addiction. She gets an appointment with her long term addiction treatment professional (preventative care) the day after her pain med stops. The relapse is prevented, thousands of healthcare dollars are saved and most importantly potentially a life is saved.

BARRIERS TO PROGRESS, NO COST TRANSPARENCY
As we have noted above, payers are simply not looking at the medical co morbidity of these behavioral illnesses and therefore they don’t have a real grasp of actual costs. We met with one company recently with over 10,000 employees nationwide and their data shows that they “only” spend” about $1 million on substance abuse issues.  Clearly that number is not accurate and although we have not yet had a chance to parse through that data and identify what they are counting and what they are not counting, it is clear they aren’t counting indirect costs such as absenteeism, lost productivity or the cost to replace workers who either get injured or leave the job because of their problems.  They are also not counting the medical co-morbidity, which the literature and data support are significant.  At SCH we are teaching payers and employers alike that it is far less expensive to treat a patient on an ongoing outpatient basis for their behavioral problem (i.e. Symptomatic Nicotine addiction) than to ultimately see them get something like lung cancer and have extensive surgery.  We are also offering to parse through data for employers and payers in order to help them understand the true costs of some of these behavioral illnesses.  Many of them admit they know their numbers are not accurate and yet sometimes because the silos for medical and mental health are so strong or sometimes because they just don’t have the interest or the resources, they won’t allow us to do the work for them.  Yet we believe this is an important piece of our mission.  Once we can show the investment is worth it, critical mass will begin to move- especially with self-insured companies who would like nothing more than to see their employees more healthy AND reduce their TOTAL healthcare spend in the process!

The other critical piece of transparency and the lack thereof in this space involves the lack of universally accepted outcome measurements.  Many providers measure no data.  Many measure what they are good at it and through their own biases and unsophisticated analyses, report what looks good and conveniently leave out what may not look so good.  Although established and highly regarded groups like Michael Porter’s ICHOM have a standard set (of outcome measurements) for depression, there is currently nothing (that we are aware of) established for substance use disorder or eating disorders.  There are some common measurements but nothing standardized across the industry used by most of not all providers.  This makes it impossible for patients to compare providers when trying to make an informed decision on where to seek treatment and it makes it impossible for payers to negotiate fairly between providers based on the value they provide their patients and their patients families.  At SCH we are working with leaders in the industry to establish outcome measurements that we feel accurately reflect measurements that matter to our patients and to us as their providers.  We are tracking those outcomes using an electronic health records management system and we intend to share the data with our patients and their payers as we go.  Further, we intend to publish what we are measuring, why and how we are doing it with the hope that others will follow.  Without standardized and universally accepted outcome measurements, it will be impossible to move from a fee for service reimbursement model to a model based on the value we provide our patients.  As a new entrant eager to be reimbursed for our value rather than our volume, this initiative is an integral part of our mission.

BARRIERS TO PROGRESS- MOVING TOWARD VALUE IS NOT EASY IN THIS SPACE!

In order to move to a reimbursement model where we are rewarded for the value we create for our patients and their families we need to do share in some of the risk for our portion of the provision of care over which we agree to be responsible.  This requires, amongst other things, that we can risk adjust in to three of four buckers as patients present and it also requires a definition of “the episode of care”.  Unlike those who may be getting a knee replacement, these are not easy tasks with our population.  Further, we ideally create not only care teams that include various medical, behavioral, therapeutic specialists- all designed around the conditions of our patients- but we ideally bundle our payment so that we are all fully aligned as we treat our patients.  This is particularly difficult in mental health given that many therapists and psychiatrists themselves want nothing to do with insurance and in many cases don’t feel, given current state of fragmentation and lack of coordinated care, that they could afford to be help responsible for say what the patients primary care doc does (or does not do) in the provision of care over “the episode”.  At SCH we understand the challenge is significant.  Yet we are convinced that the current fee for service model is not only broken but it is unsustainable and truly does not work in the best interest of our patients or our families.   We are actively and diligently working on piloting different models of how to bring the right care team together and have a reimbursement model that works.  We feel strongly that for a patient suffering from a mental illness that it should be the psychiatrist who could be the gate keeper of sorts and leader of the team- who is responsible for care coordination and who creates the care team and pays all other providers based on the value the team delivers.  By no means do we claim to have this ironed out, yet we are moving the conversations we have and contract discussions we have in this direction to the extent we can.

CONCLUSION:  The data supports the inherent value of an integrated treatment model where medical and (sometimes multiple) behavioral issues are treated both equally and with regard for one another.  The data shows that that there is a tremendous opportunity to a save a tremendous amount of total healthcare dollars by investing in effective and integrated treatment.  The data shows that this is an international problem of epic proportion with depression leading as the most costly illness on the planet.  Despite the multiple barriers getting in the way, we know we can and will do better by chipping away at the barriers one by one.  At SCH we are providing care by designing our care teams around our patient’s needs and conditions.  We are measuring outcomes and we know what our cost drivers are.  By modeling to the industry that this treatment model is in the best interest of our patients, their families and their payers, we hope to make a difference and move the needle toward better care at a lower total cost.   In as much as a relatively small, independent and currently self-funded new entrant such as SCH might not have the data nor the volume we need to move as quickly as we might like, we know we are doing our job so long as we remain true to our guiding principles and continue to break down these barriers every day we come to work.  It is what our patients deserve.  It is what we all deserve.

THE SCOPE OF THE PROBLEM:  In 2013, it is estimated that Americans spent over $200 Billion treating Mental Health conditions, more than on any other medical condition including heart conditions, trauma, cancer and diabetes. (1) This does not include an additional $193.2 billion in lost earnings per year caused by those with serious mental illness (2).  Approximately 1 in 5 adults in the US experiences mental illness in a given year (3), and approximately 1 in 25 adults in the US experiences a serious mental illness in a given year that substantially interferes  with or limits one or more major life activities (4).  Behavioral health disorders are the leading cause of disability in the US and Canada (7) Individuals living with serious mental illness face an increased risk of having medical conditions (5), and adults living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions (6).

IT IS AN INTERNATIONAL PROBLEM:  The problem is not just related to the United States.  According to the World Health Organization, depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease.  More than 350 million people are estimated to suffer from depression worldwide and as the WHO clearly and properly states, “Especially when long lasting and with moderate or severe intensity, depression may become a serious health condition.  It can cause the affected person to suffer greatly and function poorly at work, at school and in the family…” (9)

MENTAL AND MEDICAL CO-MORBITIES:  The connections, both medically and financially, between “mental” illness and “medical” illnesses are well established.  Logically, people with mental illness are more likely to have additional medical complications, and people with medical illnesses are more likely to have mental health complications.  According to the National Council for Behavioral Health, medical costs for treating those patients with chronic medical and comorbid mental health/substance use disorder (MH/SUD) conditions can be 2-3 times as high as those who don’t have the MH/SUD conditions.  The additional healthcare costs incurred by people with behavioral comorbidities were estimated to be $293 billion in 2012 across commercially insured, Medicaid and Medicare beneficiaries in the United States.  (8)  In a study examining 150,000 Medicaid claims for beneficiaries in six states, authors determined that people with substance abuse disorders had significantly higher expenditures for health problems compared to others.  (15).

AGAIN, THIS IS INTERNATIONAL: As the Canadian Mental Health Association clearly states in its 2008 report titled, “The Relationship between Mental Health, Mental Illness and Chronic Physical Conditions”, “Mental health and physical health are fundamentally linked”. People living with a serious mental illness are at higher risk of experiencing a wide range of chronic physical conditions.  Conversely, people living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population.  Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes”.  (16).  Diabetes rates are significantly higher among people with mental illness, obesity rates are up to 3.5 times higher in people with mental illness in comparison to the general population, people with mental illnesses often experience high blood pressure and elevated levels of stress hormones and adrenaline which increase the heart rate, which significantly elevates the risk of heart disease.  In Canada, women with depression are 80% more likely to experience heart disease than women without depression.  Similarly, people with mental illness have up to three times greater likelihood of having a stroke.  (17)  The relative risk of people with a mental illness developing specified chronic physical conditions is as follows:  Diabetes:  1.6 for people with depression; Heart Disease:  1.6 for people with depression; Stroke: 3.1 for people with depression.  Conversely, there are significantly elevated risks of depression among people with heart disease, elevated rates of anxiety and depression among people living with chronic respiratory diseases and highly elevated rates of substance abuse and eating disorders among people with a history of trauma.  (all Canadian article and facts we know to be true)

INTUITION AND MORE CONNECTIONS BETWEEN MENTAL AND MEDICAL: We know that a person suffering from depression or anxiety is less likely to routinely go to their annual primary care doc visits.  We know that a person with bulimia nervosa is causing massive damage to their GI system.  We know that a person suffering with alcoholism is causing massive damage to their liver.  We know that tobacco smoke causes cancer of the mouth, throat, larynx, blood, lungs, stomach, pancreas, kidney, bladder, and cervix.  We know that injection of drugs such as heroin, cocaine, and methamphetamine currently accounts for about 12 percent of new AIDS cases.  (18)  And we know that people suffering from anorexia nervosa are at increased risk of the following medical comorbidities:  Thinning of the bones (osteopenia or osteoporosis), mild anemia and muscle wasting and weakness, brittle hair and nails, severe constipation, low blood pressure, slowed breathing and pulse, damage to the structure and function of the heart, brain damage and multi organ failure.

SO MUCH GOES UNTREATED:  Yet as the WHO also notes, although there are known effective treatments for depression, “fewer than half of those affected in the world receive such treatments”.  The National Council for Behavioral Health notes that more than one in three adults with serious impairment received no mental health treatment during the past year, with less than one third of adults with mental health disorders who do get treatment and receive care considered to be minimally adequate.  (10)  According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health, 23.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol abuse problem in 2009 (9.3 percent of persons aged 12 or older). Of these, only 2.6 million—11.2 percent of those who needed treatment—received it at a specialty facility. (11)

LACK OF PARITY: Despite the growing costs of mental health care, these illnesses do not get the same level of research funding as heart disease, diabetes or cancer.  The National Institute of Health estimates it will spend $396 million on serious mental illness in 2016, whereas heart disease, cancer and diabetes will receive $1.3, $5.7 and $1 billion in funding respectively.  Anxiety disorders and depression, the most common mental health conditions, will receive much less- $163 and $406 million (19)!  Further and as noted above, despite the enormity of the problem less than half (41%) of adults in the US with a mental health condition received mental health services in the past year.

PROPER TREATMENT WORKS, AND IT’S “WORTH IT”:  The case for duly treating mental health as vigorously as we treat “medical” health could not be any more substantiated.  Proper treatment saves lives and it can save billions in healthcare dollars.  Researchers have noted that, “the vast majority of individuals with mental illness who receive appropriate treatment improve….. For major depression, panic disorder and obsessive compulsive disorder rates (of improvement) are about 70%.  This is comparable to rates of improvement for people who suffer from physical disorders, including diabetes and asthma at 70-80%, cardiovascular disease from 60-70% and heart disease at 41-52% (12).  The National Institute on Drug Abuse estimates that every dollar invested in addiction treatment programs yields a return of between $4 and 7$ in reduced drug related crime, criminal justice costs and theft.  When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1! (13). The US Department of Health and Human Services estimates that for every $100,000 invested in treatment for substance abuse (measured in California, New York and Washington), there are savings of $484,000 in health care costs and $700,000 of crime costs were shown to be avoided.  (14)  In a comparison of medical expenses of Medicaid clients who received treatment, the following savings were noted (measured in Washington):  $170.00/month for patients receiving inpatient; $215/month for those in outpatient treatment, and $230/month for those receiving medication assisted therapy (specifically methadone).  In California treated patients have been shown to reduce ER visits by 39%, hospital stays by 35% and total medical costs by 26% (14).

Just by integrating medical and behavioral services, The National Council for Behavioral Health estimates that between $26- $48 billion can potentially be saved!

If we are to make real progress, we need to increase access to care and we need to address the current state of fragmentation both between mental and medical health as well as within mental health itself.  We must adapt universally accepted outcome measurements (leading to greater cost transparency) that can be used by providers, patients and payers alike to make informed decisions and to hold one another accountable for their part of treatment and recovery.  If we can make headway in these three key areas, more people will seek and receive treatment for their mental health issues, patients will become more healthy both “mentally” and “physically”, and total healthcare dollars will be saved as a result.

BARRIERS TO PROGRESS:  STIGMA AND SHAME:  Many still living in the dark ages believe addiction is a choice.  At SCH we believe addiction is a disease, just like diabetes or cancer.  We know from science that an addicted person’s brain has a disrupted choice mechanism.  As The National Institute on Drug Abuse says, “However much we may wish that a person’s choices were free in all instances, it is simply a fact that an addicted person’s failures in the realm of choice are the product of a brain that has become greatly compromised—it is readily apparent when we scan their brains…”  The whole concept of anonymity in Alcoholics Anonymous or any of the other twelve step programs is telling. When people go to physical rehab for a broken and healing bone, is there an oath of secrecy associated with the patient’s visit?  There is nothing to be ashamed of by attending a recovery meeting for addiction, and yet this persists. At (SCH), we support the de-stigmatization of these diseases that has occurred over the years. We teach our patients that what they are suffering from is a disease, just like diabetes or cancer. We don’t believe people choose to ruin their lives and families when they become addicted to opiates. The activity in the brain that occurs when an addict is sick is nothing she can control.  We are working with EAP programs and Human Resource Executives at major companies trying to educate them on how to help their employees feel more comfortable asking for help.   We learned recently and were abhorred to hear that one EAP program actually tells first time callers that their calls are being recorded!!!!  As more and more people begin to understand that these are real medical diseases that manifest themselves similarly to other disorders around which the patient has little control, more people will seek help earlier and recover quicker, which will also result in diminished disease burden and need for long-term health resources. Most importantly, fewer people will die because they were ashamed to ask for help.

BARRIERS TO PROGRESS, LACK OF PARITY:  Why has mental health been separated or carved out from mainstream health care delivery?  Why do mental health providers spend so much of their time arguing with payers over authorization and medical necessity of their services when this rarely happens with medical conditions? Why is there a special (and additional) deductible for “mental health” with many insurers?  Despite the federal “parity” law enacted in 2010 (Mental Health Parity and the Patient Protection and Affordable Care Act of 2010), “discrimination still exists toward mental health and substance use conditions”, according to NAMI Executive Director Mary Gilberti.  She goes on to say in an April 1, 2015 report published by NAMI, “Progress is being made, but there is still a long road ahead.  The act contains a number of provisions that generally combine to extend the reach of existing federal mental health parity requirements, and is a response to the disparity in insurance coverage between mental illness and other physical illnesses.  According to the Congressional Research Service report dated 12/28/2011, “…parity generally refers to the concept that health insurance coverage for mental health services should be offered on par with covered medical and surgical benefits”.  (31) Yet in the NAMI report dated April, 2015, NAMI identifies areas, “where insurance companies need to improve and greater scrutiny is needed.”  This report specifically cites some following conclusions:  1) a lack of mental health providers is a serious problem in health insurance networks. 2) Nearly a third of survey respondents reported insurance company denials of authorization for mental health and substance abuse care.   For ACA plans, denials were nearly twice the rate for other medical care.  3) High co-pays, deductible and co-insurance rates create further barriers to treatment and 4) there is a serious lack of information about mental health coverage to enable consumers to make informed decisions in choosing care”.  (30)  At SCH we make the case every day with patients, their families, their payers and their employers that mental health benefits should at the very least be treated equally with other physical illnesses.  We do this as we have utilization review calls with payers, we do this when talking with EAP’s and Human Resource and Benefits groups at major employers in the Chicago area and we blog about it on our website, on twitter, on LinkedIn and at every chance we can.  We believe the cost benefit analysis speaks for itself; Investing in mental health treatment saves lives and it saves dollars.  Further, discriminating against those with mental illness by not reimbursing or covering it like other illnesses perpetuates the myth that addiction, for instance, is a choice which feeds in to the shame stigma and ultimately gets in the way of treating these illnesses as illnesses just as we do with other illnesses- early, often and as aggressively as we can because we know our outcomes are better when we do this and because it is the right thing to do.

BARRIERS TO PROGRESS, FRAGMENTATION BETWEEN MENTAL AND MEDICAL.  In the United States health care system, there is massive fragmentation between medical and mental health provision of care. Most payers and providers alike behave as if medical health and mental health have little to do with one another. As noted above, many studies have substantiated the costly impact of untreated or under treated mental health conditions (for example depression) on a person’s medical health. Despite this, many physicians know little to nothing about diagnosing mental illness and they know even less about addiction.  Training of mental health is minimal at many medical schools and it is even less with other specialties such as Dentists.  Intuitively we know that a patient with untreated or inappropriately treated mental illness, whether that be depression, bipolar disorder, addiction, PTSD, or an eating disorder, is ill-equipped to take care of herself medically. People with active addiction or depression are less likely to see a doctor for an annual physical exam where they may receive screening for a preventable illness.  As noted by the Canadian Mental health Association’s report of 2008, people with serious mental illness who have access to primary health care are less likely to receive preventive health checks.   They also have decreased access to specialist care and lower rates of surgical treatments following diagnosis of a chronic physical condition.    ‎Mental illness, at its root, affects a person’s thinking, planning, and motivation to care for self and warps their beliefs about what they deserve and are capable of accomplishing.

Another example tells the story….  A 45 year old female with cocaine dependence, BED, bipolar disorder, opioid dependence and history of developmental trauma presents.   She came to us seeking a psychiatrist for buprenorphine. Many addiction psychiatrists would likely see her for utox and sub Oxone med management monthly.  They may see her for 15 minutes every other week, they won’t coordinate care with her primary care doc or any of her other docs and as a result they may prescribe her medicine that might very well be harmful to her given her overall health history.

At SCH, she receives a thorough bio-psycho-social-spiritual evaluation. Her former prescriber is contacted for information sharing. It turns out she has no PCP, has never had a mammogram, she does not get pap smears because she is ashamed of her body. She sees a GI doc for reflux. At SCH she gets a PCP who works with the psychiatrist to manage this patient long-term both medically and psychiatric ally. If medical recommendations are not being followed, this becomes a therapeutic issue addressed by the psychiatric team in weekly individual session and group sessions. Further, at SCH mental health care is integrated. The whole patient is addressed, not parsed out by disease treated sequentially or in parallel using fundamentally different modalities. We even go so far as to regularly check the new prescription monitoring program where we are able to see what medications our patients may be getting from other doctors.  We had a case recently where a woman who suffers from cocaine addiction was being prescribed Adderall by one of her other (ignorant) MD’s.  We learned of this by using the PMS, we confronted the patient and we coordinated her care so as to ensure this wouldn’t continue to happen.

BARRIERS TO PROGRESS, SILOS WITHIN BEHAVIORAL HEALTHCARE:  The system today is incredibly siloed and often results in a game of “whack a mole” as one “primary” symptom is addressed yet because the underlying cause was not or the “secondary” diagnosis was not made nor addressed, another symptom pops up and the patient relapses in to a similar yet on the surface different type of addiction.  Many of the most well esteemed hospital systems and providers in the country have separate tracks, for instance, for eating disorders, substance abuse disorder and trauma.  This, despite the following according to NEDA:  Research suggests that nearly 50% of individuals with an eating disorder (ED) are also abusing drugs and/or alcohol, a rate 5 times greater than what is seen in the general population. The co-occurrence of these disorders affects both men and women with up to 57% of males with BED experiencing lifelong substance abuse problems. Eating disorders and substance abuse are independently correlated with higher than expected rates of death both from medical complications as well as suicide. An example- A patient presents with what is diagnosed as binge eating disorder and they get put on the “eating disorder” track where hopefully they learn to control (and reduce) their intake of food to a moderate amount and then they are discharged.  On the other end of the hall are patients who present with, say, an addiction to drugs.  These patients will hopefully learn to eliminate their consumption of drugs through maybe medication assisted therapy, behavior therapy, family therapy and other forms of therapy.  Both populations are suffering from addictive behaviors yet they are placed on separate tracks.  What gets missed in this approach is the many commonalities each of these populations share to include the fact that some form of trauma or depression or other mood disorder is likely at the root of the primary symptom.  Thus, when the food addict is able to manage their food intake and yet the underlying cause was never addressed nor did they learn the tools needed to fight imminent future urges for other substances, the next major stressor in their life could lead them to now find themselves addicted to alcohol or some other substance.  At SCH we do not put patients on separate tracks, as we use an integrated approach where we are not only integrating medical with behavioral but we are assessing and integrating our patients overall mental health.  We seek to treat the symptom and its underlying cause, giving our patients the tools they need to be free and healthy from all addiction.  Not all providers are capable of seeing the patient in this light and the literature supports the fact that co-occurring disorders can be difficult to diagnose due to the complexity of symptoms…. And inadequate provider training or screening, an overlap of symptoms, or other health issues that need to be addressed first.  Hiring the right therapists is critical to maintaining this integrated approach, and then ensuring we do not fall in to the easy trap of segmentation, treating the one symptom without regard for others that may be going on at the same time- which all too often leads to relapse.  Supported by a 2014 SAMHSA report, we know that people with co-occurring disorders are best served through integrated treatment.  This often leads to better health outcomes and lower healthcare costs.  (32)

Yet this same SAMHSA article sheds light on an inherent major problem that is not only a major barrier to treatment but one that also forces some providers to game the system in order to treat their patients.  The report states the following:  People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder.  According to the National Institute on Drug Abuse, drug addiction is a mental illness.  An addiction changes the brain in fundamental ways, disturbing a person’s normal hierarchy of needs and desires and substituting new priorities connected with procuring and using the drug. The resulting compulsive behaviors that override the ability to control impulses despite the consequences are similar to hallmarks of other mental illnesses.  Insurance companies do the same.  When applying for in network status, SCH was asked by all whether we provide “mental health” OR “substance abuse treatment” Our answer- they are the same and so we provide both.  From a patients perspective this separation can prove fatal and sometimes leads to good intentioned providers gaming the system in order to get their patients the treatment they need.  For example, not all patients have residential coverage for all of their mental health conditions, despite ACA and Parity. Commonly, a patient with an acute substance use disorder as well as an eating disorder will have RTC (residential treatment) benefit for mental health (ED) but not substance use disorder, or vice versa.  It is possible then that this patient would not receive authorization for treatment of their substance use disorder because somehow the payer sees substance as different from mental health, and visa versa.  For people who do have benefits for both MH and SUD, most often if they have co-occuring disorders only the identified “primary” disorder is authorized for treatment.  At SCH we are being very transparent with payers that our integrated approach may lead to us not being able to provide them with a “primary” diagnosis particularly when the patient presents with co-occurring diagnosis.  From our perspective, it does not matter what the primary is and we do not and will not just treat the primary.  We will treat the person.  When one of our clinicians was asked in an interview what they would treat first, a substance abuse diagnosis or a depression diagnosis, the answer was literally, “it doesn’t matter…”  We will of course treat any acute aspect first and foremost but after that we are treating the whole person, meeting them where they are at and getting to the root cause(s), or as close as possible. We won’t and don’t game the system like some providers do and it is too early to tell how payers will respond to our steadfast approach to integrated treatment.

BARRIERS TO PROGRESS, REACTIVE (and more fragmented) CARE. The Current models of delivery of mental health are reactive instead of preventative. Care is episodic and fragmented, rather than a longitudinal provision of care for people with chronic illnesses (many of whom achieve full remission…AND do best with ongoing preventative care in an outpatient setting). One example illustrates the issue- The person who has been to rehab 5 times for polysubstance dependence. They have been sober for 4 years, they are attending AA, and they now need a dental surgery, or an appendectomy. They end up being prescribed post-op narcotic pain meds prescribed by a provider who has had little to no addiction training, the sober patient is not fully aware of the support warranted to take these meds as they are prescribed and decides she can do it on her own.  After all she’s been sober 4 years.  That said, she takes the medication without any support and relapses once her prescription runs out. At SCH as that patient’s outpatient provider, or monthly addiction psychiatrist, we would collaborate with the surgical team and patient’s support system to facilitate the following plan: the patient never touches the prescription, her designated loved one fills it, and the loved one hands out the med as prescribed to patient in recovery from addiction. She gets an appointment with her long term addiction treatment professional (preventative care) the day after her pain med stops. The relapse is prevented, thousands of healthcare dollars are saved and most importantly potentially a life is saved.

BARRIERS TO PROGRESS, NO COST TRANSPARENCY
As we have noted above, payers are simply not looking at the medical co morbidity of these behavioral illnesses and therefore they don’t have a real grasp of actual costs. We met with one company recently with over 10,000 employees nationwide and their data shows that they “only” spend” about $1 million on substance abuse issues.  Clearly that number is not accurate and although we have not yet had a chance to parse through that data and identify what they are counting and what they are not counting, it is clear they aren’t counting indirect costs such as absenteeism, lost productivity or the cost to replace workers who either get injured or leave the job because of their problems.  They are also not counting the medical co-morbidity, which the literature and data support are significant.  At SCH we are teaching payers and employers alike that it is far less expensive to treat a patient on an ongoing outpatient basis for their behavioral problem (i.e. Symptomatic Nicotine addiction) than to ultimately see them get something like lung cancer and have extensive surgery.  We are also offering to parse through data for employers and payers in order to help them understand the true costs of some of these behavioral illnesses.  Many of them admit they know their numbers are not accurate and yet sometimes because the silos for medical and mental health are so strong or sometimes because they just don’t have the interest or the resources, they won’t allow us to do the work for them.  Yet we believe this is an important piece of our mission.  Once we can show the investment is worth it, critical mass will begin to move- especially with self-insured companies who would like nothing more than to see their employees more healthy AND reduce their TOTAL healthcare spend in the process!

The other critical piece of transparency and the lack thereof in this space involves the lack of universally accepted outcome measurements.  Many providers measure no data.  Many measure what they are good at it and through their own biases and unsophisticated analyses, report what looks good and conveniently leave out what may not look so good.  Although established and highly regarded groups like Michael Porter’s ICHOM have a standard set (of outcome measurements) for depression, there is currently nothing (that we are aware of) established for substance use disorder or eating disorders.  There are some common measurements but nothing standardized across the industry used by most of not all providers.  This makes it impossible for patients to compare providers when trying to make an informed decision on where to seek treatment and it makes it impossible for payers to negotiate fairly between providers based on the value they provide their patients and their patients families.  At SCH we are working with leaders in the industry to establish outcome measurements that we feel accurately reflect measurements that matter to our patients and to us as their providers.  We are tracking those outcomes using an electronic health records management system and we intend to share the data with our patients and their payers as we go.  Further, we intend to publish what we are measuring, why and how we are doing it with the hope that others will follow.  Without standardized and universally accepted outcome measurements, it will be impossible to move from a fee for service reimbursement model to a model based on the value we provide our patients.  As a new entrant eager to be reimbursed for our value rather than our volume, this initiative is an integral part of our mission.

BARRIERS TO PROGRESS- MOVING TOWARD VALUE IS NOT EASY IN THIS SPACE!

In order to move to a reimbursement model where we are rewarded for the value we create for our patients and their families we need to do share in some of the risk for our portion of the provision of care over which we agree to be responsible.  This requires, amongst other things, that we can risk adjust in to three of four buckers as patients present and it also requires a definition of “the episode of care”.  Unlike those who may be getting a knee replacement, these are not easy tasks with our population.  Further, we ideally create not only care teams that include various medical, behavioral, therapeutic specialists- all designed around the conditions of our patients- but we ideally bundle our payment so that we are all fully aligned as we treat our patients.  This is particularly difficult in mental health given that many therapists and psychiatrists themselves want nothing to do with insurance and in many cases don’t feel, given current state of fragmentation and lack of coordinated care, that they could afford to be help responsible for say what the patients primary care doc does (or does not do) in the provision of care over “the episode”.  At SCH we understand the challenge is significant.  Yet we are convinced that the current fee for service model is not only broken but it is unsustainable and truly does not work in the best interest of our patients or our families.   We are actively and diligently working on piloting different models of how to bring the right care team together and have a reimbursement model that works.  We feel strongly that for a patient suffering from a mental illness that it should be the psychiatrist who could be the gate keeper of sorts and leader of the team- who is responsible for care coordination and who creates the care team and pays all other providers based on the value the team delivers.  By no means do we claim to have this ironed out, yet we are moving the conversations we have and contract discussions we have in this direction to the extent we can.

CONCLUSION:  The data supports the inherent value of an integrated treatment model where medical and (sometimes multiple) behavioral issues are treated both equally and with regard for one another.  The data shows that that there is a tremendous opportunity to a save a tremendous amount of total healthcare dollars by investing in effective and integrated treatment.  The data shows that this is an international problem of epic proportion with depression leading as the most costly illness on the planet.  Despite the multiple barriers getting in the way, we know we can and will do better by chipping away at the barriers one by one.  At SCH we are providing care by designing our care teams around our patient’s needs and conditions.  We are measuring outcomes and we know what our cost drivers are.  By modeling to the industry that this treatment model is in the best interest of our patients, their families and their payers, we hope to make a difference and move the needle toward better care at a lower total cost.   In as much as a relatively small, independent and currently self-funded new entrant such as SCH might not have the data nor the volume we need to move as quickly as we might like, we know we are doing our job so long as we remain true to our guiding principles and continue to break down these barriers every day we come to work.  It is what our patients deserve.  It is what we all deserve.

THE SCOPE OF THE PROBLEM:  In 2013, it is estimated that Americans spent over $200 Billion treating Mental Health conditions, more than on any other medical condition including heart conditions, trauma, cancer and diabetes. (1) This does not include an additional $193.2 billion in lost earnings per year caused by those with serious mental illness (2).  Approximately 1 in 5 adults in the US experiences mental illness in a given year (3), and approximately 1 in 25 adults in the US experiences a serious mental illness in a given year that substantially interferes  with or limits one or more major life activities (4).  Behavioral health disorders are the leading cause of disability in the US and Canada (7) Individuals living with serious mental illness face an increased risk of having medical conditions (5), and adults living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions (6).

IT IS AN INTERNATIONAL PROBLEM:  The problem is not just related to the United States.  According to the World Health Organization, depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease.  More than 350 million people are estimated to suffer from depression worldwide and as the WHO clearly and properly states, “Especially when long lasting and with moderate or severe intensity, depression may become a serious health condition.  It can cause the affected person to suffer greatly and function poorly at work, at school and in the family…” (9)

MENTAL AND MEDICAL CO-MORBITIES:  The connections, both medically and financially, between “mental” illness and “medical” illnesses are well established.  Logically, people with mental illness are more likely to have additional medical complications, and people with medical illnesses are more likely to have mental health complications.  According to the National Council for Behavioral Health, medical costs for treating those patients with chronic medical and comorbid mental health/substance use disorder (MH/SUD) conditions can be 2-3 times as high as those who don’t have the MH/SUD conditions.  The additional healthcare costs incurred by people with behavioral comorbidities were estimated to be $293 billion in 2012 across commercially insured, Medicaid and Medicare beneficiaries in the United States.  (8)  In a study examining 150,000 Medicaid claims for beneficiaries in six states, authors determined that people with substance abuse disorders had significantly higher expenditures for health problems compared to others.  (15).

AGAIN, THIS IS INTERNATIONAL: As the Canadian Mental Health Association clearly states in its 2008 report titled, “The Relationship between Mental Health, Mental Illness and Chronic Physical Conditions”, “Mental health and physical health are fundamentally linked”. People living with a serious mental illness are at higher risk of experiencing a wide range of chronic physical conditions.  Conversely, people living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population.  Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes”.  (16).  Diabetes rates are significantly higher among people with mental illness, obesity rates are up to 3.5 times higher in people with mental illness in comparison to the general population, people with mental illnesses often experience high blood pressure and elevated levels of stress hormones and adrenaline which increase the heart rate, which significantly elevates the risk of heart disease.  In Canada, women with depression are 80% more likely to experience heart disease than women without depression.  Similarly, people with mental illness have up to three times greater likelihood of having a stroke.  (17)  The relative risk of people with a mental illness developing specified chronic physical conditions is as follows:  Diabetes:  1.6 for people with depression; Heart Disease:  1.6 for people with depression; Stroke: 3.1 for people with depression.  Conversely, there are significantly elevated risks of depression among people with heart disease, elevated rates of anxiety and depression among people living with chronic respiratory diseases and highly elevated rates of substance abuse and eating disorders among people with a history of trauma.  (all Canadian article and facts we know to be true)

INTUITION AND MORE CONNECTIONS BETWEEN MENTAL AND MEDICAL: We know that a person suffering from depression or anxiety is less likely to routinely go to their annual primary care doc visits.  We know that a person with bulimia nervosa is causing massive damage to their GI system.  We know that a person suffering with alcoholism is causing massive damage to their liver.  We know that tobacco smoke causes cancer of the mouth, throat, larynx, blood, lungs, stomach, pancreas, kidney, bladder, and cervix.  We know that injection of drugs such as heroin, cocaine, and methamphetamine currently accounts for about 12 percent of new AIDS cases.  (18)  And we know that people suffering from anorexia nervosa are at increased risk of the following medical comorbidities:  Thinning of the bones (osteopenia or osteoporosis), mild anemia and muscle wasting and weakness, brittle hair and nails, severe constipation, low blood pressure, slowed breathing and pulse, damage to the structure and function of the heart, brain damage and multi organ failure.

SO MUCH GOES UNTREATED:  Yet as the WHO also notes, although there are known effective treatments for depression, “fewer than half of those affected in the world receive such treatments”.  The National Council for Behavioral Health notes that more than one in three adults with serious impairment received no mental health treatment during the past year, with less than one third of adults with mental health disorders who do get treatment and receive care considered to be minimally adequate.  (10)  According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Survey on Drug Use and Health, 23.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol abuse problem in 2009 (9.3 percent of persons aged 12 or older). Of these, only 2.6 million—11.2 percent of those who needed treatment—received it at a specialty facility. (11)

LACK OF PARITY: Despite the growing costs of mental health care, these illnesses do not get the same level of research funding as heart disease, diabetes or cancer.  The National Institute of Health estimates it will spend $396 million on serious mental illness in 2016, whereas heart disease, cancer and diabetes will receive $1.3, $5.7 and $1 billion in funding respectively.  Anxiety disorders and depression, the most common mental health conditions, will receive much less- $163 and $406 million (19)!  Further and as noted above, despite the enormity of the problem less than half (41%) of adults in the US with a mental health condition received mental health services in the past year.

PROPER TREATMENT WORKS, AND IT’S “WORTH IT”:  The case for duly treating mental health as vigorously as we treat “medical” health could not be any more substantiated.  Proper treatment saves lives and it can save billions in healthcare dollars.  Researchers have noted that, “the vast majority of individuals with mental illness who receive appropriate treatment improve….. For major depression, panic disorder and obsessive compulsive disorder rates (of improvement) are about 70%.  This is comparable to rates of improvement for people who suffer from physical disorders, including diabetes and asthma at 70-80%, cardiovascular disease from 60-70% and heart disease at 41-52% (12).  The National Institute on Drug Abuse estimates that every dollar invested in addiction treatment programs yields a return of between $4 and 7$ in reduced drug related crime, criminal justice costs and theft.  When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1! (13). The US Department of Health and Human Services estimates that for every $100,000 invested in treatment for substance abuse (measured in California, New York and Washington), there are savings of $484,000 in health care costs and $700,000 of crime costs were shown to be avoided.  (14)  In a comparison of medical expenses of Medicaid clients who received treatment, the following savings were noted (measured in Washington):  $170.00/month for patients receiving inpatient; $215/month for those in outpatient treatment, and $230/month for those receiving medication assisted therapy (specifically methadone).  In California treated patients have been shown to reduce ER visits by 39%, hospital stays by 35% and total medical costs by 26% (14).

Just by integrating medical and behavioral services, The National Council for Behavioral Health estimates that between $26- $48 billion can potentially be saved!

If we are to make real progress, we need to increase access to care and we need to address the current state of fragmentation both between mental and medical health as well as within mental health itself.  We must adapt universally accepted outcome measurements (leading to greater cost transparency) that can be used by providers, patients and payers alike to make informed decisions and to hold one another accountable for their part of treatment and recovery.  If we can make headway in these three key areas, more people will seek and receive treatment for their mental health issues, patients will become more healthy both “mentally” and “physically”, and total healthcare dollars will be saved as a result.

BARRIERS TO PROGRESS:  STIGMA AND SHAME:  Many still living in the dark ages believe addiction is a choice.  At SCH we believe addiction is a disease, just like diabetes or cancer.  We know from science that an addicted person’s brain has a disrupted choice mechanism.  As The National Institute on Drug Abuse says, “However much we may wish that a person’s choices were free in all instances, it is simply a fact that an addicted person’s failures in the realm of choice are the product of a brain that has become greatly compromised—it is readily apparent when we scan their brains…”  The whole concept of anonymity in Alcoholics Anonymous or any of the other twelve step programs is telling. When people go to physical rehab for a broken and healing bone, is there an oath of secrecy associated with the patient’s visit?  There is nothing to be ashamed of by attending a recovery meeting for addiction, and yet this persists. At (SCH), we support the de-stigmatization of these diseases that has occurred over the years. We teach our patients that what they are suffering from is a disease, just like diabetes or cancer. We don’t believe people choose to ruin their lives and families when they become addicted to opiates. The activity in the brain that occurs when an addict is sick is nothing she can control.  We are working with EAP programs and Human Resource Executives at major companies trying to educate them on how to help their employees feel more comfortable asking for help.   We learned recently and were abhorred to hear that one EAP program actually tells first time callers that their calls are being recorded!!!!  As more and more people begin to understand that these are real medical diseases that manifest themselves similarly to other disorders around which the patient has little control, more people will seek help earlier and recover quicker, which will also result in diminished disease burden and need for long-term health resources. Most importantly, fewer people will die because they were ashamed to ask for help.

BARRIERS TO PROGRESS, LACK OF PARITY:  Why has mental health been separated or carved out from mainstream health care delivery?  Why do mental health providers spend so much of their time arguing with payers over authorization and medical necessity of their services when this rarely happens with medical conditions? Why is there a special (and additional) deductible for “mental health” with many insurers?  Despite the federal “parity” law enacted in 2010 (Mental Health Parity and the Patient Protection and Affordable Care Act of 2010), “discrimination still exists toward mental health and substance use conditions”, according to NAMI Executive Director Mary Gilberti.  She goes on to say in an April 1, 2015 report published by NAMI, “Progress is being made, but there is still a long road ahead.  The act contains a number of provisions that generally combine to extend the reach of existing federal mental health parity requirements, and is a response to the disparity in insurance coverage between mental illness and other physical illnesses.  According to the Congressional Research Service report dated 12/28/2011, “…parity generally refers to the concept that health insurance coverage for mental health services should be offered on par with covered medical and surgical benefits”.  (31) Yet in the NAMI report dated April, 2015, NAMI identifies areas, “where insurance companies need to improve and greater scrutiny is needed.”  This report specifically cites some following conclusions:  1) a lack of mental health providers is a serious problem in health insurance networks. 2) Nearly a third of survey respondents reported insurance company denials of authorization for mental health and substance abuse care.   For ACA plans, denials were nearly twice the rate for other medical care.  3) High co-pays, deductible and co-insurance rates create further barriers to treatment and 4) there is a serious lack of information about mental health coverage to enable consumers to make informed decisions in choosing care”.  (30)  At SCH we make the case every day with patients, their families, their payers and their employers that mental health benefits should at the very least be treated equally with other physical illnesses.  We do this as we have utilization review calls with payers, we do this when talking with EAP’s and Human Resource and Benefits groups at major employers in the Chicago area and we blog about it on our website, on twitter, on LinkedIn and at every chance we can.  We believe the cost benefit analysis speaks for itself; Investing in mental health treatment saves lives and it saves dollars.  Further, discriminating against those with mental illness by not reimbursing or covering it like other illnesses perpetuates the myth that addiction, for instance, is a choice which feeds in to the shame stigma and ultimately gets in the way of treating these illnesses as illnesses just as we do with other illnesses- early, often and as aggressively as we can because we know our outcomes are better when we do this and because it is the right thing to do.

BARRIERS TO PROGRESS, FRAGMENTATION BETWEEN MENTAL AND MEDICAL.  In the United States health care system, there is massive fragmentation between medical and mental health provision of care. Most payers and providers alike behave as if medical health and mental health have little to do with one another. As noted above, many studies have substantiated the costly impact of untreated or under treated mental health conditions (for example depression) on a person’s medical health. Despite this, many physicians know little to nothing about diagnosing mental illness and they know even less about addiction.  Training of mental health is minimal at many medical schools and it is even less with other specialties such as Dentists.  Intuitively we know that a patient with untreated or inappropriately treated mental illness, whether that be depression, bipolar disorder, addiction, PTSD, or an eating disorder, is ill-equipped to take care of herself medically. People with active addiction or depression are less likely to see a doctor for an annual physical exam where they may receive screening for a preventable illness.  As noted by the Canadian Mental health Association’s report of 2008, people with serious mental illness who have access to primary health care are less likely to receive preventive health checks.   They also have decreased access to specialist care and lower rates of surgical treatments following diagnosis of a chronic physical condition.    ‎Mental illness, at its root, affects a person’s thinking, planning, and motivation to care for self and warps their beliefs about what they deserve and are capable of accomplishing.

Another example tells the story….  A 45 year old female with cocaine dependence, BED, bipolar disorder, opioid dependence and history of developmental trauma presents.   She came to us seeking a psychiatrist for buprenorphine. Many addiction psychiatrists would likely see her for utox and sub Oxone med management monthly.  They may see her for 15 minutes every other week, they won’t coordinate care with her primary care doc or any of her other docs and as a result they may prescribe her medicine that might very well be harmful to her given her overall health history.

At SCH, she receives a thorough bio-psycho-social-spiritual evaluation. Her former prescriber is contacted for information sharing. It turns out she has no PCP, has never had a mammogram, she does not get pap smears because she is ashamed of her body. She sees a GI doc for reflux. At SCH she gets a PCP who works with the psychiatrist to manage this patient long-term both medically and psychiatric ally. If medical recommendations are not being followed, this becomes a therapeutic issue addressed by the psychiatric team in weekly individual session and group sessions. Further, at SCH mental health care is integrated. The whole patient is addressed, not parsed out by disease treated sequentially or in parallel using fundamentally different modalities. We even go so far as to regularly check the new prescription monitoring program where we are able to see what medications our patients may be getting from other doctors.  We had a case recently where a woman who suffers from cocaine addiction was being prescribed Adderall by one of her other (ignorant) MD’s.  We learned of this by using the PMS, we confronted the patient and we coordinated her care so as to ensure this wouldn’t continue to happen.

BARRIERS TO PROGRESS, SILOS WITHIN BEHAVIORAL HEALTHCARE:  The system today is incredibly siloed and often results in a game of “whack a mole” as one “primary” symptom is addressed yet because the underlying cause was not or the “secondary” diagnosis was not made nor addressed, another symptom pops up and the patient relapses in to a similar yet on the surface different type of addiction.  Many of the most well esteemed hospital systems and providers in the country have separate tracks, for instance, for eating disorders, substance abuse disorder and trauma.  This, despite the following according to NEDA:  Research suggests that nearly 50% of individuals with an eating disorder (ED) are also abusing drugs and/or alcohol, a rate 5 times greater than what is seen in the general population. The co-occurrence of these disorders affects both men and women with up to 57% of males with BED experiencing lifelong substance abuse problems. Eating disorders and substance abuse are independently correlated with higher than expected rates of death both from medical complications as well as suicide. An example- A patient presents with what is diagnosed as binge eating disorder and they get put on the “eating disorder” track where hopefully they learn to control (and reduce) their intake of food to a moderate amount and then they are discharged.  On the other end of the hall are patients who present with, say, an addiction to drugs.  These patients will hopefully learn to eliminate their consumption of drugs through maybe medication assisted therapy, behavior therapy, family therapy and other forms of therapy.  Both populations are suffering from addictive behaviors yet they are placed on separate tracks.  What gets missed in this approach is the many commonalities each of these populations share to include the fact that some form of trauma or depression or other mood disorder is likely at the root of the primary symptom.  Thus, when the food addict is able to manage their food intake and yet the underlying cause was never addressed nor did they learn the tools needed to fight imminent future urges for other substances, the next major stressor in their life could lead them to now find themselves addicted to alcohol or some other substance.  At SCH we do not put patients on separate tracks, as we use an integrated approach where we are not only integrating medical with behavioral but we are assessing and integrating our patients overall mental health.  We seek to treat the symptom and its underlying cause, giving our patients the tools they need to be free and healthy from all addiction.  Not all providers are capable of seeing the patient in this light and the literature supports the fact that co-occurring disorders can be difficult to diagnose due to the complexity of symptoms…. And inadequate provider training or screening, an overlap of symptoms, or other health issues that need to be addressed first.  Hiring the right therapists is critical to maintaining this integrated approach, and then ensuring we do not fall in to the easy trap of segmentation, treating the one symptom without regard for others that may be going on at the same time- which all too often leads to relapse.  Supported by a 2014 SAMHSA report, we know that people with co-occurring disorders are best served through integrated treatment.  This often leads to better health outcomes and lower healthcare costs.  (32)

Yet this same SAMHSA article sheds light on an inherent major problem that is not only a major barrier to treatment but one that also forces some providers to game the system in order to treat their patients.  The report states the following:  People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder.  According to the National Institute on Drug Abuse, drug addiction is a mental illness.  An addiction changes the brain in fundamental ways, disturbing a person’s normal hierarchy of needs and desires and substituting new priorities connected with procuring and using the drug. The resulting compulsive behaviors that override the ability to control impulses despite the consequences are similar to hallmarks of other mental illnesses.  Insurance companies do the same.  When applying for in network status, SCH was asked by all whether we provide “mental health” OR “substance abuse treatment” Our answer- they are the same and so we provide both.  From a patients perspective this separation can prove fatal and sometimes leads to good intentioned providers gaming the system in order to get their patients the treatment they need.  For example, not all patients have residential coverage for all of their mental health conditions, despite ACA and Parity. Commonly, a patient with an acute substance use disorder as well as an eating disorder will have RTC (residential treatment) benefit for mental health (ED) but not substance use disorder, or vice versa.  It is possible then that this patient would not receive authorization for treatment of their substance use disorder because somehow the payer sees substance as different from mental health, and visa versa.  For people who do have benefits for both MH and SUD, most often if they have co-occuring disorders only the identified “primary” disorder is authorized for treatment.  At SCH we are being very transparent with payers that our integrated approach may lead to us not being able to provide them with a “primary” diagnosis particularly when the patient presents with co-occurring diagnosis.  From our perspective, it does not matter what the primary is and we do not and will not just treat the primary.  We will treat the person.  When one of our clinicians was asked in an interview what they would treat first, a substance abuse diagnosis or a depression diagnosis, the answer was literally, “it doesn’t matter…”  We will of course treat any acute aspect first and foremost but after that we are treating the whole person, meeting them where they are at and getting to the root cause(s), or as close as possible. We won’t and don’t game the system like some providers do and it is too early to tell how payers will respond to our steadfast approach to integrated treatment.

BARRIERS TO PROGRESS, REACTIVE (and more fragmented) CARE. The Current models of delivery of mental health are reactive instead of preventative. Care is episodic and fragmented, rather than a longitudinal provision of care for people with chronic illnesses (many of whom achieve full remission…AND do best with ongoing preventative care in an outpatient setting). One example illustrates the issue- The person who has been to rehab 5 times for polysubstance dependence. They have been sober for 4 years, they are attending AA, and they now need a dental surgery, or an appendectomy. They end up being prescribed post-op narcotic pain meds prescribed by a provider who has had little to no addiction training, the sober patient is not fully aware of the support warranted to take these meds as they are prescribed and decides she can do it on her own.  After all she’s been sober 4 years.  That said, she takes the medication without any support and relapses once her prescription runs out. At SCH as that patient’s outpatient provider, or monthly addiction psychiatrist, we would collaborate with the surgical team and patient’s support system to facilitate the following plan: the patient never touches the prescription, her designated loved one fills it, and the loved one hands out the med as prescribed to patient in recovery from addiction. She gets an appointment with her long term addiction treatment professional (preventative care) the day after her pain med stops. The relapse is prevented, thousands of healthcare dollars are saved and most importantly potentially a life is saved.

BARRIERS TO PROGRESS, NO COST TRANSPARENCY
As we have noted above, payers are simply not looking at the medical co morbidity of these behavioral illnesses and therefore they don’t have a real grasp of actual costs. We met with one company recently with over 10,000 employees nationwide and their data shows that they “only” spend” about $1 million on substance abuse issues.  Clearly that number is not accurate and although we have not yet had a chance to parse through that data and identify what they are counting and what they are not counting, it is clear they aren’t counting indirect costs such as absenteeism, lost productivity or the cost to replace workers who either get injured or leave the job because of their problems.  They are also not counting the medical co-morbidity, which the literature and data support are significant.  At SCH we are teaching payers and employers alike that it is far less expensive to treat a patient on an ongoing outpatient basis for their behavioral problem (i.e. Symptomatic Nicotine addiction) than to ultimately see them get something like lung cancer and have extensive surgery.  We are also offering to parse through data for employers and payers in order to help them understand the true costs of some of these behavioral illnesses.  Many of them admit they know their numbers are not accurate and yet sometimes because the silos for medical and mental health are so strong or sometimes because they just don’t have the interest or the resources, they won’t allow us to do the work for them.  Yet we believe this is an important piece of our mission.  Once we can show the investment is worth it, critical mass will begin to move- especially with self-insured companies who would like nothing more than to see their employees more healthy AND reduce their TOTAL healthcare spend in the process!

The other critical piece of transparency and the lack thereof in this space involves the lack of universally accepted outcome measurements.  Many providers measure no data.  Many measure what they are good at it and through their own biases and unsophisticated analyses, report what looks good and conveniently leave out what may not look so good.  Although established and highly regarded groups like Michael Porter’s ICHOM have a standard set (of outcome measurements) for depression, there is currently nothing (that we are aware of) established for substance use disorder or eating disorders.  There are some common measurements but nothing standardized across the industry used by most of not all providers.  This makes it impossible for patients to compare providers when trying to make an informed decision on where to seek treatment and it makes it impossible for payers to negotiate fairly between providers based on the value they provide their patients and their patients families.  At SCH we are working with leaders in the industry to establish outcome measurements that we feel accurately reflect measurements that matter to our patients and to us as their providers.  We are tracking those outcomes using an electronic health records management system and we intend to share the data with our patients and their payers as we go.  Further, we intend to publish what we are measuring, why and how we are doing it with the hope that others will follow.  Without standardized and universally accepted outcome measurements, it will be impossible to move from a fee for service reimbursement model to a model based on the value we provide our patients.  As a new entrant eager to be reimbursed for our value rather than our volume, this initiative is an integral part of our mission.

BARRIERS TO PROGRESS- MOVING TOWARD VALUE IS NOT EASY IN THIS SPACE!

In order to move to a reimbursement model where we are rewarded for the value we create for our patients and their families we need to do share in some of the risk for our portion of the provision of care over which we agree to be responsible.  This requires, amongst other things, that we can risk adjust in to three of four buckers as patients present and it also requires a definition of “the episode of care”.  Unlike those who may be getting a knee replacement, these are not easy tasks with our population.  Further, we ideally create not only care teams that include various medical, behavioral, therapeutic specialists- all designed around the conditions of our patients- but we ideally bundle our payment so that we are all fully aligned as we treat our patients.  This is particularly difficult in mental health given that many therapists and psychiatrists themselves want nothing to do with insurance and in many cases don’t feel, given current state of fragmentation and lack of coordinated care, that they could afford to be help responsible for say what the patients primary care doc does (or does not do) in the provision of care over “the episode”.  At SCH we understand the challenge is significant.  Yet we are convinced that the current fee for service model is not only broken but it is unsustainable and truly does not work in the best interest of our patients or our families.   We are actively and diligently working on piloting different models of how to bring the right care team together and have a reimbursement model that works.  We feel strongly that for a patient suffering from a mental illness that it should be the psychiatrist who could be the gate keeper of sorts and leader of the team- who is responsible for care coordination and who creates the care team and pays all other providers based on the value the team delivers.  By no means do we claim to have this ironed out, yet we are moving the conversations we have and contract discussions we have in this direction to the extent we can.

CONCLUSION:  The data supports the inherent value of an integrated treatment model where medical and (sometimes multiple) behavioral issues are treated both equally and with regard for one another.  The data shows that that there is a tremendous opportunity to a save a tremendous amount of total healthcare dollars by investing in effective and integrated treatment.  The data shows that this is an international problem of epic proportion with depression leading as the most costly illness on the planet.  Despite the multiple barriers getting in the way, we know we can and will do better by chipping away at the barriers one by one.  At SCH we are providing care by designing our care teams around our patient’s needs and conditions.  We are measuring outcomes and we know what our cost drivers are.  By modeling to the industry that this treatment model is in the best interest of our patients, their families and their payers, we hope to make a difference and move the needle toward better care at a lower total cost.   In as much as a relatively small, independent and currently self-funded new entrant such as SCH might not have the data nor the volume we need to move as quickly as we might like, we know we are doing our job so long as we remain true to our guiding principles and continue to break down these barriers every day we come to work.  It is what our patients deserve.  It is what we all deserve.

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