The team at SCH is looking to align with like-minded treatment centers, mental health professionals and business leaders as we form an alliance designed to enable close collaboration around patient care and quality improvement initiatives in the behavioral health space- specifically the addictions and mood disorders space in which SCH operates. The name of the alliance is VMH, for Value in Mental Health. We are seeking to create an atmosphere in which we as healthcare professionals are able to openly discuss outcomes data with each other in order to drive an increase in quality of care, a decrease in total cost and data which clearly shows the value that we in the mental health field provide to patients, their families and their payers. Please contact David Newton at SCH to learn more.

If ever there was a time for mental health providers to work together to demonstrate, document and prove the value that our care provides, now is that time. The fact remains unfortunately that a relatively large percentage of people in our country simply do not want to pay for mental health services. Human behavior teaches us that people generally don’t want to pay for something if they don’t see the value in it. This is absolutely the case in mental health. Those of us who have done the research, who have lived with these diseases and/or who have treated these diseases know first-hand just how valuable and powerful proper and effective treatment can be. Lives can be saved, dollars can be saved and families can be saved. However, so many people don’t know this or they don’t believe it and as a result they simply don’t want to pay for it.

We see this being played out in Washington DC with the new healthcare act coming down the pipeline, which will inevitably cut funding for mental health treatment one way or another. We also see this being played out in the way treatment is currently paid for by managed care with the sometimes ridiculous hurdles they often put providers through. At SunCloud Health, we have had two cases in the past three weeks where managed care denied our right to submit clinical’s on two separate patients (who absolutely needed what we were recommending) based on their claim that they did not receive the request to submit clinical’s in a timely manner (Yes, you read that right). Drilled down for those of us who are forced to spend and waste countless hours on contentious “peer reviews”, the facts are as follows: We were initially and in our opinion unjustly denied for the requested level of care at the pre-auth stage, we opted to advocate for the patient and elected to escalate to the next level, we left the voice mail advising as much, we have proof that we left the voice mail, they denied receiving the voice mail and as a result they closed the case and refused to even consider the case for the level of care we recommended. They never looked at the additional clinical information available for review, they did not speak to anyone on our clinical team and they refused to authorize the level of care for the patient. Clearly they do not see the value in the care being provided. If they did, this would not happen this way. It just wouldn’t.

When a payer can get away with not paying for legitimate care based not on a patient’s clinical’s but rather a technicality such as they supposedly did not receive a voice mail, when more than 50% of the highest leaders in this country are debating not whether or not to cut access and funding to mental health but rather how to cut it and when some people still believe many mental health illnesses are choices rather than diseases, we most definitely have a problem.

Living in a country and in an economic system where we pay for goods and services based on the perceived value that we place on those goods and services, the most effective way to successfully address this problem is to prove to the world that there is in fact value in what we do. We know it’s there. Our job is to convince those who don’t know it or who don’t believe it that it is there. This is done with honest and reliable data and a clear message. It requires collaboration and cooperation between like-minded quality providers who deserve to be paid for the work that they provide not just because they feel like it but because there is real tangible VALUE in the service they are providing.

To show value, we must be able to effectively and clearly show people the results (or outcomes) of the treatment we provide, and the cost to achieve those outcomes. And we must do so in a way that our patients, their families and their payers can easily understand and in a way where they can compare our services against one another so as to determine what each of us do well and what we may not do as well. It is only with this perspective that comes with being able to compare products and services that people will be able to confidently assign a value both to what we provide as an industry and as individual providers.

To actually do this, we need collaboration among ourselves as providers and we need the buy in from payers who hold all of the claims data to agree to do the analysis with the data that they have and the results that we will provide them. Together, we need to agree on a standardized set of outcome tools that we all use and we need to pool as much data as possible so as to make a convincing case. We need to be ready and willing to learn from the measurements we will be taking as we learn what we do and do not do so well, and to work to continuously improve where we can. We MUST be willing to shift our mindset and our business models from being rewarded for the volume of services that we provide to being rewarded for the value that we provide our patients and their families. We must be willing to share in some of the risk with our patients and their payers, which simply means we do better when our patients do better and we don’t do as well when they don’t do as well (due to something that was or is in our control). We should we interested in having patient representation on quality improvement teams, as patients know sometimes better than we do where we can improve. Where we can take our cooperation a step further and create mutually beneficial alliances which optimize and leverage our strengths, we should do so. And of course we need to continue to advocate for our patients and their families every chance we get.

An inspiring article was released this month from ICHOM, an international consortium based in Cambridge which measures, documents and publishes meaningful health outcomes, about a group of hospitals in the Netherlands that decided to form an alliance that would enable close collaboration around patient care and quality improvement initiatives. The group is called Santeon and what they have been able to accomplish by taking many of the steps mentioned above is simply remarkable. Though they are not in the mental health space, there are still many lessons to be learned and the path they took toward changing the paradigm is one that at the very least is worthy of looking at.

The business of healthcare has changed a lot in the past ten years. Providers are being held more and more accountable for our provision of care than at any time in recent history. The shift from paying for value over volume is one that has moved in to many area of healthcare, and it is one that mental health providers should embrace arguably more than any other specialty. Payment for our services is currently under attack from just about every angle and this is primarily because we have a very difficult time showing people just how valuable and powerful our services can be. By working together and changing the way we do business, we can address this attack head on. And the beauty is that while we do this we will not only save ourselves from the attack on everything that we do, but we will improve quality of care, we will reduce total cost and we will do our part in providing as much access as possible to patients and their families who are in dire need of our services.

Click here for the ICHOM article on Santeon.

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…
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. 

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.