Cagr workshop final


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  • Disclaimer: I am an advocate…but have not personally worked in a medical home model, so would welcome any experiences from the audience - Advocate for better medical care for our psych patients - Advocate for further breaking down stigma against psychiatry
  •,1020,899997,00.jpg Warsaw, WWII “ There is no health without mental health” - World Health Organization Remarkable at how little research how little formal research has been done on this topic Keyword “ Mental health home”: 21 Medline references “ Medical home”: 43535 PubMed references: Employer Perspectives on the Patient-Centered Medical Home. Clinical study to determine the safety and efficacy of a low-energy, pulsed light device for home use hair removal. 486 Medline references
  • Personal physician - Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Physician directed medical practice - The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientation The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life care Care is coordinated and/or integrated Across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner Enhanced access - Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff Quality and safety Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family Evidence-based medicine and clinical decision-support tools guide decision making Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement Patients actively participate in decision-makin g and feedback is sought to ensure patients’ expectations are being met Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model Patients and families participate in quality improvement activities at the practice level Payment : recognizes the added value provided to patients who have a PC-MH and based on the following framework Reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources Support adoption and use of health information technology for quality improvement Support provision of enhanced communication access such as secure e-mail and telephone consultation Recognize the value of physician work associated with remote monitoring of clinical data using technology Allow for separate fee-for-service payments for face-to-face visits. Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits Recognize case mix differences in the patient population being treated within the practice Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting Allow for additional payments for achieving measurable and continuous quality improvements **Medicaid: those with this insurance typically have more instability, more likely to utilize ED services; majority of those on this have multiple chronic conditions with wide psychosocial needs **Funding for IT will help push PCMH
  • NCQA – National Committee for Quality Assurance I want to emphasize here that in order to truly be a medical home, it is a rigorous process, not simply picking up the idea and hopefully going with it. This is one of the defining features of the medical home model and one of the reasons that not only government agencies but insurers have also jumped on board with the concept – everyone likes “numbers”
  • While money typically muddies the picture, keep in mind that a positive aspect of this focus is that, from a systems standpoint, people are finally looking at how to reward treating chronic conditions and not just acute/acuity of illness
  • Sounds like a lot of work – and it is! But the idealist in me still hopes that practitioners want to do what is best for their patients (and may actually help prevent a few grey hairs for themselves) - Another reasons various organizations are getting on board is that the data to this point shows actual improvement – it’s not just a good idea from those living in ivory towers or those that have small grants that don’t show much sustainable for the majority of the population Caveat – since most of this work has been in the pediatric realm, that is where most of the good data is. HOWEVER, it seems the lessons learned and principles for kids also works in adults CYSHCN – Children and Youth with Special Health Care Needs Medical Home index score – created by Center for Medical Home Improvement, includes many of the measures already discussed with the NCQA standards So this is great – better outcomes, decreased cost, AND families (and therefore hopefully patients) are actually happy with their care ***How often does that intersection of outcomes happen?!
  • You might be hearing all of this and be saying to yourself, “jeez, this sounds great, why am I not doing this” - well, maybe now is the time to really consider it I include the AAN to show that our “brain brethren” are already endorsing this idea PCHM model does NOT limit appropriate referrals to specialists - Not limiting referrals – not that I think many psychiatrists worry about this point (sometimes it’s hard enough to get the referral in the first place, but that’s b/c of other factors….) – > and NOT see the PCP as a “gatekeeper”
  • Provides primary care – I know that many psychiatrists feel uncomfortable even with starting basic things like meds for HTN, cholesterol, DM, but if this model was in place where we knew there could be better f/u, maybe we could provide this care sooner Typical specialist PCMH patient Receiving long-term, principal care from specialist Frequent contact Most convenient for the patient Decision should be made by patient ultimately
  • So how can psychiatrists fit in this model? Maybe taking some of the same principles from the PCMH and applying it with models already created (but not necessarily coordinated) in the mental health world. I see this as a great way to get the MH model off the ground in the world of psych, especially if practitioners are in a community that might be slower to change in other ways ***Key caveat – my hope (at least) would not to make psychiatry yet again cut off from the rest of the medical world, but figuring out yet another model to help those who need it most. There are differences (whether anyone wants to openly admit to it) for those with SPMI, and as such there might need to be some tweaking of other systems to get people the care they need….and maybe even transition into “traditional” PCMH models So you can see by examining these principles, and comparing them to what has already been discussed in regards to PCMH, that they are fairly similar and ultimately, I feel, have the same overall goal of improving the overall healthcare of our patient population Enhanced access and coordination of care Priority access to services: new referrals, homeless, criminal justice contact *here’s a difference in particular specific to psych – more flexibility with scheduling Extensive case management: providers are involved with primary care team * Mental health home team takes responsibility for coordinating different services (ex. day treatment, intensive case management) * Also works with inpatient services * Incorporates different objectives and coordinates care and communication to make one unifying treatment plan * Can create critical mass for advocacy and support Integration of primary and preventative services - Often those in the public center do not receive the services they need - *have a 20% reduction in life span expectancy - Actively work along with PCP - Focus on wellness and primary care Use of evidence-based practices and continuous quality improvement * While difficult in psychiatry, especially in those with chronic conditions, it is still something to truly strive for Has dynamic continuous quality improvement team Attempt to engage staff and recipients to identify and adopt new practices Few people actually receive evidence-based practices Adoption of recovery principles Participation and full participation of the recipient in all decision-making Attempts to provide/create choices for the recipient A single clinical care entity can help provide focus and clarity Family and community outreach - Goes beyond individual treatment plans - Mental health home establishes identity aligned with community’s prevailing cultures Adopts a “customer is always right” attitude  recipient and family are equal partners in decision making – *This is not to say that the patient always is right in regards to wanting x or y medication to treat something that is not appropriate; instead, helpful to have the attitude that what the patient wants will more likely actually get done, and to work with that
  • Spectrum of management/co-management: PCP as primary manager, specialist as consultant Specialist as primary manager, PCP less involved PCP as co-manager with specialist ****NEED care coordination for this to work Situations when co-management urgently needed Patients care “belongs” to no one Patients with multiple ED visits, preventable admissions, “bounce-backs” Patients who go to PCP for urgent visits, do not receive primary care from specialists Patients who miss multiple specialty appointments Challenges: - Coordination of public and private health insurance plans to avoid fragmentation and complexity - Policies that deny payment for more than one “entity” on the same day – even if different specialties Reimbursement – capitated/case rates in certain situations may be ideal, but may discourage providers from taking on difficult cases Risk-based reimbursement? Next steps: - Communicating key concepts to stakeholders Training clinical staff in the mental health home model Piloting initiatives with innovative providers Exploring and testing reimbursement strategies
  • These are not my tips, but rather they are lessons learned from those who have been apart of pilot programs
  • Advance slowly – can even take “breaks” from change to allow people time to adjust Reward – one program even gave out giftcards for families that would come to monthly feedback sessions
  • Not everyone – focus more on chronic conditions
  • $160 million surcharge on insurance payments $160 million assessment on hospitals $220 million from general revenue Waiver being threatened Health plans and insurance co prohbiited from using helth status to set rates and restrictedvariations in rates based on industry, age and group size to araio of two to one or fewer; individual market premiums could ary based only on age and geography; one of only 5 states with guaranteed-issue rating and 7 states with a modified community rating in the individual market Sttes starting with a norm of less generous benefits and/or a sig market share for high deductible plans will have a more difficult time setting a base level of services as high as MA
  • Ranged from 2.9% for families in the 27-36k and 9.5% for families with 93-114k People with masshealth, medicare or option of employer sponsored coverage not eligible Penalty of 672/yr adults under 26; over 26 912/yr in ‘08
  • Zero percent for those below poerty level of 27,468 and full responsibility for pople with incomes more thn 500% of the poverty level For an individual earning 31k the cheapest plan can cost 9,72 in premiums and out of pocket payments
  • UCP breakdown FPL
  • MCC – preventive and primary care, emergency coverage, hospitalization benefits, ambulatory pt services, mental health services and rx drug coverage; incremntal; over 3 years, no annual or per-sickness benefit max; lifetime benefit caps; limits annual deductible to 2k per individual, 4k per family 26 y/o or 2 yrs after no independent status Section 125 allow employees to choose over wages benefits that do not cout as taxable income
  • No of employers offering insurance rose
  • 409,000 total
  • Oversampling of safety net doc.s
  • Survey in spring ‘08 of 1,000 MA FIRSM
  • 66
  • At BMC - 30% do not speak English as a first language; suing the state CHA provides 27% and 14% of uninsured and Medicaid mental health inpatient stays; cut 20% of inpt psych beds
  • State calc’d by considering aver. Cost at Mahospitals and paying 75% of that amount to encourage efficiency
  • ER; cost; Problems obtaining care occurred across all income levels but were concentrated among lower-income adults, particularly those enrolled in public programs. These findings are consistent with an ongoing survey of physicians in Massachusetts that found the shares of internists accepting new patients and MassHealth patients dropped under health reform, while wait times for appointments increased. 21 Covered but unable to access care 1/5 adults had been told in the last 12 mo.s that a doctor or clinic ws not ccpeting new pts or would not see pts with their type of insurance Rejection rates for low income adults and those with public insurance were double the rates for higher-income residents and those with private coverage Little change in use of ERs for non-emergency tx in those with incomes less than 300% of FPL
  • First Nations people living on reserves; Inuit; serving members of the Canadian Forces and the Royal Canadian Mounted Police; eligible veterans; inmates in federal penitentiaries; and refugee protection claimants.
  • Approximately 69 per cent of health care spending is publicly funded; the remainder consists of private health insurance spending (e.g. ambulance costs, prescription drug, dental, and vision plans) and out-of-pocket spending (e.g. both prescription and nonprescription drugs).
  • In 2003-04, Canada spent $6.6 billion on mental health, representing just 4.8 per cent (or $197 per person) of the total health budget. That puts Canada, along with Italy, at the bottom of the list in mental health spending by developed countries. As a share of the total health budget, Britain spent the most (12.1 per cent), followed by Germany (10), the Netherlands (8), Denmark (8), the U.S. (7.5), Ireland (6.8) and Australia (6.7).
  • Budget 2007 announced funding for the Canadian Mental Health Commission, with $10 million over the next two years and $15 million per year starting in 2009-10.
  • Federal commitment to Improving Mental Health
  • The program is based on the success of New York City's Pathways to Housing initiative, founded in 1992 by Canadian Dr. Sam Tsemberis. Different cities, different issues The project doesn't take a one-size-fits-all approach. The Vancouver site: focus on treatment of people with substance abuse issues Winnipeg: following people with a First Nations background Toronto: focus on homeless from immigrant or ethno-racial groups Moncton: issues faced by rural residents who end up in larger cities Montreal: helping the homeless join the workforce.
  • Cagr workshop final

    1. 1. Changing Paradigms of Psychiatric Practice in an Era of Healthcare Reform Chair - Javeed Sukhera, MD Co-Chair - Sarah Vinson, MD APA Annual Meeting, New Orleans LA May 23, 2010 A Presentation of the Council on Advocacy and Government Relations Fellow Members
    2. 2. Educational Objectives <ul><li>Identify lessons learned from healthcare reform for psychiatric practice </li></ul><ul><li>Address unintended consequences of the health reform process on vulnerable populations </li></ul><ul><li>Highlight successful collaborations between psychiatry and primary care </li></ul><ul><li>Discuss the role of successful prevention programs and their importance to healthcare reform </li></ul>
    3. 3. Panel Presentations <ul><li>Beyond the Medical Home: Collaboration Between Psychiatry and Primary Care   </li></ul><ul><ul><li>Peter S. Martin, MD, MPH </li></ul></ul><ul><li>Mental Health Reform in North Carolina </li></ul><ul><ul><li>Robin Reed, MD </li></ul></ul><ul><li>Health Insurance Reform in Massachusetts </li></ul><ul><ul><li>Sarah Vinson, MD </li></ul></ul><ul><li>Mental Health Promotion & Illness Prevention in the U.S. & Canada </li></ul><ul><ul><li>Margaret Balfour, MD, PhD </li></ul></ul><ul><ul><li>Catherine Krasnik, MD, PhD </li></ul></ul>
    4. 4. Disclosures <ul><li>Javeed Sukhera, MD </li></ul><ul><ul><li>Diversity Leadership Fellow - funded by AstraZeneca </li></ul></ul><ul><ul><li>APIRE/Janssen Scholar </li></ul></ul><ul><li>Peter S. Martin, MD, MPH, Margaret Balfour, MD, PhD, Catherine Krasnik, MD, PhD, Robin Reed, MD </li></ul><ul><ul><li>APA/Bristol Myers-Squibb Public Psychiatry Fellows </li></ul></ul><ul><li>Sarah Vinson, MD </li></ul><ul><ul><li>none </li></ul></ul>
    5. 5. Slides available online <ul><li> </li></ul>
    6. 6. Beyond the Medical Home: Collaboration Between Psychiatry and Primary Care Peter S. Martin, MD, MPH University at Buffalo
    7. 7. Objectives <ul><li>Explain the current state of care coordination between psychiatry and other specialties </li></ul><ul><li>Define the concept of a medical home </li></ul><ul><li>Discuss the “mental health home” </li></ul><ul><li>Describe ways in which one can change the scope of practice to include medical home concepts </li></ul>
    8. 8. Current State of Coordination
    9. 9. Models for Collaborative Care <ul><li>Separate physical locations for PCP and specialists without any formal collaboration </li></ul><ul><li>Having a psychiatrist working within a primary care clinic </li></ul><ul><li>Having a PCP working within a mental health clinic </li></ul><ul><li>Medical home model that can have different physical locations for providers but has improved communication and formal collaboration initiatives </li></ul>
    10. 10. Joint Principles of the Patient-Centered Medical Home <ul><li>Personal physician </li></ul><ul><li>Physician directed medical practice </li></ul><ul><li>Whole person orientation </li></ul><ul><li>Care is coordinated and/or integrated </li></ul><ul><li>Enhanced access </li></ul><ul><li>Quality and Safety </li></ul><ul><li>Payment </li></ul>
    11. 11. NCQA Standards <ul><li>Access and communication </li></ul><ul><li>Patient tracking and registry functions </li></ul><ul><li>Care management </li></ul><ul><li>Patient self-management support </li></ul><ul><li>Electronic prescribing </li></ul><ul><li>Test tracking </li></ul><ul><li>Referral tracking </li></ul><ul><li>Performance reporting and improvement </li></ul><ul><li>Advanced electronic communications </li></ul>West Virginia Bureau for Public Health. Medical Home NCQA Standards.
    12. 12. Options for payment <ul><li>Fee-for-service to do care coordination, and provide incentives for measures that prevent ED visits, hospitalizations, readmits </li></ul><ul><li>Capitation payment with P4P bonuses </li></ul><ul><li>Calculate payment based on diagnosis </li></ul><ul><li>Various algorithms that pay per episode of illness </li></ul>Quinn, K. Achieving cost control, care coordination, and quality improvement in the Medicaid program
    13. 13. Why do this? <ul><li>Children who receive care in settings that demonstrate elements of the medical home have better short-term outcomes than children who do not </li></ul><ul><li>Practices with higher Medical Home Index scores had significantly lower hospitalization rates for children with chronic conditions </li></ul><ul><li>Families of CYSHCN perceived their child to be healthier and experienced less worry when they received care in a medical home </li></ul>Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today.
    14. 14. Is now the time to endorse the PCMH? <ul><li>Four major primary care specialties and now 18 specialty medical societies have endorsed the Joint Principles </li></ul><ul><ul><li>Includes the American Academy of Neurology </li></ul></ul>
    15. 15. PCHM Model for Specialists <ul><li>Requirements include </li></ul><ul><ul><li>Provides primary/principal care to patients </li></ul></ul><ul><ul><ul><li>Might require specialists’ knowledge for tx of complex disease, but also can care for most general healthcare needs </li></ul></ul></ul><ul><ul><li>Meets approved third-party (eg. NCQA) requirements </li></ul></ul><ul><ul><ul><li>Ensures structural capacity </li></ul></ul></ul><ul><ul><li>Willingness to delivery comprehensive care </li></ul></ul>Kirschner, N and Barr, M. Specialists/subspecialists and the patient-centered medical home.
    16. 16. “Mental Health Home” <ul><li>Not necessarily a new service </li></ul><ul><li>Can take existing services and coordinate with a core set of principles </li></ul><ul><ul><li>Enhanced care and coordination of care </li></ul></ul><ul><ul><li>Integration of primary and preventative services </li></ul></ul><ul><ul><li>Use of evidence-based practices and continuous quality improvement </li></ul></ul><ul><ul><li>Adoption of recovery principles </li></ul></ul><ul><ul><li>Family and community outreach </li></ul></ul>Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”`
    17. 17. Differences from existing other medical home models <ul><li>Primary coordinator may not be a physician </li></ul><ul><li>Psychiatry is not typically seen as a primary care discipline </li></ul><ul><ul><li>Psychiatrist in this model would not serve as the PCP  would coordinate and communicate, and help with monitoring basic health indicators (i.e. BP, BMI, smoking status, even blood work) </li></ul></ul>Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”
    18. 18. Potential Pitfalls <ul><li>Who is the coordinator – physician vs. NP/PA vs. another care coordinator </li></ul><ul><li>Difficult for small practices to take on extra workload </li></ul><ul><li>Difficulty with getting families involved (easier to do with children vs. adults) </li></ul><ul><li>Is the PCP the best coordinator in all cases – maybe instead specialist </li></ul>Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today.
    19. 19. Tips <ul><li>Define your program – purpose and population </li></ul><ul><li>Find a strong leader </li></ul><ul><ul><li>Work as a team, which requires support </li></ul></ul><ul><li>Have a strong, supportive staff </li></ul><ul><ul><li>Link with other groups </li></ul></ul><ul><li>Know when to lead and when to delegate </li></ul>Minnesota Medical Association. Building a home: Twenty tips for creating a medical home. McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way
    20. 20. Tips <ul><li>Have supporting documentation to show evidence why medical home beneficial </li></ul><ul><li>Use templates when/if possible </li></ul><ul><li>Advance slowly and methodically </li></ul><ul><li>Involve family members from the beginning </li></ul><ul><ul><li>That includes incorporating time to acknowledge/reward their involvement </li></ul></ul>Minnesota Medical Association. Building a home: Twenty tips for creating a medical home. McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way
    21. 21. Tips <ul><li>Monitor (and continue to monitor) progress </li></ul><ul><ul><li>Be willing to have explicit measures to see progress – both from the practice as well as patient POV (i.e. surveys) </li></ul></ul><ul><ul><li>Be flexible and willing to change </li></ul></ul><ul><li>Do not lose emphasis on the need for care coordination </li></ul><ul><ul><li>That includes not forgetting about funding! </li></ul></ul><ul><li>Be committed to utilizing and electronic medical record system (even better if this coordinates with outside providers) </li></ul><ul><ul><li>Patient registries </li></ul></ul><ul><ul><li>Patient portals </li></ul></ul>Minnesota Medical Association. Building a home: Twenty tips for creating a medical home. McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way
    22. 22. Take Home Points <ul><li>Not everyone needs to be a part of the medical home model </li></ul><ul><li>However, principles from the overall model can help improve the care of all patients with mental illness </li></ul><ul><li>Appears to bring about real cost savings </li></ul>
    23. 23. Hopeful Outcome
    24. 24. Resources <ul><li>National Center for Medical Home Implementation </li></ul><ul><ul><li> </li></ul></ul><ul><li>NCQA </li></ul><ul><ul><li> </li></ul></ul><ul><li>Center for Medical Home Improvement </li></ul><ul><ul><li> </li></ul></ul>
    25. 25. References <ul><li>National Center for Medical Home Implementation </li></ul><ul><ul><li>http://www. medicalhomeinfo .org/ </li></ul></ul><ul><li>Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services. 2009;60:528–533 </li></ul><ul><li>Bazelon Center for Mental Health Law </li></ul><ul><ul><li>http://www. bazelon . org/issues/healthreform/issuepapers/MedicalHomes . pdf </li></ul></ul><ul><li>Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today. Pediatric Annals . 2009;38(9): 483-490,2009 </li></ul><ul><li>Kirschner, N and Barr, M. Specialists/subspecialists and the patient-centered medical home. Chest. 2010;137(1):200-204 </li></ul><ul><li>Stille, C et al. Communication and Co-Management. AAP Medical Home Implementation Teleconference Series. </li></ul><ul><ul><li> </li></ul></ul><ul><li>West Virginia Bureau for Public Health. Medical Home NCQA Standards. </li></ul><ul><ul><li> </li></ul></ul><ul><li>Quinn, K. Achieving cost control, care coordination, and quality improvement in the Medicaid program. J Ambulatory Care Manage . 2010;33(1):38-49 </li></ul><ul><li>Minnesota Medical Association. Building a home: Twenty tips for creating a medical home. Minnesota Medicine . 2010;Jan:32-35 </li></ul><ul><li>McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way. Family Practice Management . 2009;July/Aug:15-18. </li></ul><ul><li>Images: </li></ul><ul><ul><li>,1020,899997,00.jpg </li></ul></ul><ul><ul><li> </li></ul></ul>
    26. 26. Unintended Consequences Mental Health Reform in North Carolina 2001-Present Robin Reed, M.D. PGY-III General Adult Psychiatry Resident 2010-2012 Community Psychiatry Fellow Department of Psychiatry University of North Carolina at Chapel Hill
    27. 27. Outline <ul><li>• Current structure of the public mental health system in North Carolina </li></ul><ul><li>Public Consulting Group Report recommendations (1998/1999) </li></ul><ul><li>State Response: House Bill 381; State Mental Health Plan (2001/2002) </li></ul><ul><li>Unintended consequences (Mental Health center closings, Increased admissions at State Psychiatric Hospitals, budgeting miscalculations, (lack of savings in state hospital consolidations, community support cost overruns) and poor retention of community psychiatrists. </li></ul><ul><li>Press Coverage </li></ul><ul><li>In Hindsight </li></ul><ul><li>Where we are today (CABHA, Revised service Definitions, Antipsychotic initiative, approximating ED waits, Electronic Records,) </li></ul>
    28. 28. Current Structure of the Public Mental Health System in North Carolina <ul><li>State Operated Services : State Psychiatric Hospitals, Developmental Disability Centers, and Alcohol & Substance Abuse Centers </li></ul><ul><li>Local Management Entities (LME) (~mental health centers): Organized over geographic areas, 24 total, state government accountable, additional county/city funding </li></ul><ul><li>Private for-profit and nonprofit Provider groups (private practice, University-affiliated) </li></ul>
    29. 29. = State Psychiatric Hospital
    30. 30. PCG Findings & Recommendations 1998/1999 <ul><li>• Area Programs are not accountable to state or local governments </li></ul><ul><li>and are guided by local forces and priorities </li></ul><ul><li>• Reduce State Hospital bed capacity, including closure of Dorothea </li></ul><ul><li>Dix Hospital, and transfer savings to community-based resources </li></ul><ul><li>• State Hospital utilization is highly variable and higher than in </li></ul><ul><li>“ peer” states </li></ul><ul><li>• State Hospital and Willie M. expenditures are disproportionate: </li></ul><ul><li>Willie M. outpatient expenditures: $37,000 / patient / year </li></ul><ul><li>Everyone else (MH): $337 / patient / year </li></ul><ul><li>1 Willie M. outpatient = 109.8 MH outpatients </li></ul><ul><li>• Financial data systems flawed </li></ul>
    31. 31. House Bill 381 & State Mental Health Plan (2001) <ul><li>HOUSE BILL 381 </li></ul><ul><li>Area Programs are not accountable to state or local governments and are guided by local forces and priorities. </li></ul><ul><li>Area programs, renamed, Local Management Entities (LME) </li></ul><ul><li>Reduce State Hospital bed capacity, including closure of Dorothea Dix Hospital, and transfer savings to community-based resources. </li></ul><ul><li>DHHS Secretary has a redefined role </li></ul><ul><li>Instructed to divest clinical staff and reformulate clinician contracts with ‘private’ providers </li></ul><ul><li>STATE PLAN </li></ul><ul><li>“ The ideal LME provides no direct services, concentrating its attention on developing and overseeing service provision throughout its entire region.” </li></ul><ul><li>Eliminate state psychiatric hospital adult beds, realign funding, and continue to develop community based services for currently hospitalized persons including specialized residential services, community nursing facilities and other supports.” </li></ul><ul><li>State sets goal of reducing ~700 beds by 2005. </li></ul>
    32. 32. Financial Crises <ul><li>• Area programs required to pay ~$75 million to the Federal Government </li></ul><ul><li>• State Budget Shortfalls: </li></ul><ul><li>$900 million in 2002 </li></ul><ul><li>$600 million in 2003 </li></ul><ul><li>• Governor removed $37.5 million of $47.5 million from Mental Health Trust Fund in 2002 </li></ul><ul><li>• Medicaid overpayment to State Hospitals: </li></ul><ul><li>1997-2003: $658 million ($245 million by State) </li></ul>
    33. 33. Unintended Consequences <ul><li>Local Management Entities unable to remain financially viable and close (37  23) </li></ul><ul><li>Increased State Psychiatric Hospital Admissions </li></ul><ul><li>Budgeting Miscalculations </li></ul><ul><li>• Lack of providers serving patients in the public system </li></ul>
    34. 34. Local Management Entities Struggle to Survive
    35. 35. Local Management Entities Struggle to Survive <ul><li>‘ Loss’ of community psychiatrists (2003-2005): </li></ul><ul><li>• Per Capita LME-sector psychiatrists fell 16.1%: Rural areas hit harder (19.7%) </li></ul><ul><li>• In 2006, North Carolina Psychiatric Association estimated 23% more psychiatrists needed </li></ul>
    36. 36. State Psychiatric Hospital Admissions Increase <ul><li>• 40% reduction in statewide capacity </li></ul><ul><li>(~1700  1000 beds) </li></ul><ul><li>• 23% increase in admissions (1999-2003/2004) </li></ul><ul><li>• C/A admissions doubled (7/03-12/04) </li></ul>
    37. 37.
    38. 38. State Psychiatric Hospital Admissions Increase
    39. 39. State Psychiatric Hospital Admissions Increase
    40. 40. Budgeting Miscalculations <ul><li>Lack of savings in State Hospitals </li></ul><ul><li>• 2004 estimate: </li></ul><ul><li>Projected: $16.2 million </li></ul><ul><li>Actual Savings: $9.2 million </li></ul><ul><li>• Increase in bed day costs 2001-2005: </li></ul><ul><li>$430  $711 /per patient bed day </li></ul>
    41. 41. Budgeting Miscalculations <ul><li>Community Support cost overruns: </li></ul><ul><li>$600 million </li></ul><ul><li>• 4/06-3/07: </li></ul><ul><li>245% increase in utilization </li></ul><ul><li>• 4/06-2/07: </li></ul><ul><li>Adult costs/month: ↑(25x) $1.2  $30.9 million </li></ul><ul><li>C/A costs/month: ↑(13.5x) $4.5  $61.8 million </li></ul>
    42. 42. Factors Influencing the Explosion of Community Support Services <ul><li>Delay in Service Definitions led to relaxed provider authorization requirements </li></ul><ul><li>Poor transition of claims processing from LME to State-funded, private contractor: Value Options </li></ul><ul><li>Lack of qualification guidelines for providing Community Support Services </li></ul><ul><li>Delays in communicating the problem between government entities </li></ul>
    43. 44. Where are the Psychiatrists? <ul><li>Poor retention of Community Psychiatrists </li></ul><ul><li>Difficult recruitment of private providers to serve people in the public system </li></ul><ul><li>Poor utilization of funding to hire psychiatrists </li></ul>
    44. 45. Where are the Psychiatrists? <ul><li>From 2003 to 2005: </li></ul><ul><li>• Per Capita LME-sector psychiatrists fell 16.1%: Rural areas hit harder (19.7%) </li></ul><ul><li>• In 2006, North Carolina Psychiatric Association estimated 23% more psychiatrists </li></ul><ul><li>• 24% increase in patient/psychiatrist ratio: </li></ul><ul><li>= ~31,000 patients unable to access care. </li></ul>
    45. 46. In Hindsight <ul><li>• No clear organization for implementation </li></ul><ul><li>• Absence of data, aside from Medicaid, to monitor utilization & funding </li></ul><ul><li>• Absence of quality measures </li></ul><ul><li>• Inadequate funding </li></ul><ul><li>• Lack of accountability & description of leadership responsibilities </li></ul><ul><li>• Failure to promptly respond to system breakdowns </li></ul><ul><li>• Lack of transparency </li></ul>
    46. 47. Press Coverage <ul><li>Fayetteville Observer editorial, 3/5/02: “It's going to be a local problem, all right: a very expensive lesson, in both fiscal and human capital, in the folly of false economy.” </li></ul><ul><li>Charlotte Observer series on problems in children’s group homes in January 2005 </li></ul><ul><li>--State suspends group home licensing </li></ul><ul><li>Mountain Xpress (Asheville): “Nowhere to turn; state mental-health reform widens gap in crisis management” in February 2005 </li></ul><ul><li>Hendersonville Times-News series on mental health reform: “Nurse sees jail as ‘dumping ground’ for many of the mentally ill” in February 2005 </li></ul><ul><li>Winston-Salem Journal series: “Breakdown: A Crisis in Mental Health Care” </li></ul><ul><li>Asheville Citizen-Times : “NC’s mental health ‘reform’ is a train wreck right now” </li></ul><ul><li>Raleigh News and Observer series “--Mental Disorder” runs from 2/24 to 3/2/08 </li></ul>
    47. 48. Provider Perceptions of Mental Health Reform in North Carolina*
    48. 49. Where we are today <ul><li>CABHA (Critical Access Behavioral Health Agency): The new mental health center </li></ul><ul><li>Revised service Definitions : Preventing excessive pay for under qualified professionals </li></ul><ul><li>Atypical Antipsychotic initiative : Improving utilization in psychiatry and primary care </li></ul><ul><li>Approximating ED wait times and ED utilization </li></ul><ul><li>Electronic Medical Records </li></ul>
    49. 50. References <ul><li>“ An Act to Phase in Implementation of Mental Health System Reform at the State and Local Level”. Session Law 2001-437. House Bill 381. General Assembly of North Carolina. Session 2001. </li></ul><ul><li>State Plan 2001: Blueprint for Change . November 30 th , 2001. </li></ul><ul><li>State Plan 2002: Blueprint for Change . July 1 st , 2002. </li></ul><ul><li>“ Report Card on the Clinical Impact of North Carolina’s Mental Health Reform”. North Carolina Psychiatric Association. June 2005. </li></ul><ul><li>“ An Analysis of State-Operated Hospital Downsizing in North Carolina”. Presentation by the Clinical Services Support Workgroup of the North Carolina Council of Community Programs and Approved by the Board of Directors of the North Carolina Council of Community Programs. 2005. </li></ul><ul><li>“ There Is Not Enough Money for Mental Health”. The Second Report Card by the North Carolina Psychiatric Association. March 16 th , 2006. </li></ul><ul><li>“ Discarding Community Psychiatrists”. The Third Report Card by the North Carolina Psychiatric Association. April 18 th , 2006. </li></ul>
    50. 51. References <ul><li>“ Compromised Controls and Pace of Change Hampered Implementation of Enhanced Mental Health Services”. Final Report to the Joint Legislative Program Evaluation Oversight Committee. Report Number 2008-05-3. July 29 th , 2008. </li></ul><ul><li>“ Caring for Previously Hospitalized Consumers: Progress and Challenges in Mental Health System Reform.” Final Report to the Joint Legislative Program Evaluation Committee. Report Number 2008-12-04. December 10, 2008. </li></ul><ul><li>“ A History of Mental Health Reform in North Carolina”. North Carolina Center for Public Policy Research. March 1 st , 2009. </li></ul><ul><li>“ How North Carolina Compares, A Compendium of State Statistics”. North Carolina General Assembly Program Evaluation Division. June 2009. </li></ul><ul><li>“ Proposed Report on the Continuation and Expansion of Budgets 2009-2011” . House Appropriations Subcommittee on Health and Human Services. June 4 th , 2009. </li></ul><ul><li>“ Enhanced Services Package Implementation: Costs, Administrative Decision Making, and Agency Leadership”. Final Report to the Joint Legislative Program Evaluation Committee. July 6 th , 2009. </li></ul><ul><li>“ Lessons from Mental Health Reform in North Carolina, 2001-2008”. Harold Carmel, MD. 2009. </li></ul><ul><li>“ Critical Access Behavioral Health Agency”. North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. March 10 th , 2010. </li></ul>
    51. 54. Acknowledgements <ul><li>UNC Center for Excellence in Community Psychiatry </li></ul><ul><li>• Brian Sheitman, M.D., Bebe Smith, LCSW/MSW </li></ul><ul><li>Harold Carmel, M.D. </li></ul><ul><li>Elizabeth Reynolds, M.D. </li></ul><ul><li>Elizabeth Bullard, M.D. </li></ul>
    52. 55. Health Insurance Reform in MA A Case Study for Expanded Coverage and Individual Mandates Sarah Y. Vinson, MD APA/SAMHSA Minority Fellow PGY3 Adult Psychiatry Resident Cambridge Health Alliance
    53. 56. Presentation Outline <ul><li>MA Health Reform </li></ul><ul><ul><li>Key components </li></ul></ul><ul><ul><li>Coverage Gains </li></ul></ul><ul><li>Physician Perspectives </li></ul><ul><li>Employer and Employee Perspectives </li></ul><ul><li>Survey of MA Psychiatrists </li></ul><ul><li>Special Considerations </li></ul><ul><ul><li>Safety Net Hospitals </li></ul></ul><ul><ul><li>Low-income Patients </li></ul></ul><ul><ul><li>Immigrants </li></ul></ul><ul><ul><li>Mentally Ill </li></ul></ul><ul><li>Key Differences in MA Plan and National Plan </li></ul>
    54. 57. Massachusetts Health Care Reform Law <ul><li>Enacted as Chapter 58 of the Acts of 2006 of the Massachusetts General Court: “An Act Providing Access to Affordable, Quality, Accountable Health Care “ </li></ul><ul><li>Characteristics Unique to MA at time of passage </li></ul><ul><ul><li>10% uninsured compared to 15% national average </li></ul></ul><ul><ul><li>Higher rate of employer coverage </li></ul></ul><ul><ul><li>Broader Medicaid program </li></ul></ul><ul><ul><li>Pre-existing Uncompensated Care Pool (UCP) </li></ul></ul><ul><ul><ul><li>Payments made directly to hospitals and community health centers </li></ul></ul></ul><ul><ul><li>Bi-partisan collaboration between Republican governor and Democratic legislature </li></ul></ul><ul><ul><li>Relatively high per capita income </li></ul></ul><ul><ul><li>Existing regulation of small group & individual insurance market </li></ul></ul><ul><ul><li>State w/ highest per capita rate of physicians and psychiatrists </li></ul></ul>Sources 1-3
    55. 58. Medicaid Expansion Commonwealth Care (CC) Commonwealth Choice Rerouting UCP Funds Insurers Employers Mandated Health Insurance Coverage or Pay Tax Penalty Source 2
    56. 59. Individuals <ul><li>Individual mandate for Minimum Credible Coverage (MCC) if “affordable” * </li></ul><ul><li>Pts transitioned from UCP to CC </li></ul><ul><ul><li>150%-300% of FPL </li></ul></ul><ul><ul><ul><li>Sliding-scale premiums and co-payments </li></ul></ul></ul><ul><ul><li>Up to 150% FPL </li></ul></ul><ul><ul><ul><li>No premium and small medication co-payments </li></ul></ul></ul><ul><li>Limitations to CC eligibility * </li></ul><ul><li>Penalties for uninsured enforced through DOR* </li></ul>*National Health Insurance bill has similar component Source 2
    57. 60. Cost of H.I. Premium For Family Source 5
    58. 61. Government <ul><li>Medicaid expansion* </li></ul><ul><ul><li>Coverage extended to children in families with income up to 300% FPL </li></ul></ul><ul><li>Subsidized insurance plans* </li></ul><ul><ul><li>“ Commonwealth Care” </li></ul></ul><ul><ul><li>Sliding scale subsidies for those below 300% of FPL </li></ul></ul><ul><li>Private insurance connector* </li></ul><ul><ul><li>“ Commonwealth Choice” </li></ul></ul><ul><ul><li>Unsubsidized insurance plans for individuals and small businesses employees </li></ul></ul><ul><li>UCP funds reallocation to CC subsidies </li></ul><ul><li>Built upon pre-existing insurance regulations </li></ul>Source 2
    59. 62. Business <ul><li>Employers </li></ul><ul><li>Expansion of Insurance Partnership Program </li></ul><ul><ul><li>Subsidies/incentives for employers/employees to participate in employer sponsored insurance </li></ul></ul><ul><li>Fees if Coverage Not Provided* </li></ul><ul><ul><li>of $295 per employee per year for employers who do not provide health insurance or </li></ul></ul><ul><li>Required Section 125 Cafeteria Plans </li></ul><ul><li>Insurers </li></ul><ul><li>Can not deny coverage due to Pre-existing condition* </li></ul><ul><li>Minimum Creditable Coverage* </li></ul><ul><li>All Health Plans Required to cover essential benefits* </li></ul><ul><li>Limits on Annual Deductibles* </li></ul><ul><li>Merger of small group and individual markets </li></ul><ul><li>Coverage under parents’ plan through age 26* </li></ul><ul><li>Young Adult Plan (YAP) </li></ul>Source 2
    60. 63. After 2 years… <ul><li>Over 400,000 Newly Insured </li></ul><ul><li>No evidence of crowd out </li></ul><ul><li>Strongest success in expanding coverage for lower income adults (less than 300% FPL) </li></ul><ul><ul><li>Uninsured rate 24%  8% </li></ul></ul><ul><li>Remainder of uninsured disproportionately young, male, single and or healthy </li></ul><ul><li>Affordability a barrier for uninsured </li></ul><ul><ul><li>41% of the uninsured said they had tried to find coverage they could afford </li></ul></ul>Source 2, 6
    61. 64. Sources of Coverage for Newly Insured Source 6
    62. 65. MA Physicians’ View of Reform <ul><li>2,135 Practicing MA Physicians </li></ul><ul><ul><li>70% expressed a favorable view </li></ul></ul><ul><ul><li>In 21/22 areas majority of physicians said that law either did not have much of an effect or was having a positive effect on their practice </li></ul></ul><ul><ul><ul><li>Including quality, overall practice, wait time for appointments, financial situation of practice </li></ul></ul></ul><ul><ul><ul><li>Administrative burden elicited the most negative response </li></ul></ul></ul><ul><ul><li>Negative evaluations from a majority of physicians for overall cost of care in the state </li></ul></ul>Source 8
    63. 66. MA Employers’ & Employees Views of Reform <ul><li>Employers </li></ul><ul><li>Majority viewed reform as “good for MA” </li></ul><ul><li>Percentage of firms with 3 or more workers offering coverage increased from 73-79% </li></ul><ul><li>Less likely than employers nationally to indicate plans to terminate coverage or restrict eligibility for health benefits </li></ul><ul><li>Employees </li></ul><ul><li>Concerns about employers’ dropping coverage or scaling back benefits had not been realized </li></ul><ul><li>Access to employer coverage increased </li></ul><ul><li>Quality and scope of coverage increased </li></ul><ul><li>Premiums and out-of-pocket expenses higher for employees in small firms </li></ul>Sources 9, 10
    64. 67. MA Psychiatrists Survey <ul><li>Web-based survey disseminated through the Massachusetts Psychiatric Society listserv </li></ul><ul><li>Anonymous </li></ul><ul><li>Convenience Sample </li></ul><ul><li>154 respondents </li></ul><ul><li>Included multiple choice, likert scale and free response questions regarding </li></ul><ul><ul><li>Reform’s effects in MA overall </li></ul></ul><ul><ul><li>Reform’s effects on respondent’s personal practice </li></ul></ul><ul><ul><li>Impressions of reform </li></ul></ul>Source 11
    65. 68. MA Psychiatrists Survey <ul><li>41% of respondents provided most of their direct patient care in private practice setting </li></ul><ul><li>Vast majority provided direct patient care in multiple settings </li></ul><ul><li>97% in urban or suburban settings </li></ul><ul><li>71% had seen patients on Medicaid w/n the past 30 days </li></ul><ul><li>56% had seen legal non U.S. citizens w/n the past 30 days </li></ul><ul><li>Majority had been practicing psychiatry in MA 20+ years </li></ul>Source 11
    66. 69. Respondents Support of the Law No Support Full Support Source 11 66%
    67. 70. MA Psychiatrists Survey Source 11
    68. 71. Rate Agreement: Access Has Improved Source 10
    69. 72. Reasons M.H. Service Access Has Not Improved or Gotten Worse Source 11
    70. 73. Survey Free Response <ul><li>Support Limiting Issues: </li></ul><ul><ul><li>administrative hassles, cost, low reimbursement rates for Medicaid and CC, coverage gaps, insufficient providers </li></ul></ul><ul><li>Many expressed support for a Single Payer Option </li></ul>Concept is good. Implementation is weak based on the very low reimbursement rates on the Commonwealth Care plans. Access is also poor most likely due to the reimbursement issue Private Practice Psychiatrist Access to treatment for co-morbid medical & substance use disorders has improved with insurance reform & has made a huge difference for poor & previously uninsured persons with major mental illness. Public Sector Psychiatrist Source 11
    71. 74. Special Considerations <ul><ul><li>Safety Net Hospitals </li></ul></ul><ul><ul><li>Low-income Patients </li></ul></ul><ul><ul><li>Immigrants </li></ul></ul><ul><ul><li>Mentally Ill </li></ul></ul>
    72. 75. MA’s Largest Safety Net Hospitals Source 12 BMC CHA % Uninsured Pre-reform 20 23 % Medicaid Pre-reform 27 21 % Racial /Ethnic Minorities 70 40 Payment : Cost Ratio for Low Income Pts Pre-Reform 82:100 77:00 Payment : Cost Ratio for Low Income Pts Post-Reform 64:100 60:100
    73. 76. Sources 12, 13, 14
    74. 77. UCP  CC Patients Source 14
    75. 78. More MA Residents Directly Affected Said Reform was Hurting Them Source 16
    76. 79. Immigrants <ul><li>CC coverage cut abruptly for 31,00 refugees, green card holders and others who have lived in the country <5yrs </li></ul><ul><li>Population’s coverage not matched by the fed. govt. </li></ul><ul><li>$40 million eventually restored to the $130 million program for limited coverage through a specific provider </li></ul><ul><ul><li>Disruptions in Care </li></ul></ul><ul><ul><li>Higher copayments </li></ul></ul><ul><ul><li>Limitations to Access </li></ul></ul><ul><ul><ul><li>Clinic Locations </li></ul></ul></ul><ul><ul><ul><li>Translator Services </li></ul></ul></ul><ul><ul><ul><li>Mental Health </li></ul></ul></ul><ul><li>Legal immigrants and undocumented people with greater reliance on struggling SNH for culturally competent care </li></ul><ul><li>Politically vulnerable population </li></ul>Sources18,19
    77. 80. Mentally Ill <ul><li>DMH cuts </li></ul><ul><ul><li>¼ of case managers laid off as MA attempted to balance budget in wake of higher CC enrollment than anticipated and the recession </li></ul></ul><ul><ul><li>Cuts in many services </li></ul></ul><ul><ul><ul><li>Day Programs </li></ul></ul></ul><ul><ul><ul><li>Social clubs </li></ul></ul></ul><ul><ul><ul><li>Supported Employment (SEE) </li></ul></ul></ul><ul><ul><ul><li>Reduction in Jail Diversion Programs </li></ul></ul></ul><ul><li>Lower Reimbursement for MH Services </li></ul><ul><li>CHA, largest MH provider and SNH, closed inpatient units and limited outpatient services due to budget strains </li></ul><ul><li>Added administrative and cost-sharing requirements for those in 150-300% FPL may be particularly challenging for CMI </li></ul><ul><ul><li>Limitations due to illness </li></ul></ul><ul><ul><li>Medical and psychiatric co-morbidity </li></ul></ul><ul><ul><li>Risk of missing required yearly re-enrollment </li></ul></ul><ul><li>Politically vulnerable population </li></ul>Source 20
    78. 81. Key Differences in MA & National Plans <ul><li>National Plan </li></ul><ul><ul><li>Creates dedicated funding source </li></ul></ul><ul><ul><li>Gradually increases Medicaid rates to Medicare rates for primary care providers </li></ul></ul><ul><ul><li>Prohibits lifetime benefit limits </li></ul></ul><ul><ul><li>Requires insurers to devote at least 85% of premiums in the large group markets and 80% in the small and individual markets to medical benefits, or provide consumer rebates if medical-benefit spending falls below this percentage </li></ul></ul><ul><ul><li>Establishes pilot programs to test new strategies for improving quality while reducing costs </li></ul></ul><ul><ul><ul><li>Accountable care org.s, global payments, med. homes </li></ul></ul></ul>Sources 2, 21
    79. 82. Sources <ul><li>Health Care and Affordability Conference Committee Report. </li></ul><ul><li>Doonan, Michael. Tull, Katharine. Health Care Reform in Massachusetts: Implementation of Coverage Expansions and a Health Insurance Mandate. The Milbank Quarterly, Vol. 88, No. 1, 2010 (pp 54-80) </li></ul><ul><li>State Health Workforce Profiles: Massachusetts. U.S. Department of Health and Human Resources: Health Resources and Services Administration. </li></ul><ul><li>Commonwealth Connector Authority 2009. Commonwealth Health Insurance Connector Authority Affordability Information Sheet </li></ul><ul><li>Commonwealth Connector Insurance Authority. 2009. Find Insurance: Individuals and Families, Frequently Asked Questions. </li></ul><ul><li>Commonwealth Connector Health Insurance Authority. 2009. Facts and Figures. https// </li></ul><ul><li>Long, Sharon. Stockley, Karen. Health Reform in Massachusetts: An Update on Coverage and Support for Reform as of Fall 2008. Urban Institute. 2009 </li></ul><ul><li>Steelfisher, Gillian. Blendon, Robert et al. Physicians’ Views of the MA Health Care Reform Law – A Poll. New England Journal of Medicine. 2009; 361(19):e39. </li></ul><ul><li>Long, Sharon. Stockley, Karen. Massachusetts Health Reform: Employer Coverage From Employees’ Perspective: Access to coverage has grown—even as some workers in small firms have faced higher contributions to premiums. Health Affairs Web Exclusive. 2009;28(6):w1079–87. </li></ul><ul><li>Gabel, Jon R. Whitmore, Heidi. Et al. After The Mandates: Massachusetts Employers Continue To Support Health Reform As More Firms Offer Coverage Bay State employers have fewer reservations about the reform than they did last year, shortly after the reform took effect. Health Affairs. 2008; 27 (6) :w566–w575. </li></ul><ul><li>Vinson, S. Massachusetts Psychiatrists Survey – unpublished </li></ul><ul><li>Massachusetts health Reform: Lessons Learned about the Critical Role of Safety Net Health Systems. National Association of Public Hospitals and Health Systems. Issue Brief April 2009. </li></ul><ul><li>Krasner, Jeffrey. Health Provider Predicts Big Loss; Hospital alliance cites impact of reform law; Could cut 300 jobs, suffer $25m shortfall. The Boston Globe. March 17, 2008. </li></ul><ul><li>Kowalcyk, Liz. Boston Medical sues state for funds. The Boston Globe. July 16, 2009. </li></ul><ul><li>Long, Sharon. Masi, Paul. Access And Affordability: An Update On Health Reform In Massachusetts, Fall 200. Health Affairs. 2009. 28 (4): w578–w587 . </li></ul><ul><li>Blendon, Robert J., et al, “Massachusetts Health Reform: A Public Perspective From Debate Through Implementation,” Health Affairs. 2008. 27(6 ): w556-562. (published online 28 August 2008; 10.1377/hlthaff.27.6.w556). </li></ul><ul><li>Long, Sharon. Masi, Paul. Access to and Affordability of Care in MA as of Fall 2008: Geographic and Racial/Ethnic Differences. Urban Institute.2009 </li></ul><ul><li>Goodnough, Abby. Massachusetts Takes a Step Back from health Care for All. New York Times. July 15 2009. </li></ul><ul><li>Lazar, Kay. Immigrants face hurdles with new care coverage: network changes, delays vex clients. November 5, 2009. </li></ul><ul><li>Goldberg, Carey. Mental health liaisons laid off: Agency loses 100 case managers; more cuts feared. The Boston Globe. January 8,2009. </li></ul><ul><li>Patient Protection and Affordable Care Act., </li></ul>
    80. 83. Mental Health Promotion & Illness Prevention: The U.S. and Canada Margaret Balfour, MD, PhD University of Texas Southwestern Medical Center at Dallas Catherine Krasnik, MD, PhD McMaster University Medical Centre, Hamilton, Ontario APA/BMS Fellows in Public Psychiatry
    81. 84. Disclosures <ul><li>Both presenters are supported by the APA/Bristol-Myers Squibb Fellowship in Public Psychiatry </li></ul>
    82. 85. Outline <ul><li>Basic concepts of mental health prevention </li></ul><ul><li>Prevention resources and US health reform </li></ul><ul><li>The Canadian System and Mental Health Reform </li></ul><ul><li>What do the U.S. and Canada have in common?: An evidence-based, interactive case example of screening for depression. </li></ul>
    83. 86. Why prevention? <ul><li>Most mental disorders begin in adolescence or young adulthood </li></ul><ul><li>Mental health linked with physical health </li></ul><ul><li>Results in substantial cost to individuals, families, and society </li></ul><ul><li>Prevention has the potential to prevent years of human suffering, as well as decrease costs across multiple service systems </li></ul>
    84. 87. What is mental illness prevention? Public health paradigm <ul><li>Primary prevention: preventing a disease from occurring (reducing the incidence) </li></ul><ul><ul><li>Example: an intervention to discourage adolescents from trying cigarettes to prevent nicotine dependence </li></ul></ul><ul><li>Secondary prevention: lowering the rate of established cases (reducing the prevalence) </li></ul><ul><ul><li>Example: early detection and screening for depression and suicidal ideation so that it can be treated </li></ul></ul><ul><li>Tertiary prevention: reducing disability in those that already have the disease </li></ul><ul><ul><li>Example: ACT teams, supported employment, etc. </li></ul></ul>
    85. 88. A different paradigm: Mental health intervention spectrum Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Institute of Medicine (1994)
    86. 89. Preventive Interventions <ul><li>Universal: Targets general public or all members of a group (no identified risk) </li></ul><ul><ul><li>Example: premarital counseling before marriage, prenatal care, antismoking efforts </li></ul></ul><ul><li>Selective: Targets individuals or groups with increased risk for developing mental disorders </li></ul><ul><ul><li>Example: preschool programs to all children in low-income neighborhoods, support groups for elderly widows </li></ul></ul><ul><li>Indicated: Targets high-risk individuals with minimal symptoms or biological markers </li></ul><ul><ul><li>Example: parent-child interaction program for children with behavioral disorders, early treatment of prodromal SCZ </li></ul></ul>
    87. 90. Mental health promotion <ul><li>Targets general public </li></ul><ul><li>To enhance appropriate development/competence, self esteem, mastery, well-being, social inclusion, ability to cope with adversity </li></ul><ul><li>Example: school programs that promote social competence through activities emphasizing self-control and problem solving </li></ul>Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Institute of Medicine. (2009)
    88. 91. Other core concepts <ul><li>Inherently interdisciplinary </li></ul><ul><ul><li>Effective tobacco control involves law, education, community behaviors, health care, </li></ul></ul><ul><li>Coordinated community-level systems </li></ul><ul><ul><li>Costs and benefits shared across systems </li></ul></ul>Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Institute of Medicine. (2009)
    89. 92. Where to find evidence-based programs <ul><li>National Registry of Evidence-Based Programs and Practices </li></ul><ul><li>Preventing Drug Abuse among Children and Adolescents </li></ul><ul><li>Suicide Prevention Resource Center </li></ul><ul><li>Center for the Study and Prevention of Violence </li></ul><ul><li>Promising Practices Network </li></ul><ul><li>Society for Prevention Research </li></ul><ul><li>SAMHSA Pocket Guide to Evidence Based Practices on the Web </li></ul>
    90. 93. What’s in the new health care bill? <ul><li>Creation of a National Prevention, Health Promotion, and Public Health Council and Advisory Group: develop strategic plan </li></ul><ul><li>Preventive Services Task Force: identify evidence-based preventive interventions </li></ul><ul><li>Coverage of preventative services </li></ul><ul><li>Prevention and Public Health Fund: transformation grants, education </li></ul><ul><li>Community health team grants </li></ul><ul><li>Wellness program grants for small businesses </li></ul><ul><li>Increasing public health workforce </li></ul>
    92. 95. Canadian Health Care “Medicare” <ul><li>Universal coverage for medically necessary services provided on basis of need rather than ability to pay </li></ul><ul><li>Canada Health Act (federal legislation) </li></ul><ul><ul><li>&quot; to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.&quot; </li></ul></ul><ul><li>Integrated system between Federal government and 10 provinces and 3 territories </li></ul><ul><ul><li>Canada Health Tax Transfers; based on Canada Health Act Principles </li></ul></ul><ul><ul><li>Provinces/territories responsible for deciding how to use the money </li></ul></ul><ul><ul><li>Federal government is directly responsible for Native populations, the armed forces and prisoners </li></ul></ul>
    93. 96. The Canada Health Act (1984) <ul><li>5 Basic Principles </li></ul><ul><li>Universal: available to all eligible residents of Canada; </li></ul><ul><li>Comprehensive in coverage; </li></ul><ul><li>Accessible without financial and other barriers; </li></ul><ul><li>Portable within the country and during travel abroad; </li></ul><ul><li>Publicly administered </li></ul>Ottawa Parliament
    94. 97. What’s included in Canadian Medicare? <ul><li>Covers physician services and hospital-based care </li></ul><ul><li>Emergency care available to everyone </li></ul><ul><li>Wait times for specialty appointments and procedures </li></ul><ul><li>Mental health care </li></ul><ul><li>Preventive care </li></ul><ul><ul><li>Physicians paid to do prevention counseling (this varies by province) </li></ul></ul><ul><li>*drug coverage is not included unless you have third party insurance or are on social welfare </li></ul><ul><li>*allied health professionals not included (e.g. psychologists, unless part of mental health clinic) </li></ul>
    95. 98. Share of Health Budget Spent on Mental Health (2003-04) Expenditures on Mental Health and Addictions for Canadian Provinces in 2003-2004 Canadian Journal of Psychiatry, May 2008; 54(5):306-13 Canada spent $6.6 billion on mental health = 4.8% of total health budget; $197/person
    96. 99. Current State of Canadian Mental Health Prevention <ul><ul><li>Initially leader in Preventive Care </li></ul></ul><ul><ul><ul><li>Canadian Task Force on Preventive Health Care (1976); never in mental health though </li></ul></ul></ul><ul><ul><li>Last of G-8 countries to develop a National Mental Health Strategy </li></ul></ul><ul><ul><li>Several programs in place (not all of them evidence-based) </li></ul></ul><ul><ul><li>Still Reactive vs. Proactive Care </li></ul></ul><ul><ul><li>Focus on Individual vs. Community/Populations </li></ul></ul><ul><ul><li>Collaborative Mental Health </li></ul></ul><ul><ul><ul><li>Integrating mental health into primary care (e.g. Hamilton, Ontario) </li></ul></ul></ul><ul><ul><ul><li>Screening at Schools, community centers, church communities </li></ul></ul></ul><ul><ul><li>Patient-centered care ? </li></ul></ul><ul><ul><ul><li>Follow-up care left up to the patient </li></ul></ul></ul>
    97. 100. Key Organizations <ul><li>Canadian Task Force on Preventive Health Care </li></ul><ul><ul><li>1976-2005; recently resurrected </li></ul></ul><ul><ul><li>Adopted in 1980’s by US – US Task force </li></ul></ul><ul><li>Mental Health Commission of Canada (MHCC)(2008) </li></ul><ul><ul><li>Kirby Report </li></ul></ul><ul><ul><li>Out of the shadows (2008) </li></ul></ul><ul><ul><li>Towards Recovery and Wellbeing (2009); action plan (2011) </li></ul></ul><ul><li>Canadian Mental Health Association (CMHA) </li></ul><ul><ul><li>Oldest Cdn voluntary Health Organization </li></ul></ul><ul><ul><li>Mental Health Promotion </li></ul></ul><ul><li>Public Health Agency of Canada (PHAC) </li></ul>
    98. 101. Current Framework <ul><li>Developed by Mental Health Commission of Canada </li></ul><ul><ul><li>$10 million federal funding at inception; $15 million for subsequent years </li></ul></ul><ul><ul><li>Advisory Group made up of people with lived experience of mental illness & addiction, family members, health care providers and researchers. Reflective of range of perspectives, such as children and youth, aboriginal peoples, seniors, women and adults, and in the workplace. </li></ul></ul><ul><ul><li>Public Consultation </li></ul></ul><ul><ul><ul><li>15 mtgs in 12 cities; all stakeholder constituencies </li></ul></ul></ul><ul><ul><ul><li>electronic consultation with stakeholders & general public </li></ul></ul></ul><ul><ul><ul><li>1700 individuals and >250 organizations submitted </li></ul></ul></ul><ul><li>Linking chronic disease, social determinants, mental health </li></ul><ul><ul><li>E.g. Chronic disease prevention framework includes looking at schizophrenia & depression as risk factors for diabetes </li></ul></ul>Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)
    99. 102. Current Framework <ul><li>Greater emphasis on addressing social determinants of mental health </li></ul><ul><ul><li>“ At Home” Homelessness studies across 5 major Canadian cities (pilot research studies) </li></ul></ul><ul><ul><li>Largest study of its kind; $110 million federal funding </li></ul></ul><ul><ul><li>Determine the value of providing housing first -- and then following it with rehabilitation and treatment -- for those who are homeless and mentally ill. </li></ul></ul><ul><ul><li>Altogether 1,350 people in Moncton, Montreal, Toronto, Winnipeg and Vancouver will be provided housing, and close to 1,000 other people will be provided health and social services but won't receive housing. </li></ul></ul><ul><li>Psychoeducation and supporting families & whole communities </li></ul>Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)
    100. 103. Current Framework <ul><li>Early detection and intervention </li></ul><ul><li>Patient-centered care </li></ul><ul><ul><li>equitable and timely access to appropriate and effective programs, treatments, services and supports that are seamlessly integrated around their needs. </li></ul></ul><ul><li>Workplace Mental Health Promotion </li></ul><ul><li>Preventive Health Care Task Force: Implementing evidence-based programs </li></ul><ul><li>Part of a National Mental Health Strategy (2011) </li></ul>Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)
    101. 104. What do we have in Common? <ul><li>Screening for Depression – evidence-based prevention program in both Canada and the US </li></ul><ul><li>How would this take shape in your community or region? </li></ul>
    102. 105. Resources <ul><li>Mental Health Commission of Canada(MHCC) default.aspx </li></ul><ul><li>Canadian Mental Health Association(CMHA) </li></ul><ul><li>Public Health Agency of Canada(PHAC) </li></ul><ul><li>Canadian Task Force on Preventive Health Care </li></ul><ul><li>Ministry of Health and Long Term Care </li></ul><ul><li>Health Canada </li></ul><ul><li> </li></ul><ul><li>Ontario Federation of Community Mental Health and Addiction Programs </li></ul>
    103. 106. Resources on Mental Health Promotion & Mental Illness Prevention <ul><li>Towards Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada, 2009 </li></ul><ul><li>Every Door is the Right Door, 2009 </li></ul><ul><li>Out of the Shadows Redux, 2008 </li></ul><ul><li>Position papers on Mental Health Promotion, Stigma, and Knowledge Exchange, 2007 </li></ul><ul><li> </li></ul><ul><li>A Framework for Support, third edition, 2004 </li></ul><ul><li>Mental Health Priorities of the Voluntary Sector, 2004 </li></ul>
    104. 107. Acknowledgements <ul><li>Dr. Nick Kates </li></ul><ul><li>Professor 
Associate Member, Department of Family Medicine
Director of Programs, Hamilton Family Health Teams </li></ul><ul><li>Dr. Harriet MacMillan </li></ul><ul><li>Professor, Psychiatry & Behavioural Neurosciences and Pediatrics </li></ul><ul><li>David R. (Dan) Offord Chair in Child Studies
Associate Member, Clinical Epidemiology & Biostatistics
Associate Member, Psychology
Member, Offord Centre for Child Studies
Member, Child Advocacy and Assessment Program </li></ul>
    105. 108. Questions & Discussion