2. Who Controls the MessageWho Controls the Message
About Behavioral Health?About Behavioral Health?
Ed Jones, Ph.D.Ed Jones, Ph.D.
SVP, Strategic PlanningSVP, Strategic Planning
Institute for Health & Productivity ManagementInstitute for Health & Productivity Management
August 3, 2015August 3, 2015

3. “The only interesting answers are
those that destroy the questions”
Susan Sontag

4. 90 Minute Presentation!
Who Is This Guy?
 Ph.D., Northwestern University, 1980
 Private Practice
 Group Practice (Co-Founder)
 PacifiCare Behavioral Health (CCO)
 ValueOptions (President, Commercial Div.)
 ERJ Consulting, LLC
 Institute for Health and Productivity Management
(SVP)

5. Session Description
The behavioral health care field has all too often had
others frame the terms of the debates that are key to its
existence. As the health care landscape evolves in
dramatic ways following health care reform, we are
once again faced with the question of who controls the
message about behavioral health (BH). This is an
attempt to frame that debate.

6. Session Objectives
a. Understand the primacy of behavioral health (BH) in
health care settings
b. Understand the significant impact of behavioral health
disorders on total health care costs
c. Understand the prevalence of psychosocial issues in a
primary care setting and the effectiveness of non-
pharmaceutical interventions

7. How to Win a Debate
 Long before the determination of who wins any
debate is the decision, or the struggle, about
who controls the framework, the predominant
terms, message, language, or available solutions
 Example: Is today’s political debate about:
- Immigration Reform
- Comprehensive Immigration Reform
- A Path to Citizenship
- Amnesty

8. Today’s Debate
 The behavioral healthcare field has all too often
allowed others to frame the terms of the debates
that are key to its existence
 As the health care landscape evolves in dramatic
ways following health care reform, we are once
again faced with the question of who controls the
message about behavioral health (BH)
 This presentation is an attempt to frame that
debate in a way that promotes the value and
importance of BH practitioners
It is a polemic, grounded in data

9. The Polemic
 A contentious debate between different positions,
with my argument being:
- Against the current structure of the health care
delivery system in the U.S.
- Against the passivity of the BH industry
- Against the medical model as the only guide
for understanding illness and recovery
- In favor of the primacy of behavioral health in
achieving overall health and wellbeing

10. Primacy
 Definition: the state of being first, as in importance,
order, or rank
 How does BH fare in terms of primacy?
- Importance? Yes, based on data to be presented
- Order? Yes, in health care, remember, “head first”
- Rank? No, not even close to highest ranking
 Goal of most presentations:
- RECOGNIZE THE VALUE OF BEHAVIORAL HEALTH
 Goal of this presentation:
- RECOGNIZE THE PRIMACY OF BEHAVIORAL HEALTH

11. Debating or Searching for the Truth
 Many thoughtful people approach an issue with the goal of
searching for the right answer so that everyone can then
agree to its truthfulness
 This is not how business, politics, or policy actually work
 Marketing, sales, debate, and advocacy are more the tools
of the trade
 The BH industry needs to embrace these tools
---------
The current plan for BH, as distilled from BH industry actions, may win a
few battles while losing the war (i.e., the war over limited health care
resources) and we can do better than win table scraps

12. Welcome to the Funhouse…
Current BH Problems: Distorted,
Misleading, and Unbalanced Messages

13. Example 1
 Reporting of the latest gun violence in America
with hand-wringing about taking better care of
the mentally ill
- Progressive legislation is not enacted, even
though there is some pontificating
- The public does not know that many people
with SMI actually recover with the right
treatment
- Few SMI individuals are actually ever violent

14. Example 2
 Psychotropic medications and erectile
dysfunction drugs
- Ubiquitous and expensive TV commercials
and print ads
- Marketing for psychotherapy, peer counseling,
and other psychosocial tools barely exists
- “Psychotherapy is remarkably efficacious”
(Bruce Wampold, summarizing 50 years of
research)

15. Example 3
 Accountable Care Organizations were
embedded in Obamacare to move away from
FFS medicine to coordinated, quality care, at
lower cost
 ACOs nominally recognize behavioral health, as
did patient-centered medical homes, but the
focus is minimal and financially insignificant
 Yet most agree that we have a crisis of
behavioral health costs driving up the cost of
chronic medical conditions

16. Example 4
 Estimates are that 50 to 70% of our health status
is attributable to health behaviors and lifestyle
choices
 We are mainly exposed to well-advertised,
passive solutions such as diet foods,
medications, supplements, and surgeries

17. Example 5
 Insurers pay for the latest medical interventions,
with marginal outcomes, without much question
 Psychosocial interventions are not assumed to be
effective and they are subjected to vague return
on investment (ROI) expectations
 Consider funding for a “Me Too” medication vs.
Assertive Community Treatment

18. Big Data…
The Numbers Tell the Story

19. The Scientific Imbalance
 Number Needed to Treat (NNT):
- Number of patients who need to be treated
to achieve one additional successful
outcome: lower numbers represent more
effectiveness
- http://ktclearinghouse.ca/cebm/glossary/nnt/
 Comparison of Common Treatments
- Beta blockers – NNT = 40
- Flu vaccine – NNT = 12
- Proton Pump Inhibitors – NNT = 6
- Psychotherapy – NNT = 3

20. The DALY Imbalance
 Disability Adjusted Life Years (DALY)
- DALY = YLL (Years of Lost Life) + YLD (Years of Living
with Disability)
- Global shift toward Non-Communicable Diseases (NCD)
 U.S. Findings as of 2010 (The Lancet, 2012)
- Ischemic Heart Disease (1)
- COPD (2)
- Low Back Pain (3)
- Major Depressive Disorder (5)
- Drug Use Disorders (11)
- Anxiety Disorders (13)
- Self-Harm (14)
- Alcohol Use Disorders (19)
- Schizophrenia (23)
- Interpersonal Violence (25)

21. Prevalence of BH Issues
 Milliman has estimated that over 20% of total
health care costs are driven by BH problems (esp.,
depression and anxiety) due to comorbidity with
chronic medical conditions
- Since chronic medical conditions account for more than
half of total health care costs, our focus on BH issues
should be much more intense than it is today
 One could also argue (without data at this point)
that disease management and care coordination
would be better done by BH specialists than
nurses

22. Why See Your PCP?
 70% of primary care visits “stem from
psychosocial issues,” as stated by the Milbank
Memorial Fund in 2010, Evolving Models of
Behavioral Health Integration in Primary Care
 Yet primary care physicians are poorly equipped
to address these issues

23. The PCP Shortage
 The PCP-centric model makes even less sense given
the projected shortage of PCPs (shortage of 45,000
by 2020 as a conservative estimate)
- In 1998 half of internal medicine residents chose
primary care, but in 2006 over 80% became
specialists
 The PCP-driven delivery model conflicts with well-
known realities – MDs view primary care as less
desirable than other specialties due to lower income
and increased time demands

24. Morbidity & Mortality: Risk Factors
 Obesity
 Inactivity
 Sleep Debt
 Stress
 Loneliness
 Social Isolation

25. Alone and Lonely
 Robust research literature
 Unknown to professionals and consumers
 How significant:
- As big an impact, if not more, as the other
widely discussed risk factors (diet, exercise,
etc.)
- These two are distinct factors – low correlation
- Nobody is paying attention since people are
wary of discussing deeply personal issues
- People can learn how to discuss & change!

26. Behavioral Health: A Label Redefined
 Origins of BH: Insurance benefit language
- Mental Health and Substance Abuse (MHSA) benefits
combined for coverage and benefit administration
 Proposed Purview of BH: All Health Behaviors
- In contrast to an industry focused on medical
interventions (with medications, devices, and surgeries),
the BH industry embraces a primary role addressing the
critical behaviors that drive health, wellness, and
wellbeing
 What other specialty should own behavior change?
--------
The specialty owning behavior change is essentially embracing
prevention as a primary mission

27. The Behaviors of Behavioral Health
 Insomnia
 Inactivity
 Bingeing
 Starving
 Crying
 Inattention
 Isolation
 Compulsive Use
 Avoidance
 Hoarding
 Rage Outbursts
 Hyperactivity
 Gambling
 Suicide
 A Very Long List…..

28. The Funding Imbalance
 BH represents a small % of expenditures
 2013 Medical = $3 Trillion
- 2013 BH = $200 Billion
 2020 Medical est. = $4.3 Trillion
- 2020 BH est. = $281 Billion
 BH costs are well under 10% of the overall costs
• Annual increases of 6.7% from 1998 to
2009; 4.6% increases estimated through
2020
 Yet, what conditions, interventions, and costs
should we include under the heading of BH?

29. Funding Inadequacy: The Treatment
Gap*
 In 2013, an estimated 22.7 million Americans
needed treatment for a problem related to drugs
or alcohol – 8.6% of the population
 Only 2.5 million people received treatment at a
specialty facility – 0.9% of the population or
11% of those needing treatment
*National Institute on Drug Abuse @ www.drugabuse.gov

30. Waste in Health Care: The 30% Problem
(Health Affairs, December 13, 2012)
 Failures of Care Delivery
- e.g., adverse events
 Failures of Care Coordination
- e.g., unnecessary readmissions
 Overtreatment
- e.g., defensive medicine
 Administrative Complexity
- e.g., lack of standardized forms and procedures
 Pricing Failures
- e.g., absence of transparent and competitive markets
 Fraud and Abuse
- e.g., billing scams
*Health Affairs, December 13, 2012

31. BH Offers a Waste Reclamation Project
 Comorbidity
- Very ill people wasting medical resources due to BH
comorbidities
 Somatization
- Distressed people wasting PCP visits/medications
 Missed BH Diagnoses
- Distressed people wasting PCP visits/medications
 Sub-Clinical BH Conditions
- Distressed people below the radar of M.D. detection
 Lonely and Isolated
- The smoker of the 21st
Century

32. Raise Your Hand…
The Case for the Primacy of BH

33. Recognizing the Power of Big Ideas
 Health care is in the news every day since it
accounts for 17% of our GDP
 This means a new headline every day, a new crisis,
and a new route to disaster/salvation
 Behavioral health is typically a side line and not a
major part of the story – this must change
 When we fully recognize certain realities about
behavioral health, changes will follow
 Our fight today is for hearts and minds, with BH
and outside BH, before all else

34. Let’s Help Change Health Care in U.S.
 ACOs will evolve as a delivery and payment
structure, and it is estimated that 1/3 of all
Americans will receive treatment within an ACO
by 2017
 We are at a crossroads for our field, much as we
were in the 1980s when managed care entered
the arena to confront the excesses of for-profit
hospital chains that were dedicated to chemical
dependency and adolescent treatment
 Nick Cummings on business literacy: “find a
need and fill it”

35. BH is Now Seen as Consequential
 Patient-centered medical homes clearly
recognize the importance of BH
- View the framework elaborated in the BH
workgroup of www.pcpcc.org
 ACOs today neglect BH simply due to basic
integration challenges among physician groups,
hospitals, and health plans (and also because BH
is carved out for many ACO populations)
 Yet the impact of BH disorders on overall health
care costs is well understood

36. Care Coordination
 Care coordination by nurses has not been
demonstrated to be better than coordination by BH
specialists
 Yet this is not even a debate
 Nurses are general medical professionals and it is
assumed that medical knowledge is key
 At this point there will be a few social workers in
the mix, but this is not even a discussion

37. Medical Model Limitations
 PCPs and nurses have been trained within the
medical model to identify symptoms, diagnoses,
and recommended treatments
 BH specialists have been trained to have strong
“people skills” and to address how people get
stuck in negative health behaviors that drive their
chronic ill health

38. Alternative to Medical Model
 MEDICAL MODEL
- exemplified by medications – specific ingredients in the
medication have a mechanism of action that reduces
symptoms, blocks advancing disease, or cures the
illness – other factors are incidental
 PSYCHOSOCIAL MODEL*
- exemplified by psychotherapy – based on a therapeutic
alliance, agreed upon goals, a framework for treatment,
and a course of therapeutic discussions/activities, a
social healing process may occur – the people in the
interaction are most important
*Identified as Contextual Model by Wampold and Imel (2015)

39. Clinical Teams
 The PCP is typically described as the
quarterback of the PCMH or ACO who promotes
coordination of care
 May have the wrong sport
 Basketball is a better analogy since this is a team
sport in which every role is critical and anyone
can shoot and score

40. Head First
 Let’s dive into this head first
 Health care should start with the head first since
health behaviors drive over 50% of health status
 If another medical specialty could claim
ownership of even 15% of health status it would
be a call to reorient medicine around that
specialty!

41. Behavior Change
 Behavior change experts need to take the lead
since behavior change is the key to improving
health
 Are you a behavior change expert?

42. Behavior Change Experts
 Don’t exist…
 If you were to make one up, wouldn’t you:
- start with people who can engage others in a
helping relationship
- focus on personal motivation for change
- identify achievable goals for change
- agree on practical steps toward improvement

43. Leader or Advisor?
 PCPs would welcome us as advisors
- Coordinate care with them, or co-locate our services
with them, or find some other way to work for them
 This is backwards since the real specialists in the main
areas of dysfunction should take the lead – has anyone
suggested such a reorganization toward BH primacy?
 There is a long history of tension between primary care
and specialist physicians – we need to establish more
tension between PCPs and BH specialists

44. Usual Care
 Only 20% of adults with common mental disorders
receive care from a mental health (MH) specialist
- Primary care practices are the de facto location of
care for most adults in US with MH disorders
 Collaborative Care Model (which augments primary
care and is rooted in the Chronic Care Model) is better
than usual care in over 70 randomized controlled trials
 Fixing the broken model of usual care through
collaboration provides a reparative model, but it is not
necessarily a paradigm for best care
 Do we need a retrofit solution or a fresh start?

45. Today’s Mantra: Integration
 It is the paradigm for transforming health care today,
espoused by thought leaders in both medical and
behavioral health care
 Fragmented health care delivery is identified as the
key failing – resolved through Chronic Care Model
 Driven by the clinical goal of well-coordinated care
and the financial goal of reduced health care costs
 BH industry is advised: integrate with primary care!
 One likely outcome of the integration paradigm:
well-coordinated care that is blind to the primacy of
behavioral health

46. New Professional Roles to Consider
 Primary Care Psychiatrist
 Primary Care Psychologist
 Primary Care Social Worker
 Primary Care Therapist
 Primary Care Counselor

47. Reflections on Primary Care
 “Medical care and primary care were at one time
synonymous. All health care was primary. The concept
and terminology of primary care came into widespread
use during the 1960’s, reflecting a specific policy
agenda… The essential point is that ‘primary care’ was
born out of tension with other forms of medical care. In
the future, primary care will be reinvented, and changes
will be caused by the sorts of external social, political,
and economic forces that previously led to systematic
transformation.” (JD Howell, Health Affairs, May 2010)

48. A Roadmap to the Primacy of BH
 1) New Position in Health Care
- The Primacy of BH over the Value of BH
- Structural and organizational changes after “hearts and
minds”
 2) Behavioral Health Redefined
- Mental health and SUD plus health behaviors
 3) Core Health Measurement
- Wellbeing: not illness/symptom reduction (Jones 2013)
 4) Primary Care Transformation
- Reformulate primary care, esp. chronic care, “head first”

49. A Final Word on Paradigms
 Merriam-Webster: “a theory or a group of ideas about
how something should be done, made or thought about”
 Thomas Kuhn’s 1962 book on scientific revolutions
made the term famous as a concept for understanding
progress in science: Copernicus vs. Ptolemy paradigms
 My focus is on a model for clinical practice that
organizes well-documented empirical findings and ideas
 The primacy of BH can be translated into different ways
of organizing clinical practice, yet each way is grounded
in the paradigm
 A paradigm is not a conceptual straight-jacket

50. Big Challenges…
A Call to Action

51. Consumer Faces and Voices
 Every medical condition needs a compelling personal
story and a face – do we know the faces of depression
and anxiety?
 Faces for the primacy of BH
- Co-morbidity and the face of successful care based
on a head first approach
- A face for every health behavior
 Consumer voices are the loudest and most impactful
- Advocates for autism achieved government
mandates that far exceeded the impact or the
clarity of its scientific knowledge base

52. Let’s Launch the BH Debate
 Dollars
- driving over 20% of healthcare costs in the U.S.
 Disability
- largest driver of disability globally
 Pervasiveness
- a bigger issue than we know: it is still in the
shadows
 Efficacy of safe treatments
- psychotherapy is remarkably efficacious
 Disruption & Dissonance
- no satisfying resolution without first having
dissonance

53. Establish a Broad Platform for Advocacy
 Broadly Inclusive
- Go beyond professional associations
- Go beyond BH specialists and publications
- Collaborate with consumers in leadership roles
 Sharpen the Message
- Science and Testimonial
- Promote the BH Value Proposition (while
avoiding conflicts with other health care
constituencies)
Leverage existing BH organizations rather than
creating expensive new enterprises

54. Deus ex machina
 In Greek drama – a “god” is introduced into a play
to resolve dead-end entanglements of the plot
 In modern times – something enters the story and
solves a problem that previously seemed
impossible to solve
 BH may seem like an improbable solution to our
health care entanglements, but the primacy of BH
could be transformative
 The health care “machine” needs disruption – let’s
get started!

55. The 8 Tenets of Behavioral Health Primacy
1) Behavioral Health should be understood to include a
focus on traditional BH disorders – mental health and
SUD – along with all critical health behaviors that
drive over 50% of our health status.
2) Since 70% of primary care visits are motivated by a
psychosocial concerns, health care professionals
should start with the “head first” and BH specialists
should self-identify as primary care providers.
3) Calls for the integration of health care services, as
well as the coordination of physical and behavioral
healthcare, should be regarded skeptically as PCP-led
models that do not embrace a “head first” orientation.

56. The 8 Tenets of Behavioral Health Primacy
4) Since the comorbidity of BH conditions with chronic
medical conditions is one of the largest sources of
unnecessary spending (due to BH conditions being
largely undiagnosed and undertreated), this should
be the leading clinical initiative for BH clinicians.
5) A BH marketing campaign should be planned which
conveys: 1) the importance of health behaviors; 2)
the prevalence of disabling BH conditions; 3) the
superiority of psychotherapy over many general
medical procedures that have poorer results and yet
receive a greater percentage of the health care
dollar.

57. The 8 Tenets of Behavioral Health
Primacy
6) While physicians treat illnesses and help improve
health, BH specialists address the thoughts, feelings,
and behaviors that drive health and wellbeing.
7) Behavioral Health is not driven by opposition or
hostility toward primary care physicians. BH is
emerging from decades of clinical experience and
research that demand a larger role for BH specialists
and a concerted focus on the thoughts, feelings, and
behaviors that drive health and wellbeing.
8) We shouldn’t complain about funding levels for BH.
We should assert the primacy of behavioral health and
demand that the dollars follow the leader.

58. Raise Your Hand?

59. QUESTIONS

60. References
 Cummings, N.A., et. al., “We Are Not a Healthcare Business: Our Inadvertent Vow
of Poverty,” J Contemporary Psychotherapy, 2008.
 Druss, B.G. and Walker, E.R., “Mental Disorders and Medical Comorbidity,”
Research Synthesis Report No. 21, The Robert Wood Johnson Foundation,
February 2011.
 Holt-Lunstad, J. et.al., “Loneliness and Social Isolation as Risk Factors for
Mortality: A Meta-Analytic Review,” Perspectives on Psychological Science, 2015,
Vol 10(2), 227-237.
 Jones, E. et.al., “Wellbeing: A Critical Health Domain,” Journal of Health &
Productivity, 7, No. 1 (December 2013) 6-13.
 Lewis, V.A., et. al., “Few ACOs Pursue Innovative Models That Integrate Care for
Mental Illness and Substance Abuse with Primary Care,” Health Affairs, 33, No. 10
(2014) 1808-1816.
 Melek, S. and Norris, D., “Chronic Conditions and Comorbid Psychological
Disorders,” Milliman Research Report, July 2008.
 Murray, C.J., et al., “Disability-adjusted life years…” The Lancet, Vol. 380,
December 2012, 2197-2223.
 Unutzer, J., et. al., “The Collaborative Care Model…” CMS Brief, May 2013
 Wampold, B.E. and Imel, Z.E., The Great Psychotherapy Debate, Second Edition,
Routledge, 2015.

61. Key Learnings, Process Improvements
and Take-Aways
a. Take-away 1: While the Affordable Care Act is 5 years old, it is
the next 5 years that will determine how health care delivery is
transformed in this country. We expect fee-for-service medicine
to decline dramatically, systems of care to become highly
integrated, and both quality and cost measures to be closely
scrutinized. Behavioral Health will either be a footnote or a
leader in this transformation. Robust data support a leadership
role for BH, but leaders must emerge to push this agenda.
b. Take-away 2: This polemic in favor of the primacy of behavioral
health must lead to action, and yet this cannot be an insular
process consisting only of professionals and executives within
BH today. We need a broad-based coalition of health care and
consumer leaders promoting this new paradigm.