Yes, our healthcare system still needs work.
When will healthcare have its “Occupy Wall Street" moment?
In order to answer this question, let me first define what the occupy wall street movement is about. According to ABC News:
"Their [Occupy Wall Street] causes include everything from global warming to gas prices to corporate greed, and the Occupy Wall Street website says organizers took their inspiration in part from the so-called Arab Spring demonstrations that have tried to bring democracy across the Arab world.
But while their message might be a tad muddled, all are united by their anger over what they say is a broken system, a system that serves the wealthy and powerful at the expense of the rest.
Protester Brendan Burke insists he and the others are fighting for more than 99 percent of the American population.”
Let me highlight one section from above:
"…all are united by their anger over what they say is a broken system…"
Those of you who have looked this blog before know that I like to talk a lot about integrating mental health and primary care. No doubt this is a solution to the problem of fragmentation, but I digress.
What I want to know is why the public is not more outraged at the broken healthcare system?
While healthcare costs continue to grow uncontrollably, the public continues to suffer. In the face of this suffering, there does not appear to be much relief. Thankfully, the Affordable Care Act does try to mitigate some of these issues (especially cost), but is this sufficient without adequate community “outrage” over healthcare?
As Gawande has written - “In every industrialized nation, the movement to reform health care has begun with stories about cruelty.”
Not to be overly melodramatic here, but one needs look no further than “mental health” to see how the system has often failed folks who have this as their presenting problem. Not to imply that this is cruelty, but when one starts to cite statistics about mortality in the severely mentally ill, there should be some outrage.
There should be a demand from across the community that healthcare should be high quality, affordable and integrated as to avoid fragmentation. Yet where is the demand?
Maybe healthcare has not had it’s “Wall Street” moment because there is no one place the national community can gather to express their outrage. Yes, we advocate in our own unique ways - write letters to our legislators, visit them and on speak up in town hall meetings, but is this sufficient? Even if we had a special street corner to meet to talk about healthcare, would we?
How can we begin to engage the community so that healthcare can have its “Occupy Wall Street” moment? Or, as the Occupy Wall Street movement has shown, where are the select individuals who will rise up and fight for “the 99%”?
Isn’t it time?
Maybe soon seen we will start to see the beginning of an Occupy Healthcare movement.
Sometimes it is the simple things that have the most significant impact.
"…researchers from the University of Exeter and the University of Copenhagen tried recruiting homeless men off the streets of Copenhagen to see whether they could get the men to play soccer and improve their health.
Fifty-five men enrolled in the study and were randomized either to receive soccer training two or three times a week or to serve as a control group. After 12 weeks, the group who regularly played soccer reduced their body fat and lowered their blood pressure and cholesterol levels, compared with the control group. The soccer players also improved other markers of cardiovascular health, which the authors suggested may help reduce their risk of early death.
The study found high attendance among the homeless men, suggesting that organized soccer games could have some potential to improve health outcomes in the homeless or in other underserved populations.”
Soccer, yes soccer began to make a difference in these fifty-five lives. Sometimes health can be so simple. Yes, these folks began moving around more and playing soccer thus improving their health, but is there something else at work here?
I think so, and I think it is a word we often take for granted in health.
Think of all the various ways we use the word community healthcare.
"Each health center takes a unique approach to meet the needs of the people in the surrounding community. That local approach to health care, combined with an innovative emphasis on comprehensive preventative care, generates $24 billion in annual savings to the health care system – to taxpayers and private payers alike."
People want to have a sense of belonging. They want to have a sense of being apart of something bigger than them. Community does this. Community single-handedly accomplishes connection, and can be defined in multiple ways.
At the heart of much of the social media movement, there is a sense of engagement and community. Twitter, Facebook, Linked In - they all build off of the idea that people need connection and have a voice. Community.
In primary care, the largest platform of healthcare delivery in the country, continuity is one of the “secret ingredients” for success (and improved health outcomes). At the heart of continuity is a relationship. This relationship may lead the patient to feeling an enhanced sense of a community with their healthcare provider.
This is also the basis for the patient-centered medical home (PCMH) -consider one of the PCMH “joint principles”:
“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.”
Primary care aims to bridge across all elements of healthcare, including the community. In the process, does primary care become its own community for patients. Is it already?
My point with this post is that if we forget about the most simple thing in healthcare, community, we begin to miss the boat entirely for improving people’s lives. How we define community is often unique to us as individuals; however, our health may be more connected to our definition of community than we are willing to admit.
Be afraid, be very afraid.
There are two graphs that I have seen that make me quite worried about healthcare and the majority of the public in need of healthcare. The “one” (really two) above is definitely one of those.
From the Times:
"A new study by the Kaiser Family Foundation, a nonprofit research group that tracks employer-sponsored health insurance on a yearly basis, shows that the average annual premium for family coverage through an employer reached $15,073 in 2011, an increase of 9 percent over the previous year."
Yes, healthcare cost continue to rise and often the public must take on these additional costs as employers are running out of places to find the money to pay this benefit.
What happens if nothing changes?
Well it just so happens that the other graph that scares me is from the Robert Graham Center and is an example of what could happen:
Essentially this graph shows that by the year 2025 the annual household income in the US will be surpassed by the average health insurance premiums.
"Shifting health care coverage from a commodity to a social good could reduce disparities and produce better population health. Changes in health care coverage will require more equitable and sustainable models of health care delivery and aligned advocacy to support them. The instability of health care financing and delivery provides an opportunity for family physician leaders to develop new models of efficient practice, with care that is accessible to everyone."
So in the face of statistics like the ones mentioned above, how will we respond? Healthcare expenditures and premiums are growing at an uncontrollable rate. When cells do this we call it cancer - when healthcare does this, what do we call it?
Now is the time to start to demonstrate that there are indeed innovative models of healthcare that are out there that can bend the cost curve, improve quality and enhance overall healthcare.
Let your voice be heard.
The CMS Innovations Center has a section where you can send in your ideas on healthcare. How many ideas have you sent in?
Let’s try and avoid coming to a place where the average family cannot afford healthcare insurance.
The important investments that AHRQ has made in addressing mental health issues was highlighted during this forum and town hall. Specific topics include the integration of behavioral and mental health into the primary care setting, the role of the PCMH in improving the quality of mental health care, and the AHRQ Academy for Integrating Mental Health and Primary Care.
The AHRQ mental health town hall meeting was set up to be as interactive as possible. Various leaders in healthcare, including Dr. Ofttedahl ( @norskedoc ) were there to participate both in the room and virtually.
There were 9 national leaders in healthcare on the stage prepared to talk about the clinical/community, financing/policy and research aspects of integrating mental health into primary care.
Some of the first questions were to provide overview of where mental health integration currently stands.This panel specifically examined the role of clinical integration and the community.
Once Dave was done with his panel, he started doing what Dave does best.
Regina Holliday, live painting throughout the town hall, was not content - rather disappointed at the number of attendees in the room.
This week is the Agency for Healthcare Research and Quality (AHRQ) annual meeting. For those not familiar with AHRQ, from their website:
"The Agency for Healthcare Research and Quality’s (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research."
While the AHRQ annual meeting has had sessions that address mental health in the past, what is happening this Wednesday is quite spectacular. AHRQ is hosting a half day mental health town hall meeting. This town hall will address the future of mental health in a transformed delivery system. Undoubtedly, there will be a great deal of discussion on the research behind integrating mental health, the various ways to clinically integrate mental health and the need for patient and community engagement with any redesign effort. There will be various leaders from the healthcare community there dialoguing around mental health. No doubt, this will be a very exciting event.
To add a layer of innovation to an already innovative event, the event this year will be broadcast online through ustream (URL to be announced) and have a robust active twitter feed (#AHRQac is the general hashtag for meeting).
Want to participate?
Join us this Wednesday (September 21) from 8:00 AM to 11:30 AM at the AHRQ meeting to discuss mental health and healthcare.
There are few things that we know for certain about mental health in healthcare:
1) Half of Americans will experience some form of mental health problem within their lifetime
Consider the recent CDC report on the topic. USA Today reported:
"There are ‘unacceptably high levels of mental illness in the United States,’ said Ileana Arias, principal deputy director of the CDC. ‘Essentially, about 25 percent of adult Americans reported having a mental illness in the previous year. In addition to the high level, we were surprised by the cost associated with that — we estimated about $300 billion in 2002.’”
Take away: Mental health issues are real, growing, and becoming increasingly more visible within healthcare.
With more mental health being seen in primary care than anywhere else, it seems like there is a unique opportunity to impact mental health by better identifying, treating and studying mental health in primary care.
From the seminal IOM report on mental health and primary care:
"Most likely this country will retain a parallel primary mental health system. Among the most interesting and complex issues we face are those having to do with the complementarity and integration of services between these two systems, the proportion and makeup of the population that will avail themselves of these respective systems, the factors that affect the interface between primary care and specialty mental health care, and the relative cost and effectiveness of mental health care rendered by clinicians within these different systems."
3) When mental health conditions are often identified in primary care, accessing mental health services can sometimes be tricky.
From a Health Affairs article examining the impact of mental health parity on primary care:
"About two-thirds of primary care physicians (PCPs) reported in 2004–05 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care."
In the face of adversity, we must seek opportunities for innovation. Nowhere is this more evident than in integrating mental health providers into primary care.
While the road to accomplishing this is fraught with challenges, isn’t it time to consider an alternative to what is currently happening in healthcare? Isn’t it time to consider that some of the things we have taken for granted in healthcare are in need of refinement?
I believe so. If we do not start changing, more and more reports like the one the CDC released will emerge. It is time to get a grip on this critically important issue - mental health.
In my work, there is a fine line and need for balance around challenging the field to move forward and supporting those on the ground who may not be as ready as others to change. This can be a complicated dance.
Take for example the need to screen for mental health conditions in primary care.
A recent article in the Wall Street Journal highlighted the importance of screening for mental health in school based health clinics. No doubt, this is important, yields positive outcomes and is useful and meaningful for the community.
Other studies have shown the significance and importance of screening for mental health conditions, like depression, in primary care.
The problem around most screening is twofold:
1) Positive screens often highlight the lack of immediate mental health treatment for those who may need it at the time of the screening;
2) Paying for screening (and subsequent treatment ESPECIALLY if it is immediate, onsite and integrated) is complicated and often not paid for.
Based on the research, the United States Preventive Services Task Force (USPSTF) recommended that for adults, screening in primary care for depression should really only occur with “staff assisted supports” in place to help treat patients who are identified.
Here is the balancing act.
While wanting to advance mental health in primary care, there needs to be more research and policy work done to change policies that would better support treating mental health in primary care.
Screening is just one example.
So, does the field charge forward making the case that more screening should be done for depression in primary care? Does the field attempt to fix some of the problematic policies that prevent financially sustaining mental health in primary care that often are barriers for robust screening, treatment and healthcare integration?
The needs of the community should be placed first. We should work on doing what is right. Better healthcare integration, including mental health, is complicated and challenging, but does that mean it should not be pursued because policies don’t necessarily align properly?
A fine line. A balance.
Being a policy wonk researcher who cares a great deal about primary care and mental health integration, I thought I would take a stab at trying to present some of our work on integration in Austin next year for SXSW.
SXSW is a innovative and exciting “conference” held each year in Austin. Most commonly associated with music, SXSW is so much more. Not familiar - learn more here.
So I decided to take a chance and submit a proposal. Here is the abstract from my 2012 SXSW Abstract:
"The current healthcare system is broken and incapable of meeting the needs of the American public. Fragmentation abounds, costs are soaring and our health is not getting any better. It is time to disrupt; it is time to innovate. Since more mental health is seen in primary care then anywhere else, there appears an opportunity to change the way healthcare is delivered and make it much more comprehensive and patient-centered. By placing mental health providers in primary care, the largest platform of healthcare delivery in the country, we take a step towards disruption and innovation simultaneously in healthcare policy. This presentation will take on of the most significant issues in healthcare, the separation of mental health from the larger healthcare system, describe how disrupting the status quo in healthcare can be as simple as consolidating two separate systems (mental health and physical health) into one, and challenge the community to demand more from healthcare."
Will this make it through to be a presentation at SXSW? I hope so. To help, you can always vote to support this presentation here.