11 Points For Mental Health Care Reform

Due to greater understanding of how many Americans live with mental illnesses and addiction disorders and how expensive the total healthcare expenditures are for this group, we have reached a critical tipping point when it comes to healthcare reform. We understand the importance of treating the healthcare needs of individuals with serious mental illnesses and responding to the behavioral healthcare needs of all Americans. This is creating a series of exciting opportunities for the behavioral health community and a series of unprecedented challenges mental-health organizations across the U.S. are determined to provide expertise and leadership that supports member organizations, federal agencies, states, health plans, and consumer groups in ensuring that the key issues facing persons with mental-health and substance use disorders are properly addressed and integrated into healthcare reform.

In anticipation of parity and mental healthcare reform legislation, the many national and community mental health organizations have been thinking, meeting and writing for well over a year. Their work continues and their outputs guide those organizations lobbying for government healthcare reform..

MENTAL HEALTH SERVICE DELIVERY

1. Mental Health/Substance Use Health Provider Capacity Building: Community mental health and substance use treatment organizations, group practices, and individual clinicians will need to improve their ability to provide measurable, high-performing, prevention, early intervention, recovery and wellness oriented services and supports.

2. Person-Centered Healthcare Homes: There will be much greater demand for integrating mental health and substance use clinicians into primary care practices and primary care providers into mental health and substance use treatment organizations, using emerging and best practice clinical models and robust linkages between primary care and specialty behavioral healthcare.

3. Peer Counselors and Consumer Operated Services: We will see expansion of consumer-operated services and integration of peers into the mental health and substance use workforce and service array, underscoring the critical role these efforts play in supporting the recovery and wellness of persons with mental health and substance use disorders.

4. Mental Health Clinic Guidelines: The pace of development and dissemination of mental health and substance use clinical guidelines and clinical tools will increase with support from the new Patient-Centered Outcomes Research Institute and other research and implementation efforts. Of course, part of this initiative includes helping mental illness patients find a mental health clinic nearby.

MENTAL HEALTH SYSTEM MANAGEMENT

5. Medicaid Expansion and Health Insurance Exchanges: States will need to undertake major change processes to improve the quality and value of mental health and substance use services at parity as they redesign their Medicaid systems to prepare for expansion and design Health Insurance Exchanges. Provider organizations will need to be able to work with new Medicaid designs and contract with and bill services through the Exchanges.

6. Employer-Sponsored Health Plans and Parity: Employers and benefits managers will need to redefine how to use behavioral health services to address absenteeism and presenteeism and develop a more resilient and productive workforce. Provider organizations will need to tailor their service offerings to meet employer needs and work with their contracting and billing systems.

7. Accountable Care Organizations and Health Plan Redesign: Payers will encourage and in some cases mandate the development of new management structures that support healthcare reform including Accountable Care Organizations and health plan redesign, providing guidance on how mental health and substance use should be included to improve quality and better manage total healthcare expenditures. Provider organizations should take part in and become owners of ACOs that develop in their communities.

MENTAL HEALTHCARE INFRASTRUCTURE

8. Quality Improvement for Mental Healthcare: Organizations including the National Quality Forum will accelerate the development of a national quality improvement strategy that contains mental-health and substance use performance measures that will be used to improve delivery of mental-health and substance use services, patient health outcomes, and population health and manage costs. Provider organizations will need to develop the infrastructure to operate within this framework.

9. Health Information Technology: Federal and state HIT initiatives need to reflect the importance of mental-health and substance use services and include mental-health and substance use providers and data requirements in funding, design work, and infrastructure development. Provider organizations will need to be able to implement electronic health records and patient registries and connect these systems to community health information networks and health information exchanges.

10. Healthcare Payment Reform: Payers and health plans will need to design and implement new payment mechanisms including case rates and capitation that contain value-based purchasing and value-based insurance design strategies that are appropriate for persons with mental health and substance use disorders. Providers will need to adapt their practice management and billing systems and work processes in order to work with these new mechanisms.

11. Workforce Development: Major efforts including work of the new Workforce Advisory Committee will be needed to develop a national workforce strategy to meet the needs of persons with mental health and substance use disorder including expansion of peer counselors. Provider organizations will need to participate in these efforts and be ready to ramp up their workforce to meet unfolding demand.

School-Based Mental Health

School-based mental health services are sorely needed to deal with mental health issues that are often barriers to learning. Such services need to be a critical component in schools to combat barriers to academic success. Unfortunately, schools are often poorly equipped to deal with such problems. Because states tend to bundle educational and mental health services, funds are directed primarily toward education and not treatment. In many school districts communities are also lacking in emotional support services and families do not have the means to purchase needed medical insurance to support outside treatment. Transportation to mental health clinics may not be available. Parents are often reluctant to send their children out of district to such centers. School psychologists are overloaded with assessment responsibilities while school counselors deal mostly with classroom problems, college applications, and day-to-day crises. Additional services from trained psychologists, social workers, and psychiatrists are badly needed to treat emotional problems and for prevention of future problems.

A number of studies report on the prevalence of mental health problems in children. A report of the Surgeon General (1999) indicates that 20.9 percent of children and adolescents, aged 9-17, have mental or addictive disorders. Other studies support the statement that one in five students in school may have mental health concerns. At least two to three students in every classroom may have emotional problems of varying degrees of severity. One estimate is that 4.3 million students nationally suffer from mental illness that impairs their functioning at home, in school, and with peers. A report by Katoka, Zhang & Wells (2002) indicates that 78 percent of children aged 6 to 17 with mental disorders and 88 percent of Latino children do not receive needed mental health care. Mental health concerns are likely to increase in response to the recent economic downturn.

Mental health is not only the absence of mental illness but also includes the skills needed to deal with life’s challenges. Emotional and behavioral health problems represent serious barriers to academic success and behavioral adjustment in school. Children and adolescents with emotional problems have the highest failure rates; fifty percent of such children drop out of high school. Emotional disability is the fastest growing special education in schools. In Ohio, one in five high school students reported seriously considering a suicide in the previous twelve months. Suicide is the third leading cause of death among young people and is considered a public health crisis by both the Centers for Disease Control and Prevention and the World Health Organization.

Federal and state requirements mandate that schools attend to mental health issues since behavioral problems are treatable. Students who receive social and emotional support and decision-making skills have better overall grades and higher standardized test scores. Youth who received mental health services in schools showed significant reductions in psychiatric symptoms as measured by both parent and teacher ratings., Trained therapists serving on a consultant basis coordinate their efforts with school counselors and social workers. The cost of their services is often offset by savings from maintaining students in public schools who might otherwise need to attend more expensive specialized private facilities at the expense of the school district.

Psychiatric EHR Data Sharing a Must For Quality Care of Mental Health Patients

Among the many common myths in the healthcare world, it is also believed that like other illnesses, mental health patients do not need antibiotics, labs and physicals. This myth has been further strengthened because of the way data of mental health patients are recorded in the Psychiatric EHR.

Even Obama’s Affordable Care Act could not make much of a difference in treatment of mental health patients’ data. Unfortunately, data entry, collection and sharing are given secondary importance for psychiatric patients. Our mind and body make us whole, then why is there a gap in dealing with psychiatric data and other EHRs.

According to a study by National Council for Community Behavioral Health patients suffering from mental illness have a higher chance of dying earlier than general population. This is mostly in case of cardiac and diabetic patients, who haven’t been provided with adequate mental health services after a surgery or prolonged illness. This study emphasizes on the issue of equal treatment of mental health patients and psychiatric EHR data sharing.

Adam Kaplin, MD, assistant professor of Psychiatry and Behavioral Sciences and assistant professor of Neurology at Johns Hopkins University has laid emphasis on mental health rehabilitation of cardiac and diabetic patients. Dr. Kaplin said these patients usually experience a depression spell after they have been operated on. He said, “As an example, whether or not you have depression following a heart attack is as big as or bigger than any other risk factor as to whether you are going to die in the year following that heart attack.”

Access to mental health records

Despite making progress in healthcare technology, particularly electronic documentation, there is a wide chasm in psychiatric patients’ data collection and sharing with non-psychiatric physicians. The lack of data sharing is a huge obstacle in providing quality healthcare to patients.

Although integration of electronic data sharing and patient care is considered as the solution for healthcare problems, but the adoption of EHRs in psychiatric facilities is quite dismal. Only 44% of top hospitals have adopted Psychiatric EHR, among which only 28% share their patient data with non-psychiatric physicians.

Reasons for lack of data sharing

Physicians have highlighted two main obstacles in sharing of psychiatric records, which is hurting patients.

  • Stigma of mental health issues in the society is the most important reason. Psychiatrists refrain from sharing data with non-psychiatric physicians from fear of stigmatizing the patient. Usually, patients do not feel comfortable in revealing their mental health history and medication to other physicians during the record making. As a result, patients have been harmed due to clash in effect of medication.
  • The fear of stigma also forces psychiatrists and behavioral therapists to avoid EHR adoption, as patients don’t feel comfortable in keeping electronic records. There have been incidences of data hacking in hospitals, which comprises patient privacy. Therefore, fear of data leak keeps patients away from psychiatrists who have implemented EHRs at their practice.
  • There is slow adoption of health technology among psychiatric hospitals because they are not eligible for Meaningful Use incentives.

In order to make a difference in lives of mental health patients, it is necessary that psychiatrists and behavioral therapists adopt EHRs and share data with non-psychiatry physicians to keep patients away from any harm.

How Freedomland Became A ‘Health Care’ Center

My parents were in their early 40s in 1969, the year we moved to the massive Co-op City housing development in the Bronx. My brother and I were preteens.

When it was completed a few years later, Co-op City had more than 15,000 apartments, most of them in high-rises scattered across 300 formerly swampy acres that had once been the Freedomland amusement park. Within a few years, the community’s schools and shopping centers appeared. Most of Co-op City’s occupants were working-class laborers and civil servants, drawn mostly from elsewhere in the borough. Direct and indirect subsidies made their new apartments affordable.

My brother and I both left for college within a decade. Our parents stayed until 1990, when they retired, departed for the suburbs of central New Jersey and rebuilt their lives around the activities of the local senior citizens’ center. But many of their peers stayed in Co-op City, and quite a few of the kids my brother and I grew up with ended up staying with their parents, or inheriting apartments when their parents died.

For thousands of people like my parents, Co-op City became a “naturally occurring retirement community,” also known as a NORC. The survivors of their generation who have stayed put, now advanced far into old age, have had the benefit of family, friends, familiar neighborhood institutions and a host of social services to sustain them. The phenomenon of this open-air retirement home that came into being quite by accident has been apparent for more than a decade. The New York Times wrote about it as far back as 2002. (1)

In New York, Medicaid pays for a lot of the services these people need. To the extent that Medicaid is a low-income health care program, this is not necessarily surprising. Yet what makes New York’s situation different is that Medicaid often covers even those services that don’t have much to do with health care as most people understand it. In literature about the “Health Homes” initiative, introduced in 2012, the state’s Medicaid administrators described the function of a “care manager,” an individual who coordinates those seeing to an individual’s medical, behavioral health and social service needs. The theory is that by making sure people can live independently in their own homes, Medicaid saves money on hospital costs, ambulance rides, repetitive doctor visits and, most of all, nursing home care.

The same thing is happening in the mental health arena. Several years ago, New York expanded Medicaid coverage to provide housing for individuals with mental illness. In addition to the Health Homes program, New York also offers “supportive” housing that combines subsidized housing with a host of services, including medical, but also legal, career and educational, among others. Keep people off the streets and make sure they take their meds and get regular meals, the theory goes, and you’ll ultimately save money on emergency room and other acute-care costs.

Brenda Rosen, the director of the organization Common Ground, which runs a supportive housing building called The Brook, told NPR, “You know, we as a society are paying for somebody to be on the streets.” (2) And the outgoing New York State commissioner of health published an article in December 2013 arguing that housing and support services are integral to health, so Medicaid should help support the costs.

The state may be on board, but the arguments in favor of these programs haven’t made much headway with the federal government, which normally shares Medicaid expenses with the states. The feds won’t pay for these housing services, on the grounds that housing is not health care. Bruce Vladeck, who formerly administered the federal Medicaid (and Medicare) programs, said, “Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem.” (2)

That’s true. Not all care that leads to better health is health care. Good nutrition, having the time and place to get a full night’s sleep, and access to clean air and water are all essential for health, but we do not expect health insurance to pay for these things. Providing housing to people who need it is what we used to call social work, and most people don’t view social workers as health care providers.

But it is easier to gain political support for providing health care – with its image of flashing ambulance lights and skilled professionals dressed in white – than for subsidized housing for the aging or the disabled, especially the mentally disabled. So it is easier for Gov. Andrew Cuomo’s administration to organize these services under the label of Medicaid Health Homes. They are not homes at all in any traditional sense. Care managers are typically not doctors or nurses, but they are trained in social services or health care administration. Health Homes is a potentially worthwhile initiative that comes with clever, voter-ready branding.

The approach itself is not nearly as novel as the marketing. We have known for decades that good community support, including safe housing and close supervision for people who need it, is a lot less expensive than parking people in hospitals, nursing homes and other institutions. As New York State Medicaid Director Jason Helgerson pointed out when arguing in favor of Medicaid-funded housing support, Medicaid (and taxpayers) bear the cost of long, expensive hospital and nursing home stays. Giving people support to stay in their own homes is also a lot more humane in many, if not most, cases.

The challenge is to develop and market these programs in ways that sustain public support in the face of their predictable abuse. People misusing a service does not make it bad, but it does make it harder for politicians to defend. Disability insurance is also a good thing, but the Social Security disability program is just a couple of years away from going broke, in large part because of the wave of malingering that accompanied and followed the recent recession. Offer a benefit and people will want to use it, even if they are not genuinely part of the target population.

Well-supported housing with an effective array of social services for people who need them can do a lot of good, and can save society significant money as long as we are not prepared to make people in need survive on their own. NORCs can make excellent places for the elderly to live out their days, and housing for mentally ill and developmentally disabled people can keep them safely off the streets and out of the ERs.

But the feds are right that efforts to do so are not health care. It’s human care. If we don’t manage it effectively – keeping the malingerers out and holding costs at sustainable levels – some humans are going to be left on their own, no matter what we call it.

Sources:

1) The New York Times, “Haven for Workers in Bronx Evolves for Their Retirement”

2) NPR, “New York Debates Whether Housing Counts As Health Care”

Behavioral Health and Sensitivity – Finding Balance

Good behavioral health and real balance depend on sensitivity and goodness. Human beings don’t become human because they are able to think. What gives us our humanity is our capacity to feel other people’s pain.

We must cultivate goodness in our hearts in order to become really human. Without sensitivity and goodness, we will never attain wisdom, nor will we find peace.

This is why the wise unconscious mind that produces our dreams is constantly trying to help us become more sensitive. All dream messages work like warnings for our human conscience, and at the same time, like stimuli that wake up our senses.

I’m going to explain how I arrived at these conclusions. As a writer, I could study and relate many scientific discoveries that basically showed us the same truths. As a poet and philosopher, I could analyze these findings and sincerely criticize them, without any hypocritical or selfish intention.

However, what really helped me find out the truth about our mental and behavioral health, was the fact that I had to fight against craziness myself. I continued Carl Jung’s research in the unknown region of the human psyche through dream interpretation. This was how I discovered the roots of the human absurdity. After discovering the anti-conscience, the wild and primitive conscience that occupies the biggest part of our brain, I found explanations for all mysteries.

The anti-conscience is our animal and violent personality, which refuses to change its behavior. This is why it generates mental illnesses within the human side of our conscience.

However, the anti-conscience pretends to belong to the human side of our conscience, which it frequently invades, sending us various absurd thoughts. These wild thoughts seem to be generated from our human mind, when in fact, the anti-conscience is not human. It is totally absurd. It is also totally cruel, because it is an indifferent animal.

This is why whenever someone becomes mentally ill they are violent, immoral, and cruel, even when this is not apparent. In grave cases their violence is clearly visible. They are not themselves. They are dominated by their wild nature.

However, they cannot understand that they are under the control of their sneaky anti-conscience. They believe that their horrible actions are the result of their own lack of balance. Everyone around them has the same false impression.

However, the truth is that whenever human beings are violent, immoral, cruel, or totally indifferent to human suffering, they are dominated by their wild conscience. They are not responsible for their actions.

This means that we have to completely change the way our world functions. Nobody should go to jail for committing crimes. Nobody should be condemned by everyone else when they lose their minds. They need psychotherapy. The anti-conscience possesses great negative energy. It can easily destroy a person’s human conscience through craziness.

We must show compassion to those who are controlled by their wild and violent nature. On the other hand, we must seriously face the truth, and care about saving the new generations from mental illnesses and mental disorders.

Now we know that the anti-conscience is responsible for the formation of all mental and behavioral abnormalities observed in human beings. Thus, we must help everyone get rid of this primitive content before losing their human conscience; especially young people.

Dream therapy is a revolutionary healing method that will completely change the way we live our lives. It will put a definitive end to violence, craziness, indifference, and to all the horrors that mark our absurd civilization. This is how we will finally find peace and happiness that last forever.