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Two Steps Forward, One Step Back

Posted By Ben Miller, Tuesday, August 03, 2010
Updated: Thursday, June 02, 2011

In the current redesign of healthcare, there is precious little time for meetings to discuss what should be done next. The convening of various healthcare stakeholders to Baltimore, Maryland for the URAC/HAYES Paul Wellstone Mental Health Parity Stakeholders Conference was a unique opportunity for dialogue to occur around the future of mental health. This meeting was timely and precise in its attempt to examine the impact of mental health parity on current healthcare legislation, clinical practice, and payment strategies. There were three main points that emerged from the meeting that I will briefly address.

First, there appears to be growing sentiment that mental health parity is an important step for mental health treatment, but remains insufficient. Mental health parity law is in direct response to the fragmentation of the healthcare system. From an insurance perspective, parity brings mental health on an equal footing with medical benefits. This is a positive step for individuals in the community who need access to mental health services, but have previously been unable to access due to insurance barriers. However, it is important to note that just because insurance barriers have decreased does not mean more people will access mental health services. For example, we know that the majority of the public receives their mental health care in primary care, and that when referred to outpatient mental health, they often do not go. This may not change just because one has insurance to pay for services.

Second, within the redesign of primary care in the patient-centered medical home (PCMH), there is an increased opportunity to make the case that mental health and substance use must be included. While many know of the inseparability of mental health from primary care, this point still needs to be made every time the PCMH is discussed. The integration of mental health providers into the PCMH is one possibility for primary care’s redesign; however, mental health needs to constantly be at the table of discussions on the PCMH for this to happen. While this is just one future for mental health, acting now and acting fast is key to success as the fluidity of primary care’s redesign will not stay this way long.

Third, more research is needed to support the importance of mental health in the larger healthcare system. Without enhancing the evidentiary support for mental health and psychological treatment in medical settings, recommendations will be anecdotal and possibly ineffective. A golden opportunity could be missed. At a point in our nation’s history where we are looking to "bend the cost curve” and provide higher quality more effective and efficient care, our arguments should be grounded in science. There are many examples of this type of research happening now throughout the country. Mental health providers interested in the future of their field should consider using similar measures, tracking similar outcomes, and sharing this data so a stronger "business case” can be made for integration. Yes, there is a robust literature base on psychological treatments for medical conditions, but they have predominately been disease specific and limited in generalizability. We need more effectiveness trials that look at the heterogeneity seen in our healthcare settings.

There are rare opportunities in healthcare where systems can be profoundly impacted by their redesign. This may be one of those times. While mental health parity brought a group together in Baltimore, the passage of the bill itself was more confirmation of how far we still have to go. Dichotomizing mental health from physical health is a false separation. Two systems have developed from our inability to treat the whole person. Will healthcare providers of all ilks be able to rise to this momentous occasion and define itself in a new system? Will we be able to know what our future looks like and actively work towards this point? As I outlined above, there are many opportunities for mental health to become a major player in healthcare. Are we willing to take the risk? Are we willing to innovate? The choice is entirely up to us; but make no mistake, if we do not move, and move now, we will be left behind fighting for another version of parity in 10 years.

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