The anticipated intensity of this debate was such that it may have altered the
actual "Ways” of the Universe and subsequently caused one of the debating
members to be absent. Yes folks, we have already lost a presenter.
Well lost necessitates a "found” and to that matter, he was found in the
airport at Grand Junction, Colorado. The reason: his plane had a flat
tire. A plane with a flat tire, sounds a bit like "the dog ate my homework”.
We hope sabotage isn’t involved in this unfortunate event.
Randall Reitz, Dr. AJ [Ajantha Jayabarathan], and Dr. Eduardo Sanchez take the stage with music to
welcome them to the great debate. Shaking hands, each take their respective
podium to open up with their position statement.
Dr. AJ opened up her position statement with a reference to the Triple
Aim. The Institute of Medicines focus on access to high quality care,
care that results in improved health outcomes and the care must be sustainable;
all of these happening all together. Dr. AJ, an eloquently and soft yet
direct spoken Canadian physician, speaks of the Canadian Rubiks Cube to
demonstrate the micro, meso and macro levels of systems care. She urges
for U.S.A. to adopt this as their own model.
Dr. Reitz speaks towards the historical connections of the nascent nature of
collaborative care. Relative historical physician interactions as Reitz
have included, removing humors, enemas and leeching. We now are in a new
phase of care, one that he would admit needs to be aligned over the Three World
View:Clinical, Financial and Operational.
A metaphor has arisen already that may represent this debate. Dr. AJ during
her opening statements referenced s a graphic of what she described as a "Rubiks Cube”. Dr. Sanchez has
referenced multiple times his love of baseball; perhaps his Dominican roots are
showing--Yogi Berra being his favorite philosopher. Although Dr. Reitz,
arrived in his red U.S.A. sweat jacket, tear-away warm-up pants, and donning
boxing gloves, I can’t help but think that the Xbox version of this boxing idol
may be a more accurate representation of American ways (and subsequent health
level). Is it possible that these three
icons represent us well? Rubik’s Cube,
the Intelligent Canadians, Baseball, the athletic Dominicans and Virtual
Boxing, the lazy Americans? In many
ways, we need to put away the game controller and act. I might have missed on this one but you may get
where I’m going.
Sanchez, focused heavily on behavioral and mental health related co-morbidities
as one of the most significant players in the ill-health of America.
Sooner than later, the financials of this situation will come to
realization. We are headed towards collaborative care because of the
AJ disagrees and states that to make an omelet, you have to crack some eggs.
If the omelet is collaborative care, you’re the egg. How are you going to
feel about "being broken” if you are the egg. Currently the "Rub” comes
at an individual level [PCP] and we must create. I want to be the
quarterback that counts; you must change my mind at the individual level
Sanchez recommends we create an omelet without eggs? Possibly. They
do agree that it needs to change. He uses the concept of a team that
changes to the game; to meet the new rules. The opposite of this approach
is changing the entire team to meet one player; please reference Tim Tebow’s
offense to challenge to this idea.
Randall states that commercial insurance is to collaborative
care as condoms are to pregnancy: They are 92% effective at
Sanchez questions what we are paying for is evidence based (EB). There
are PCMHs out there that are not PCMHs but we are going to call them one. Us
bloggers question, "Is that a misunderstanding of the definition or an abuse of
system?” The dollars are going to drive
this change more so than people gathered around a podium bantering.
Barry Jacobs, audience member, states that collaborative care is not going to
happen. Treatment via a care management approach, not necessarily
treating the mental health illness connected to the problem.
AJ comments that Political Will and a Leadership Socialist approach are
what Americans are afraid of as a possibility. Triple Aim reference to
treatment being local and grass root generated. She discusses the
Canadian use of office redesign; something that they created out of a
grassroots collaborative care model – every person needs to make small changes
and expand their own scope of practice within each professional position.
PCMH are words that are used, doing
Integrated care before it had a label.Overall, it is recognized as a team
approach. Practice medicine the way football was played 50 years ago, you
really can be a one person team back then. Primary care is a team, health
team, driven endeavor. W
Dr. Reitz points out that our medical system lacks a general contractor. Medical care has too many outlets in their
"home” because the electrician makes a lot of money for each outlet he installs. We need a GC. Through federal CPCI initiative, clinics in nine states will earn a $20/per
patient per month for collaborative care. Put BH in primary care and it
will be paid for.
continued to speak towards the micro level of change; the grassroot generated
individual impetus for larger change. If every office, every worker made
small changes, it would collectively make a more significant change. To
follow the football analogy, it would be like having every player on the team
be more universally trained [say simply in MI or trauma focused care] , than
having "special teams”.
If you have a safe place but people are not honest, that does not work out that
well. Honesty in this case is driven by finances.
Dr. Sanchez states that in Texas they are working on a system of payment that focuses on bundled
payments. The model's first draft showed that the MH community became very
nervous; fearing being "cutout” of the process. Second, when a plane
comes down when the wheels just touch ground, you get the traction "we love
this” but a bit of a jerk because it is scary. The pushback was around
"we cannot do it” not because of the lack of unity in the idea, but there are
no true systems to make or even allow it to work. We cannot get a new model
without fracturing the process.
"Culture of Shared Benefit” is it really a question of Health vs.
with the money and power are not interested in collaboration.
AJ points out the Mental Health Commission: Canada--they are transition
funds and incentives for treating the behavioral side
The question by moderator, Ben Miller, asks if Integrated
Behavioral Health costs more - is this correct? Dr. Sanchez responds with
no, it is cost-effective. Dr. Reitz states that it doesn't cost more, but does cause significant cost shifting. Counties with a higher percent of primary care
always have lowest overall healthcare costs.
AJ: You Americans put the man on the moon w/ a focus on the change, once again, we are a shining
model for the rest of the world but we have to put a focus on it at an
audience member asks if there are any Financial Benefits managers and large
corporations in the room. Crickets.
The member goes onto state that they are the ones who pay for care. If we are going to change this (have
collaborative care carry on), we need them. They are trying to control
cost; not pay more to the people and not cost more at the end. The
payers need to understand we bring something to the table that helps them.
We need to talk to the benefits managers.
take home message: If we really do want to push this forward, who is not at the
table: Employers? Who else?
One main point of this discussion around the future of collaborative care
(whether we will be a mainstream healthcare model CC by 2022) is that we need to look around the
table and realize who is not there. Mainly, invite those to the table who can
help us move the field forward. Dr. AJ challenges people to stop being
onlookers and become motivated to seek out others. She asserts her stance on changing others at
AJ states that for all of the eggs out there, in every end there is a new
beginning. We (U.S.A.) put man on the moon, the Rubiks cube with the
traffic lights, a very robust depiction of how to do this micro and meso levels;
now we need to move on to the macro.
Onlookers, we pass the flame on
to you: support collaborative care and disseminate the word. 2022.