Posted By Lisa Zak-Hunter,
Thursday, August 9, 2012
| Comments (1)
Throughout our lives
there are times when we realize the permanency or magnitude of the change we’re
experiencing. I’ve had the great honor (or horror?) of going through a few of
these watershed moments in a relatively short time. Yikes! The first moment was
during a very positive conversation at the end of a 2 day interview for the job
I now hold. I had somehow managed to survive the cross-country interview at 9
months pregnant and was beginning to see that my patience through two years of
job hunting was likely going to be rewarded. Fast forward 2 weeks to what
turned out to be my last pregnancy check-up. After informing me I was about a
week away from labor, the midwife returned and said I needed to go home and
rest because they were going to induce me in a few hours. Three months and one
bundle of joy later, I was sitting in orientation for my new job, in a new
state, with a new baby. My identity as ‘pregnant woman’ had become ‘mom’ and my
identity as ‘graduate student’ was suddenly ‘faculty’. I’m acutely aware of the
process I’m undergoing to integrate these new and monumental roles and the
challenges this presents.
|Integrating the various
personal and professional opportunities feels like being at an all you can eat buffet
with a salad plate. There are many options--almost too many. As a parent, there is a ridiculous amount of choices for child toys, room décor, clothes,
schooling, activities etc. Then, there is what all the experts (from the other
parent at the grocery store to the child development specialist) say is the
‘best’ way to raise a child. There are child and parent personalities
intermingled in family dynamics. Within this framework, a parent entangles how
to do best by their child. Throughout the day, I pay attention to whether our
daily activities best capitalize on my child’s current development and
appropriately support and challenge her growth. I get bombarded by parenting
newsletters and emails with suggestions that further enhance my choices for
child rearing. It’s exhilarating and exhausting.|
An intersection of motherhood and work:
new office furniture.
Establishing myself as
a professional is no different. There are so many different opportunities that
were not afforded to me as a graduate student. I am torn between loving the
newfound freedom of ‘new professional’ and yearning for the security of
‘graduate student’. Now, I feel more in control of my work load and what I
decide to busy myself with during the day. I have more choices and the freedom
to make them. Yet, the lack of constant accountability is unsettling. If I need
to leave in the middle of the day for a meeting, I inform my colleagues,
realizing full well this is a courtesy on my part. If I were to not show up for
class, not only would my professor wonder, but my fellow students would as
well. I can guarantee someone would be checking in to see where I was.
I am also learning how
to prove myself and my abilities. As a young woman, mother, and mental health
professional working in medicine, I see how some of the cards are stacked
against me. I try to anticipate questions and assumptions about my profession
and personhood while learning the culture of my new work environment. Despite
my preparation, I have been asked if I plan to continue working full time or if
I will work part time to care for my child/future children. The question seems
innocent, but I doubt someone would ask a male physician the same. I have also
been mistaken for a resident and support staff. On the other hand, I have been
encouraged to be selfish about my career and focus on activities that enhance my
professional development. Some of the physicians introduce me to others as Dr.
Zak-Hunter instead of Lisa. I have spoken with faculty who are excited about
what I offer the residency and are interested the small changes I’d like to
make within my first month or so of hire. I have plans for my advancement and
am learning who to contact to get started.
Then, there is the
intersection of these two roles. I have had more time to develop my role as
‘mom’ than ‘faculty’. Because of that, I am more cognizant of how being mom
affects my new position, instead of vice versa. I missed the first new resident
meeting that the behaviorists run because my daughter’s doctor was late. I
wondered what type of impression I was leaving and how missing a meeting may
impact my relationship with the residents. I also love getting texts and
voicemails about how my baby’s doing during the day. It helps me stay connected
with her. Sometimes I worry that others may perceive it as taking away from my
work- even though it takes about 5-10 minutes of my day. I also wonder how
supportive the fast-paced nature of medicine will be over time when I continue
to take a few daily breaks to keep my milk supply up. Nursing is important to
me, but how will this priority impact others’ views of my competency and
collaborative abilities? These uncertainties are reflective of my personal
struggles to adjust, integrate, and confidently own these new roles.
All together, this is a
time of great change and opportunity. I walk the line between feeling the need
to charge forth with confidence and retreat into my office, uncertain which of
my ideas are valued and how to present them. I enjoy having the best of both
worlds. Despite some of my uncertainty and desire to establish myself, I am
excited by what each day holds. I have a fairly clear idea of my personal and
professional goals and how to achieve them. So, as I stand at the big buffet, I
decide that I am not limited to that salad plate. There’s a variety of dishes
from which to choose. I simply need to decide what I am in the mood for that
day and how it will come together to create a balanced diet over time.
Lisa Zak-Hunter, PhD is behavioral science faculty
with the Via Christi Family Medicine Residency in Wichita, KS. She earned her
PhD in Child and Family Development, specializing in Marriage and Family
Therapy, from the University of Georgia.
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Posted By Paul D. Simmons,
Thursday, August 2, 2012
| Comments (3)
medicine is a young specialty, a mere forty-three years old (1). Unfortunately, family medicine will be
extinct before it reaches its 70th
birthday if current trends
continue and—although I write as a family physician who educates family
medicine residents and loves the idea and ideals of family medicine, I say—this
might not be a bad thing. Several
forces, both from within and external to family medicine, are conspiring to
make us irrelevant, unnecessary and obsolete.
We’ve all seen the Match Day trends (2).
Each year until 2010, fewer medical students pursued training and
careers in family medicine, and the slight increases over the last few years
are largely attributable to more family medicine residency positions
available. We cannot fill our available
positions with US graduates. Many of
those who match in family medicine are trained in a shrinking spectrum of
skills. Many new graduates quickly
jettison any broader skills they may have had in the name of work-life balance
(3). Across the country, specialists and
insurers implicitly or explicitly argue that family physicians cannot and
should not be doing surgical (or non-surgical) obstetrics, endoscopy, minor
surgery, ICU care or hospital medicine (4).
We are often complicit in this effort to minimize our domain of
practice, again in the interest of lifestyle or avoiding liability.
our skills and practice scope are diminishing, a wave of mid-level
practitioners (i.e., physician assistants and family nurse practitioners) are
moving into primary care medicine (5,6,7).
They share many of our same skills, are able to prescribe and order just
as we are in a growing number of states, and are paid less. Most of these so-called "physician extenders”
do excellent work and are viewed as equivalent to physicians by many
patients. It is inevitable that health
systems, policy-makers and third-party payers will soon realize—with dollar
signs in their eyes—that these practitioners are inexpensive physician substitutes rather than physician
"extenders.” All of the skills, more
empathy and a similar scope of practice without the egos or paychecks of
support for the Patient-Centered Medical Home (PCMH) model, while
predicated on admirable ideals, could easily be speeding our demise.|
family physicians are ill-equipped to resist our own demise because we lack a
clear sense of what, exactly, it is we do.
Not only does the public have little sense of how a "family doctor”
differs from an old-fashioned "GP” or an internist, many of us have a difficult
time explaining the distinction apart from defensively sputtering, "We’re a
specialty, too!” Family medicine, some
say, takes care of 90% of medical problems that present in the outpatient
setting. Of course, so do internists
(for adults), pediatricians (for children), and emergency physicians (for
everyone). Family medicine, some say,
provides continuity of care over the lifespan.
Perhaps thirty years ago this was true.
Now, however, vanishingly few family physicians will spend a career in
the same location, taking care of the same population.
more troubling, however, is a deeper sense of inadequacy within the family
physician’s psyche. Yes, I take care of
adults, but can I really do so as well as an internist? Yes, I take care of children, but can I really do so as well as a
pediatrician? I may deliver babies, but
can I really provide the same quality
of care as an obstetrician? If the
reader balks at these questions, consider:
if your wife were to experience a pregnancy complication, and you had the
option, would you ask for an obstetrician or a family physician? If your child was suddenly struck with
serious illness, would you bring her to a pediatrician or a family
physician? We claim we are "equal” to
our specialty colleagues—yet when serious or complex illness strikes those we
love, we may find we have been playing doctor and we want a Real Doctor to step
in to save us. Do patients sense this as
larger medical world certainly seems to have detected our impotence. Family physicians exert minimal or no
influence in determining our own payment structure, nor are our protests taken
seriously. The Accreditation Council of
Graduate Medical Education (ACGME) frequently ignores or delays our specialty’s
recommendations or intentions (8). The
AMA/Specialty Society Relative Value Scale Update Committee (RUC) continues to
perpetuate an unjust payment model despite our protests (9). Family physicians are not the doctors that
come to mind when patients think of disease-detecting, mystery-solving
"experts” at the Mayo Clinic or Cleveland Clinic, nor do many tertiary- and
quaternary-care institutions see a significant role for us in their delivery of
medical care. Our medical journals are
of comedically dubious quality, and we seem to be best at publishing, if
anything, within the review article genre (10).
support for the Patient-Centered Medical Home (PCMH) model, for example, while
predicated on admirable ideals, could easily be speeding our demise. The PCMH model rests on the idea of
team-based care, where many of the functions previously carried out by
physicians are delegated to nurses, medical assistants and case managers. This is intended to free up the physician to
deal with the "hard” cases for which we are best suited. The problem is: we are not best-suited. The
endocrinologist is best-suited to deal with the complicated, uncontrolled
diabetic patient that cannot be brought under control by the nurse
practitioner’s efforts. Similarly, the
cardiologist is best-suited to deal with the refractory hypertensive; the
gastroenterologist with the complicated hepatitis C patient. The family physician, in the PCMH model, is
an unnecessary (and expensive) middle-man who has very little to add to the
best management efforts of a high-functioning team operating with
evidence-based protocols and guidelines.
Inevitably, someone in authority will realize this cost-saving,
our specialty shrinks and delegates itself out of existence, some of us take
refuge in the ridiculous romanticism of "biopsychosocial” or "patient-centered”
or "holistic” flag-waving—as if patients would rather have sympathetic
hand-holding than competent, efficient, expert medical care. That’s all fine, of course. We’re generally nice people. But while we’re spending our collective
efforts on patient focus groups, learning acupuncture, satisfaction surveys,
lifestyle balancing acts and "restoring the mystery” to medicine, our
colleagues in internal medicine, pediatrics, obstetrics, critical care, surgery
and emergency medicine are taking care of actual seriously sick people and
showing that they can do a better job of it than we can. Perhaps we should step aside and let them get
back to work.
1. Piscano, NJ. (n.d.) History of the Specialty.
From American Board of Family Medicine website.
Retrieved from https://www.theabfm.org/about/history.aspx.
2. Porter, S. (2012) Family Medicine Match Rates
Increase Slightly. AAFP News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/education-professional-development/20120316matchresults.html.
3. Kotmire S. (2012) Shrinking Scope of Practice
Raises Questions About Future of Family Medicine Training. Leader
Voices Blog, American Academy of Family Physicians. Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/shrinking_scope_of_practice_raises.
4. Should Colorectal Surgeons and Family Doctors
Perform Colonoscopy? (2012).
Gastroenterology.com, retrieved from http://www.gastroenterology.com/featured/should-colorectal-surgeons-and-family-doctors-perform-colonoscopy.
5. Rough G.
(2009). For many, a nurse
practitioner is the doctor. Arizona Republic. Retrieved from http://www.azcentral.com/news/articles/2009/02/21/20090221nursepractitioners0220.html.
6. Horrocks S, Anderson E, Salisbury C. (2002).
Systematic review of whether nurse practitioners working in primary care
can provide equivalent care to doctors. British
Medical Journal 324: 819-23. Summary
retrieved at http://apps.who.int/rhl/effective_practice_and_organizing_care/SUPPORT_Task_shifiting.pdf.
7. Flanagan L.
(1998). Nurse practitioners: growing competition for family
physicians? Family Practice Management 5(9): 34-43. Retrieved from http://www.aafp.org/fpm/1998/1000/p34.html.
8. Wood J. (2012). Changing training standards for maternity
care. Leader Voices Blog, American
Academy of Family Physicians. Retrieved
9. AAFP Opts to Remain in the RUC (2012). AAFP
News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20120313rucdecision.html.
10. Van Driel L, Maier M, De Maeseneer. (2007).
Measuring the impact of family medicine research: scientific citations or societal impact? Family
Practice (2007) 24 (5): 401-402.
Retrieved from http://fampra.oxfordjournals.org/content/24/5/401.full.
Paul D. Simmons, MD FAAFP, is Extremely Junior Faculty at St.
Mary's Family Medicine Residency in Grand Junction, Colorado where he
serves mainly as a negative example for malleable trainees. He
practiced family medicine, including obstetrics and endoscopy, for
several years in rural eastern Colorado and Wisconsin before joining St.
Mary's. His interests include antique Jungian archetypewriters,
obscure eponymous diseases, superhero movies, Sherlock Holmes and
misanthropy. He will debate the future of collaborative care during a keynote address at the CFHA Conference in Austin, October 4-6, 2012.
This post has not been tagged.
Posted By Peter Fifield,
Thursday, July 26, 2012
| Comments (2)
primary care physician referred me to an orthopedic surgeon to finally
figure out a solution to fifteen years of chronic bilateral ankle pain.
I was optimistic but after 15 years of failed alternative methods
including physical therapy, acupuncture, shambala, voodoo medicine and a
bit of old fashioned "suck it up” I knew it was most likely not going
to be great news. I met with the doctor and within a few minutes of
examining my ankles he nodded with confidence then sent me off to get
x-rays with the promise that we would discuss my treatment options upon
returned to the exam room and waited, socks off, feet on the cold tile
floor. He returned and assured me that as far as my ankles go, my fears
were true; "You’ve got minimal tread left…about a thousand miles left
on those sixty thousand mile tires”. His metaphor was clear. The course
of treatment for Acquired cavo-varus deformity [aka "minimal tread
left”] was going to include a fairly benign first step of physical
therapy combined with orthotic inserts. No big deal. But if this
process did not work I was to have a bilateral operation which he informed me would require five weeks of bed rest for each ankle and if this was unsuccessful then, "complete ankle replacement” or as a last resort there was always fused anklesas an option. The standout bold type in the preceding sentences was all my brain absorbed.
"fused” I shut down. All I heard was the waning ostinato of "wahwahwah
wahwah wah”; similar to what I’m sure Charlie Brown heard from his
phantasmalteacher. In my head I was running through all of my options
regarding how I was going to continue living my life as I know it with
fused ankles. How can I keep running, hiking, skiing, mountaineering,
surfing, etc?, All these things I love to do. How do I keep being who I
am with this set of threadbare tires I’ve got? I’m embarrassed to say I
think I would have been less reactive to news of a death in the family.
"fused” I shut down. All I heard was the waning ostinato of "wahwahwah
wahwah wah”; similar to what I’m sure Charlie Brown heard from his
phantasmal teacher. In my head I was running through all of my options
regarding how I was going to continue living my life as I know it with
fused ankles. How can I keep running, hiking, skiing, mountaineering,
surfing, etc?, All these things I love to do. How do I keep being who I
am with this set of threadbare tires I’ve got? I’m embarrassed to say I
think I would have been less reactive to news of a death in the family.||After
"fused” I shut down. |
All I heard was the waning ostinato of "wahwahwah
has been a few days now and I’ve managed to relax a bit and
problem-solve the situation with a clearer head. However, I cannot help
but reflect back to that moment in the doctor’s office trying to think
of what I would have done differently if I were the one giving me the
"bad” news. As an integrated behavioral health provider who consults
with patients on a daily basis about medical issues, what could I have
said or done that would have changed my experience?
keep coming back to two different interactions—the first being with the
podiatrist, the other with my mother. The podiatrist could tell that I
was bummed and offered me some story from his youth dealing with "bad
knees” and how he had to stop playing basketball. Not to be callous,
but I have never been able to shoot, nor dribble a basketball and to be
honest; I did not care if he could either. This basketball reference did
nothing for me. I retreated. My mother, in her very sincere, genuine
and overly pragmatic way offered me this: "that must be hard sweetie”
followed by "Aren’t we glad you are not sick like Amy,”a high school
friend of mine recently diagnosed with cancer. Strike two!
don’t misconstrue my sarcasm for antipathy towards my doctor, my
mother, or my high school friend. I do consider myself blessed in most
aspects of my life. I am grateful that my knees are good and I’m cancer
free, but really neither of these things has anything to with
troubleshooting my ankle recovery. Sympathy is not what I needed, nor
wanted. Thinking back, what might have worked better was a bit of
empathy, followed by some problem solving assistance. Second I wanted to
play more of an active role in deciding what the treatment was going to
be or to at least to feel like I did. Intellectually I knew that the
emotional child in me was standing in the way of recovery, but in
reality I wondered if I could just up and change all my activity?
what? If I was to remove something so important in my life (such as
exercise) what was I going to replace it with? And, if I found that
something, what would it take to actualize it all? Lastly, at some
point I wanted to be asked if I had any questions. After I realized my
brain had been shut off for the past five minutes, I had a lot of them.
visit galvanized my faith in Motivational Interviewing as a very
effective way of "being with" a patient. Sympathy, apathy and antipathy
do nothing for bonding with a client. The relationship is created
between the provider and the patient through the use of empathy for it
helps in fostering the patient’s autonomy and hopefulness. Figuratively
pulling up next to a patient and reflecting back to them their
difficulties with the current situation and offering empathy in
accordance to their experience. How could my doctor or my mother help if
they had the same feelings and ideas about this situation? What may
have been beneficial was a provision of a shared experience yet through a
different lens; a different point of view based on similar, yet clearly
the examples once again from the doctor and my mother we can hopefully
glean some insight into a better use of their words. The doctor, instead
of leading into an unsolicited story of his declining athletic prowess
could have led with a simple reflection "I can tell this is going to be
hard for you" and then followed with an open-ended question "when I went
through something similar playing basketball in my youth, I had a hard
time too. How could I help you figure this out?". The difference between
these two versions is slight, but very important. First, the reflection
offers up empathy letting me know he is on my team, second, the request
to offer suggestions encourages me to invite him in, become refractory to his attempt at aligning with me. I believe this
slight modification would have changed my reaction to him and I could
have left with a plan; thus giving me confidence that I could pull this
off. From him I needed a plan. Regarding my mother, although she was
just trying to make me feel better,she could have stopped at "that must be hard". Sometimes less is more. I Love you mom!
|Pete Fifield is the Manager of Integration and Behavioral Health Services at Families First Health and Support Center; an FQHC in Portsmouth NH. Read more of his CFHA blog posts here.|
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Posted By Randall Reitz,
Thursday, July 19, 2012
| Comments (0)
This blog post is taken from my comments to the incoming class of
residents of the St Mary’s Family Medicine Residency in Grand Junction, CO. The
setting was the Devil’s Kitchen trail in the Colorado National Monument during
our annual orientation hike.
Long ago, there
was a traveler who came upon three men working with stone. Curious as
to their labors, the traveler approached the first worker and asked, "What are
you doing with these stones?” Without halting, the worker responded, "I am a
stonecutter and I am cutting stones.”
Not satisfied with this answer, the traveler approached the second and asked,
"What are you doing with these stones?” The worker paused for a moment, wiped
his brow, met the traveler’s eyes, and stated "I am a stonecutter and I am making
money to support my family.”
Having two different answers to the same question, the traveler made his way to
the third and asked, "What are you doing with these stones?” The worker thought, laid the chisel on the stone, engaged the traveler with his smile, and
declared, "I am a stonecutter and I am building a cathedral that will bless my family,
friends, and townsfolk for generations.”
This oft-told tale seems
particularly poignant in this setting.
We talk today in a natural formation that belies both its name and its natural
provenance. Rather than a devilish pile
of random rocks, to me it is the closest structure Grand Junction has to a timeless
Within this serene space, we
reflect on the beginning of your vocation as a family physician. Over the next three years, your training will
offer experiences that could easily inspire the perspectives of each of the
stone cutters. First, there will be
times when your duties feel like laborious, mindless stonecutting. Second, as this is the first time you’ve been
employed as a doctor, you are now straddling the worlds of the learner and the paid
staff physician. And third, each of you
brings with you a vision of why you chose this noble, yet demanding profession.
While each of these
perspectives is reasonable and grounded in the truth, I assert that your time in
residency will be more fruitful, meaningful, and agreeably fast-paced if you approach
it as the third stonecutter. He
benefits from vision, passion, and ownership of his craft. To build your cathedral, you will need to
hold-on to all three.
Fortunately, there exists a
detailed blueprint for your cathedral that will guide you through this process. Revisiting the blueprint will lift your eyes
to the spires and away from the inane hassles. You designed the plans yourself,
about one year ago as you were preparing to apply for residency programs. Each of you wrote a personal statement in
which you described in vibrant terms why you had entered medicine and why family
medicine was the ideal specialty for you.
For some it was a passion for enduring "cradle to grave” human interaction. For others, it was the intellectual challenge
of a comprehensivist practice. And for others,
it was a mission to bless the under-served of rural America and third-world
With time (predictably during
the winter of your second year), this blueprint might begin to seem corny or naïve
to you. The challenges of full-spectrum
training and the comments of others in the medical field might obscure this
vision. Guard against this disillusionment. Based on my experience with
previous classes, I predict that the closer you remain to your initial vision,
the more meaning and delight you will derive from residency and your career.
Like stonecutting, family medicine
is a worthy craft. Unlike stonecutting,
it will also afford a very comfortable life for you and your loved ones. But,
the noblest reason to engage fully in your training is to build
the cathedral that you initially envisioned.
I look forward to witnessing the realization of your plans and to
offering a scaffold to your labors.
Randall Reitz , PhD, LMFT is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO. In addition to training residents he also directs a fellowship in Medical Family Therapy. His scholarly pursuits include medical family therapy, professional development, healthcare ethics, and integrated primary care.
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Posted By Invited Blog Post from Milliman Inc.,
Thursday, July 12, 2012
| Comments (0)
In a 5-4 ruling, the U.S. Supreme
Court has preserved the individual mandate and upheld the
constitutionality of the Patient Protection and Affordable Care Act (PPACA),
with the notable exception that states can now opt out of Medicaid
expansion. Milliman consultants cannot offer legal interpretations of
this historic decision, but we can offer perspective on what it means to
the healthcare system. The many stakeholders that have been preparing
for PPACA for more than two years can continue
that preparation. And while there remains some uncertainty—a Republican
victory in November could still lead to a repeal of the law—many
stakeholders that have been slow to move may now see an incentive to do
In this article, we outline 10 strategic considerations for insurers, employers, providers, taxpayers, and the government.
In 2009, as the American healthcare
reform conversation began in earnest, Milliman was already several
years into an effort to better understand American healthcare reform. We
had invested millions of dollars in research, developing models and
methodologies that could study vast changes to the current system. At
that time, we recognized that there were certain ideas that might have
been controversial before but that are now anticipated to be part of the
solution. Value-based pricing. Prevention. Managed care. Evidence-based
medicine. A move away from fee-for-service. Improved transparency,
especially around costs. Electronic health records. Consumerism.
But there is a difference between knowing what to do and doing it. PPACA
jumpstarted several efforts, forced lessons around some of these
concepts (sometimes difficult lessons), and mobilized the industry to
change. Now in 2012, the healthcare industry—especially insurers,
employers, providers, and the government—has learned some things it did
not know before. The ultimate test is acceptance by the public once
these concepts are implemented on a widespread basis.
we awaited the Supreme Court's decision, we realized that regardless of
the outcome many of these concepts are now becoming entrenched in the
system. While this decision has important and unique ramifications, much
of the change coming to American healthcare is already underway.
Ten strategic considerations
- Adverse selection may still be a challenge.
Guaranteed issue and community rating make the individual insurance
market more accessible to the uninsured, but without an effective
individual mandate these reforms create adverse selection.1
The key word there is effective. If enrolling in a healthcare plan is
viewed as optional for U.S. citizens because the penalties have limited
teeth, those who consider themselves healthy are less likely to enroll
because it may not be in their immediate economic best interest. For
pricing to be sustainable, these healthier people must enroll in order
to balance out the insurance pool costs and health risk.
Milliman analysis on the effectiveness of the individual mandate
indicates that much depends on a person's household income, age, and
family type.2 As the exchanges come online in 2014, many will
be focused on the enrollment to determine how this theoretical
underpinning bears out in actuality.
One new wild card: The court's ruling on Medicaid expansion
complicates the adverse selection question, because the decision raises
access questions for certain low-income individuals. Which brings us to
- Medicaid expansion just became a far more complex and variable proposition.
The Supreme Court decision gives states the option not to participate
in Medicaid expansion. In states that opt not to participate, there are
big questions about how their Medicaid programs will function and how
all this may affect the population that would have been
Medicaid-eligible through the expanded coverage.
If a state does not participate in the Medicaid expansion, to what
extent will those below the 133% federal poverty level (FPL) threshold
qualify for premium tax credits and cost sharing subsidies?
Is a partial expansion possible? Are states that opt out of Medicaid
expansion able to receive any portion of the enhanced federal funding
available under PPACA through a partial expansion using waivers or a state plan amendment?
Are provisions of PPACA that are not
explicitly tied to Medicaid expansion still in effect for states that
opt out of the expansion? For example, will states have to abide by the
primary care physician fee schedule increase that is scheduled for 2013
With the court upholding the exchanges and other components of the
law, the interaction between Medicaid and these components creates a
maze of issues for states, insurers, employers, and the uninsured.
- Employers grapple with new options and plan requirements.
Employers need to consider how the employer-sponsored insurance (ESI)
model fits in their future. Many employers are intent on maintaining
such benefits, recognizing a distinct recruiting and retention
mechanism. Reports of ESI's demise are premature as of this date.
Employers will continue to review and amend their plans in efforts to
control costs, and there are distinct advantages and cost pressures
brought on by PPACA. There may also be new
incentives for pursuing a self-funded approach, even by certain small
employers. And the law does include some disruptive elements for ESI
that bear watching. For example, many feel that the summary of benefits
and coverage statements that employers must send to employees are
burdensome and won't be sufficiently useful to employees.
The change to Medicaid expansion could also complicate matters for employers. Under PPACA,
employers with over 50 employees may be subject to additional plan
affordability penalties for employees under 133% FPL—unless these
individuals are Medicaid eligible. If a state does not expand Medicaid,
employers above 50 lives may be subject to more plan affordability
penalties than they would be were their state to pursue Medicaid
expansion. In this sense, a state's decision to expand Medicaid may have
cost implications for employers. How will the anticipated healthplan
costs for employers change now that low-income employees may not be able
to qualify for Medicaid in certain states?
- What is the effect on early retirees? PPACA may change the landscape for how employers handle early retiree healthcare coverage.3
New options emerge for those between ages 55 and 65, with the exchanges
becoming very attractive for attaining affordable coverage. The absence
of medical underwriting, the limitations placed on age rating (i.e., a
maximum 3-to-1 ratio between insurance premiums for the oldest and
youngest), and the availability of premium and benefit subsidies make
the exchanges an affordable place for people 55-65 years old to purchase
- Rate review scrutiny and no risk selection: Something's got to give. PPACA
has brought about increased scrutiny of rate increases, and it seems
likely this will continue. But with a 10% increase now deemed
potentially "unreasonable" by federal regulators, and with traditional
underwriting/risk selection taken out of the system, there are all the
signs of an inevitable collision. An influx of less-healthy people could
make it very difficult for many plans to stay below the 10% ceiling
without losing money and risking financial instability. If the
individual mandate works as hoped, this may be mitigated. Risk
adjustment, reinsurance, and risk corridors are also supposed to help
with this issue, but will they be enough? This is one to watch.
- Which states will get on the exchange bandwagon?
Some states have pushed forward aggressively with implementing a state
health insurance exchange, while others have resisted. Will the Court
decision set exchange efforts in motion in the states that were not
Given the often political nature of this resistance, and the
outstanding question of the presidential election and whether a
Republican victory could bring about a repeal of PPACA,
in many states the delay may continue. With states empowered to opt out
of Medicaid expansion, states that have pushed back against exchanges
have another front on which to not participate with PPACA.
But states with efforts already under way now have more wind at their
backs. The 2014 deadline is becoming imminent, creating an incentive to
get moving. And states also face a deadline on January 1, 2013, at
which time the federal government will assess whether states have the
infrastructure in place to proceed with an exchange. For some states
these two deadlines may be enough to begin implementation efforts.
- Minimum loss ratios (MLR) pose an ongoing challenge for insurers.
While the minimum loss ratio requirement—the idea that 80-85 cents of
every healthcare dollar should go toward medical care—sounds good, it is
out of step with the financial realities many insurers face. Claims do
not always move in a predictable way, meaning that medical costs can be
volatile.4 Previously, an insurer's lower claim cost years
could help balance out the higher claim cost years. However, under the
MLR rules, insurers need to pay out rebates during lower claim cost
years as opposed to building up reserves for higher claim cost years.
This dynamic will be amplified if the individual mandate is ineffective
and adverse selection ensues.
The MLR rules, as written, also present challenges to high-deductible
health plans (HDHPs), because the MLR calculation only includes plan
expenses, not patient expenses. These plans give consumers greater skin
in the game, thereby encouraging more judicious use of care.5
Expenses to administer these plans are typically higher as a percentage
of premium than they are for richer benefit plans. To the extent that
the MLR requirement takes these plans off the table, it could also
remove a possible cost-reducing concept from the mix.
The MLR rules challenge smaller insurers, which are more susceptible
to the underwriting cycle because they lack the volume to absorb down
years or to spread risk across multiple business lines.6 The
MLR rules also do not allow smaller health plans to pool large claims
across states, creating a significant issue for small multi-state plans.
Efforts are afoot to tweak the MLR rules and fix these problems, but
that doesn't change the reality that this rule is hard on insurers. The
difficulty is exacerbated by new rating rules. Insurers face a low
ceiling and a high floor, without much room to stand up.
- Risk adjustment is essential. The idea that
fee-for-service is broken and the reimbursement paradigm should be
turned on its head has popular support. Risk adjustment7 is
an important part of this new paradigm because it helps align revenue
with health status, a key calculus in a system that competes on health
and efficiency rather than volume.
To the extent that the exchanges face adverse selection challenges,
risk adjustment may be even more important. With a higher concentration
of morbidity potentially entering the market, there's an increased need
to balance those costs between carriers based on their relative risk
- Will cost shifting hold steady, increase, or decrease?
The current system includes various examples of cost shifting.
Uncompensated care pushes the cost of the uninsured onto other payors,8
and many providers cite low Medicare and Medicaid rates as an excuse to
push higher costs onto the employer-sponsored insurance market.9 While cost shifting is not inevitable,10 it bears watching. If PPACA's
efforts to cover the uninsured are successful, the uncompensated care
cost shifting will decrease. But with Baby Boomers increasing the number
of Medicare enrollees and at least some Medicaid expansion ongoing,
there will be added pressure to cost shift—unless providers can find the
efficiency to keep their costs in order.11
Costs will also shift on the consumer level. The changing rules
around age rating and medical underwriting will create subsidies funded
by young and healthy people to lower costs for older and less-healthy
people. Consumers who receive care in this market may not always
understand why their costs are going up—especially young people and
young men in particular—who will be subsidizing other more expensive
populations thanks to limited age, gender, and health ratings.12
- The cost problem persists. What can be done about it? PPACA
focuses on expanding coverage and insurance reform, and in some cases
it shifts costs from one party to another, but it does not directly
affect the unit costs and utilization that are among the major
underlying drivers of healthcare costs.
Certain aspects of PPACA have the potential to affect costs. The option to implement an accountable care organization (ACO)13
reprises the managed care movement of the '80s and '90s, but with
better technology and information, and by transferring the financial
risk onto the provider to create an incentive for efficiency. With many
potential ACOs already establishing the tools required to succeed,14
this reinvigorated movement is already in motion. The nuts and bolts of
an ACO are still the parts needed for a more efficient system.
Most of PPACA's explicit ACO efforts center
on Medicare, and while the Medicare Shared Savings Program (MSSP) and
Pioneer Programs will continue, the potential for commercial ACOs15 may prove just as significant.
Accountable care is not a solution to everything that ails the entire
healthcare system, but it offers some hope and, to the extent it can
meaningfully control unit costs and utilization, it just may work.
Questions persist as reform marches forward
There is still at least one major point of uncertainty: the November 6 presidential and Congressional elections. PPACA
has survived the first of its existential challenges. But with four
months of intense debate and a presidential election still to come, it
is not yet out of the woods.
In the coming days and weeks the
Supreme Court's decision will be dissected by experts from many fields,
especially as it pertains to Medicaid expansion. Milliman will continue
to publish actuarial and financial analysis of healthcare reform, and
will have more to say about this decision specifically. Check back for
more at www.milliman.com/hcr and www.healthcaretownhall.com.
1Snook, T. &
Harris, R. (October 2009). Adverse Selection and the Individual Mandate.
Milliman Health Reform Briefing Paper. Retrieved May 24, 2012, from http://publications.milliman.com/research/health-rr/pdfs/adverse-selection-individual-mandate.pdf.
2Houchens, P. (March
2012). Measuring the Strength of the Individual Mandate. Milliman
Research Report. Retrieved May 24, 2012, from http://publications.milliman.com/publications/health-published/pdfs/measuring-strength-individual-mandate.pdf.
3Ge, J. (June 2012).
Health insurance exchanges and early retiree health coverage. Milliman
Benefits Perspectives. Retrieved June 16, 2012, from http://publications.milliman.com/periodicals/bp/pdfs/BP-06-07-12.pdf.
4Cookson, J. (May
2011). Healthcare Reform's Minimum Medical Loss Ratios: How to Manage
the Increased Risk? Milliman Healthcare Reform Briefing Paper. Retrieved
May 24, 2012, from http://publications.milliman.com/publications/healthreform/pdfs/healthcare-reform-minimum-medical.pdf.
5Burke, J. & Pipich, R. (April 2008). Consumer-Driven Impact Study. Milliman Research Report. Retrieved May 24, 2012, from http://publications.milliman.com/research/health-rr/pdfs/consumer-driven-impact-studyRR-04-01-08.pdf.
8Families USA (2009). Hidden Health Tax: Americans Pay a Premium. Retrieved June 16, 2012, from http://familiesusa2.org/assets/pdfs/hidden-health-tax.pdf.
9Fox, W. &
Pickering, J. (December 2008). Hospital & Physician Cost Shift:
Payment Level Comparison of Medicare, Medicaid, and Commercial Payers.
Milliman Client Report. Retrieved June 20, 2012, from http://publications.milliman.com/research/health-rr/pdfs/hospital-physician-cost-shift-RR12-01-08.pdf.
10Pyenson, B. et al.
(March 18, 2010). High Value for Hospital Care: High Value for All?
Milliman Client Report. Retrieved June 20, 2012, from http://publications.milliman.com/research/health-rr/pdfs/high-value-hospital-care.pdf.
(June 2010). Why Hospital Cost Shifting Is No Longer a Viable Strategy.
Milliman Healthcare Reform Briefing Paper. Retrieved June 20, 2012, from
12van der Heijde, M.
& Norris, D. (August 30, 2011). The young are the restless:
Demographic changes under health reform. Milliman Insight. Retrieved
June 20, 2012, from http://insight.milliman.com/article.php?cntid=7879.
13Parke, R. &
Fitch, K. (October 13, 2009). Accountable care organizations: The new
provider model? Milliman Insight. Retrieved May 24, 2012, from http://insight.milliman.com/article.php?cntid=6056.
14Fitch, K. et al.
(July 2010). Nuts and Bolts of ACO Financial and Operational Success:
Calculating and Managing to Actuarial Utilization Targets. Milliman
Healthcare Reform Briefing Paper. Retrieved May 24, 2012, from http://publications.milliman.com/publications/healthreform/pdfs/828_HDP.pdf.
15Boyarsky, V. et al.
(April 22, 2011). ACOs Beyond Medicare. Milliman Healthcare Reform
Briefing Paper. Retrieved May 24, 2012, from http://publications.milliman.com/publications/healthreform/pdfs/acos-beyond-medicare.pdf.
CFHA Blog invited Millliman Inc. to share their evaluation of the outcome of the Supreme Court ruling on the Affordable Care Act. Milliman is among the world's largest independent actuarial and consulting firms. CFHA has consulted with Milliman on numerous policy efforts. See www.milliman.com.
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Posted By Kavita Patel,
Thursday, June 28, 2012
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Dr Kavita Patel, a fellow of the Brookings Institution, and a former policy director in the Obama White House, provides high-level analysis of today's Supreme Court ruling and other important collaborative care policy issues.
CFHA: Today (June 28, 2012) the
Supreme Court ruled that the Affordable Care Act and its individual mandate
are constitutional. How do you foresee that this ruling will impact the
growth of collaborative care models?
Kavita Patel: The Supreme Court's
decision today reaffirmed that now more than ever, we need to spend less time
debating the merits of a mandate and more time doing the hard work- putting
together models of care that are truly collaborative and finding financial
incentives that help to show providers that they can deliver collaborative care
and have income security. For patients, the decision today will help them
look for collaborative models of care when they are trying to purchase a health
insurance plan that is both affordable and truly patient-centered.
CFHA: Each year at the CFHA conference, clinical
leaders and policy makers convene a 1-day summit to advance collaborative care
policy in the host state. As our 2014 conference will be in Washington
DC, it will be our first opportunity to host a national summit. If you
were chairing the DC planning committee, what would be your vision for the
Kavita Patel: I believe that the
vision for 2014 is about truly bringing the dialogue around collaborative care
into the national forefront. This means
that we will need to better illustrate how collaborative care is superior to
care in silos (not that difficult to do).
But also, demonstrate the spillover effect into other aspects of health—well-being,
workplace productivity, decreased social isolation/loneliness and ultimately
upward mobility. Now we may not have all the research to support these
claims that I am making or hypothesizing, but if we can think beyond our
traditional borders and stretch ourselves in ways that might really make us
even uncomfortable at times, than we are really making a contribution. I think
that is very worthy of Washington D.C.
The other pitch I would make is for
the CFHA to invite the policy leaders from the various sectors that
collaborative health care touches and put them on a stage and ask them to
figure out how they could redefine policies to better facilitate collaborative
care. So for example, how can folks from Medicare sit on stage with people from
the NIMH and SAMHSA and really honestly address barriers, suspend judgment and
find a path forward to accelerate these models.
CFHA: Does the production of quality
research that supports collaborative care as a best-practice actually help to
move policy? Or, does momentum to change policy come mostly from other sources
Kavita Patel: High quality
research does matter but the momentum to change policy really comes from being
strategic about utilizing research to support the policy change along with
providing policymakers with a sense of how such a policy change will meet their
short term and long term needs. For example, a pressing issue for federal
policymakers is the role of dealing withburgeoning state budgets- the
states of Illinois and Maine recently had their bond ratings downgraded by
Moody's which is devastating for states. Since they can't run a deficit and a
downgrade in a bond rating makes it difficult to borrow money for capital
investments, etc. In downgrading the states' ratings, analysts cited Medicaid
costs as a principal issue. So how can research support the notion that collaborative
care models will help to address growing state Medicaid costs? The answer might
provide the momentum for a policymaker or elected official to take action when
they otherwise might not express interest.
CFHA: As a practicing primary care
internist, what role does collaborative care play in your clinical
setting? What do you see as the obstacles to expanding collaborative care
in your practice?
Kavita Patel: I practice in a
pretty traditional fee-for-service setting.
The truth is that we don’t really practice collaborative care as a group,
but I try to do it in piecemeal. It is
frustrating. I desperately would love to see our country make bold
statements such as the following: "We will only accept care that is
collaborative in both design and in practice”, but unfortunately most of our
financial incentives do not reward such behavior.
CFHA: At the 2011 CFHA conference
you and Frank deGruy presented a plenary session on developing collaborative
care policy "From Grass Roots to Tree Tops". A frustration for
front-line clinicians is that they can see how policies that promote siloed
care and prevent funding integration have direct impact on the viability of
their careers. What do you recommend that a front-line clinician do to
promote policy change at a local or state level?
Kavita Patel: The key is to not get frustrated: persistence pays. Think about the
patients and their families who need this. That will keep you motivated to follow
these 6 steps:
- Think of all the changes you
would need to deliver collaborative care (change in payment, health IT changes,
- Now think of which policy
elements are the LEAST difficult - what would not cost a lot or take an act of
- Write down in 2 pages or less
what you need a policymaker to do and if possible, add in some cost measure.
- Get some of your fellow
practitioners to support your efforts.
- Set up a meeting with the most
likely policymaker who will listen to you.
This may be a pretty junior person, but still the most important quality
is to take you seriously.
- When you meet with her or him,
offer to help with technical support (changing or revising language) as well as
offer names of other practitioners who will be voices of support.
CFHA: Thank you, Dr Patel, for offering some of your valuable time on this notable day!
|Kavita Patel is a fellow in the Economic Studies program and managing
director for clinical transformation and delivery at the Engelberg
Center for Health Care Reform. Dr. Patel is also a practicing primary
care internist at Johns Hopkins Medicine and served in the Obama
administration as director of policy for the Office of Intergovernmental
Affairs and Public Engagement in the White House. She partnered with Dr Frank deGruy to offer the policy keynote address at CFHA's 2011 conference in Philadelphia, PA.|
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Posted By Randall Reitz and Alicia Hardy,
Thursday, June 21, 2012
Updated: Monday, June 25, 2012
| Comments (2)
The DSM and CPT manuals are collaborative care's big books of unhappiness.
In his controversial work, Warning: Psychiatry may be Hazardous to Your Mental Health, William Glasser states: "A more accurate title for the DSM-4 would be the ‘Big Red Book of Unhappiness’”. In nowhere is this more evident than in collaborative care.
Each October the American Medical Association releases a new edition of Current Procedural Terminology. Because most insurances bill based on this book, it is highly influential in the maintenance of a fee-for-service system and in setting the fees for the services. A fee-for-service system based on CPT billing will always leave collaborative clinicians unhappy.
Why do we have no love for the DSM and CPT? Because, simply put, these volumes are endemic of why collaborative care has made little progress in the for-profit mainstream of healthcare. And, if left unchecked, a CPT and DSM approach to healthcare will eventually bankrupt the entire system.
CPT codes seem innocent enough. Clinicians use them every day with most every patient. If you’re a medical or nursing provider you bill a 99212, 99213, 99214, or 99215 depending on the complexity of the visit. Behavioral health clinicians have a similar CPT system: 90804s, 90806s, etc. There are a number of inter-related problems with a CPT approach.
|First, a fee for service system puts nearly zero onus on the provider of care to ensure that the care was relevant or of quality in nature. The bottom line in a CPT system is extracting profit from patients (and the larger) system, rather than a bottom line of improving health for people and communities. The best indictment of this system was offered by Atul Gawande in his New Yorker article "The Cost Conundrum” (yes, the one with a patient in a hospital gown made up to look like an ATM machine). In this article Gawande compares cities in the US that have the highest cost per patient with those with the lowest costs per patient. In brief, here is how he describes the difference for a hypothetical patient:
"The damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue. There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?
As Gawande asserts, our CPT-based system is indeed falling apart, both because it is fee-for-service, and because it lacks a collaborative, team-based focus. What does a cost-efficient collaborative system look like? Gawande compares one of the lowest cost healthcare regions in the United States (Grand Junction, CO) with the most expensive (McAllen, TX):
McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering.
|Gawande provides another example of a collaborative healthcare system in his "Hotspotters” article (yes, the one with a patient bandaged head to toe with a $3.5 million price tag looped around his neck). The creator of the Hotspotter model, Dr Jeff Brenner was the keynote speaker at the 2011 CFHA conference in Philadelphia. This approach uses aggressive care coordination, case management, and patient engagement techniques to induce the $3.5 million patients out of the hospital and into integrated primary care settings. This healthcare system survives entirely outside of the CPT world. Yes, doctors might bill an occasional insurance code to help defray some costs, but very few insurances currently pay for the CPT codes for case management and behavioral disease management that are at the core of promoting health and saving costs.
The Diagnostic and Statistical Manual of Mental Disorders is a reference book for psychiatric conditions and their diagnostic criteria. It grew out of the Statistical Manual for the Use of Institutions for the Insane which listed 22 forms of psychosis, paralysis, melancholia, dementia, neurosis, and the positive psychology predecessor, "Not Insane”. Over time the number of diagnoses has multiplied and the diagnostic criteria have become more precise. For example, since the DSM-3, the manual has not included homosexuality as a psychiatric condition, and the DSM-5 will not include Asperger’s Syndrome. However, early drafts of the DSM-5 have included a number of examples of new diagnoses that pathologize behavior, such as internet addiction, family behavioral patterns, and grief.
Beginning with the DSM-3, the APA has intentionally moved the allegiances and influence of the tome away from Freudian psychoanalysis toward the pharmaceutical industry. In the words of APA’s 2011 President, Carol Bernstein: "It became necessary in the 1970’s to facilitate diagnostic agreement among clinicians, scientists, and regulatory authorities given the need to match patients with newly emerging pharmacologic treatments.” *
The lasting effect of this switch has been to medicalize stressors and symptoms and promote psychopharmaceuticals as the preferred treatment. Marcia Angell provides an excellent overview of the DSM-5 process that is very relevant to collaborative care and inspired much of this information. She describes the short-comings of medically-focused treatments to life ailments as follows:
"Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology. And drug companies have every interest in inducing psychiatrists to do just that.”
The APA allows the pharmacy industry direct influence on the process of identifying new psychiatric disorders and in defining their diagnostic criteria. For example, the head of the DSM-5 task force, David Kupfer self-reports to having served on advisory boards and/or receiving consulting fees from 5 pharmaceutical companies: Eli Lilly, Forest, Solvay/Wyeth, Johnson & Johnson, and Servier and Lundbeck. Under his leadership, DSM-5 task force members are allowed to maintain their positions while continuing to receive up to $10,000 per year from pharmacy companies and to hold up to $50,000 in pharmacy stock. Not all task-force members do report industry ties, but for the DSM-4 every single member of the groups overseeing the important mood and psychosis sections did.** Similarly, in states like Minnesota and Vermont, which require pharmacy companies to report payments to physicians, psychiatry is consistently the top payment receiving specialty.
How does industry influence on the DSM affect collaborative care? As described earlier, it has a direct influence on which services are reimbursed, which directly influences the services that are offered. Angell described the connection as follows:
"At the very least, we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent. In particular, we need to rethink the care of troubled children. Here the problem is often troubled families in troubled circumstances. Treatment directed at these environmental conditions…should be studied and compared with drug treatment. In the long run, such alternatives would probably be less expensive. Our reliance on psychoactive drugs, seemingly for all of life’s discontents, tends to close off other options. In view of the risks and questionable long-term effectiveness of drugs, we need to do better. Above all, we should remember the time-honored medical dictum: first, do no harm (primum non nocere).”
If a key mission of collaborative care is to increase access to systemic and behavior modification therapies in primary care settings, the DSM system fights directly against this mission. As there is no industry money to support collaborative care, the model is left to fend for itself.
This also affects the research that is published to create the empirical basis for collaborative care. While drug trials are ubiquitous, there are very few strong clinical trials for collaborative care published in top-tier journals. And, those that exist (IMPACT, DIAMOND, etc) place a strong emphasis on pharmaceutical care management along with integrated behavioral health services.
The DSM also poses a number of operational obstacles for practicing collaborative care: Do behavioral health clinicians in collaborative primary care settings have the luxury of time to complete full diagnostic assessments? Behavioral clinicians often only meet patients for 15-30 minutes. And, as was pointed out in a recent CFHA Blog post, many of us feel overwhelmed by the plethora of brief mental health screens at our fingertips, let alone the prospect of leafing through this behemoth of diagnostic classifications. And yet, at the end of the visit, the empty box for the diagnostic code is there, staring us down, waiting to be entered.
In preparing for this blog post, we spoke with many collaborative care behavioral health clinicians. Many described the DSM as an "imperative” tool; one that assists the clinician in conceptualizing the case, formulating a diagnostic overview, and determining a direction for treatment. Perhaps. Certainly the usefulness of the DSM is clearer in the arenas of specialty mental health, long-term psychotherapy and psychiatry. In primary care? The answer is much less clear.
Our current CPT code system essentially necessitates utilization of the DSM given that a psychiatric diagnosis is required to receive reimbursement for behavioral health care. In 15-30 minute visits, how accurately can a clinician be expected to diagnose a patient, verifying that all DSM criteria are met? One might question how frequently patients are mislabeled with mental health diagnoses that "mostly fit” criteria. We believe that most clinicians try to be as conscientious as possible, and avoid using a diagnostic code when time constraints do not permit a complete evaluation. The result? Thousands (tens of thousands?) of patients circulating through primary care with "anxiety NOS” or "depression NOS”. The NOS label creates a loophole of sorts for primary care. When NOS is listed on a patient’s chart (which is often), rather than reading "not otherwise specified” it more likely means "not enough time, but I want to get paid”.
Requirements of DSM based diagnoses also shift the focus away from prevention, which is a defining element of a population-based, primary care model. A preventative focus would include those patients with unhealthy behaviors, psychosocial stress, poor compliance with their medical treatment. Many of these patients do not meet criteria for a DSM diagnosis. They could be given a v-code, which manages the risk of over-pathologizing and labeling patients, but this does not solve the problem of reimbursement. The way our system is now, it discourages early intervention and preventative care, and rewards (financially) the treatment of those with established mental illness. The underlying message is that if we delay treatment until patients are sick, we can then give them a DSM diagnoses which thereby will help financially sustain our clinics. This simply does not fit with the primary care model.
We do not propose extracting the DSM from primary care completely. It does have its usefulness in providing a framework for complex cases. We do propose, however, that it become viewed as one of many clinical tools that are completely disconnected from reimbursement. Clinicians should not be forced to continually choose between accurately diagnosing a patient according to full DSM criteria, or giving them the information and brief intervention that he or she needs in 15 minutes.
The DSM does have a place in primary care, but right now it is in the wrong place. The right place is on a clinician’s bookshelf, blissfully ignorant of any and all requirements for financial reimbursement. As a clinical tool, it can be useful (at times). But, in the fast-based, prevention focused model of primary care behavioral health, there are definitely many days in which we could do our jobs without ever cracking it open.
In an earlier post on the CFHA Blog, it was observed that the growth of collaborative care has been blunted by our lack of a theme song to rally our sagging hearts. Fortunately, the theme song for the charge against the big books of unhappiness is obvious:
You down with CPT?
Nah, you know me.
You down with CPT?
Nah, you know me.
You down with DSM?
Nah, don’t need ‘em.
You down with DSM?
Nah, don’t need ‘em.
Repeat chorus until healthcare reform renders the song obsolete.
*Carol A. Bernstein, "Meta-Structure in DSM-5 Process," Psychiatric News , March 4, 2011
**Financial Ties Between DSM-IV Panel Members and the Pharmaceutical Industry," Psychotherapy and Psychosomatics , Vol. 75 (2006).
Randall Reitz, PhD is the Director of Social Media for the Collaborative Family Healthcare Association and the Director of Behavioral Sciences for the St Mary's Family Medicine Residency. He writes CFHA's CollaboBlog.
Alicia Hardy, LCSW is a Licensed Clinical Social Worker and Behavioral Health Consultant at Clinic Ole in Napa, California. She earned her Master’s degree in social welfare from UC Berkeley. Clinic Ole is a federally qualified health center that provides integrated primary behavioral health care to the underserved and uninsured members of the Napa community, which includes a large percentage of monolingual Spanish-speaking patients. Alicia provides direct clinical services as well as managing the clinic’s Behavioral Health Department.
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Posted By Ajantha Jayabarathan,
Thursday, June 14, 2012
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"If necessity is the mother of invention, then adversity must be
one of the fathers….”
In the early 1990s,
there was the widespread recognition at the grass roots that mental illness and
addictions greatly contributed to human suffering. This was evident in
communities, in the workplace, in family doctors offices, during inpatient and outpatient visits at
hospitals and in long term care facilities. And everyone did their best within
the existing system of health care. When issues were identified, a referral for
consultation with mental health professionals, private or publicly funded,
was usually arranged and the process was no different than being sent to a
cardiologist for issues identified with the cardiovascular system.
However, there was
something very different about seeking and receiving care when it involved
mental health and addictions. I believe many people, their families, health
care providers and managers of health services were aware of a myriad of issues
that contributed to this difference, and the complexity of the problems were
However, all journeys start with the first steps, and in Canada,
the formalizing of what came to be called "Shared Mental Health care” embodied
these initial incremental efforts. Family Doctors in rural communities and
smaller centers have long managed complex medical issues through "shared care”
with specialists. The process involved "getting to know one another” at doctors
lounges or during minor league baseball. Smaller communities lend themselves to
more opportunities to meet and greater ease of networking resulting in
partnerships that grow over time and through shared experiences.
A small group of
psychiatrists and family doctors in Toronto, Ontario started to experiment with
the idea of psychiatrists coming to the family doctors office for an afternoon
to help deal with issues rather than the traditional referral letter arriving
in their mail. It became evident that this simple change was yielding great
benefits to the doctors and their patients.
Dr. Nick Kates and Dr.
Marilyn Craven , approached their National organizations, the Canadian
Psychiatric Association and the College of Family Physicians of Canada, and
presented this model to them. This resulted not only in these two professional organizations deciding to form a working group to develop this model further
but also brought individuals with a systems level view to the table. The group
was influenced by Global initiatives such as the
of Alma-Ata" in 1978,
for All by 2000”, which emphasizes the role of primary care,
- "World Development Report 1993: Investing
in Health" which emphasized concentrating on economic benefits of "single
item” interventions, and
- "The World Health
Report 2008 − Primary Health Care: Now More Than Ever".
A literature review of
Shared mental health care/ Collaborative care practices was completed by Drs.
Roger Bland and Marilyn Craven and was an important milestone as well as a
foundational piece for the future directions of this journey.
What ensued in the
next ten years was a rapid acceleration of this journey.
The first position
paper , "Shared Mental Health Care in Canada” was published in 1997 and
generated widespread interest and awareness of this model. Canada’s Primary
Care Reform was underway in the early 2000s and provided two Federal grants
that funded shared mental health care pilot projects across
the country and the development of the Canadian Collaborative Mental Health
. CCMHI developed Collaborative care
toolkits and a charter that expanded this model to include people and their
families, nurses, pharmacists, dieticians, occupational therapists, social
workers and psychologists. Annual provincial conferences on Shared mental
health care were held which invited presentations from groups that had
implemented these models in their clinical settings and placed a focus on
evaluation, research and knowledge exchange in this area.
funding-incentives promoting collaborative networks of practice and learning
gave system level support to this model across the country.
The Canadian Armed
Force Initiative, RX 2000 considered this model for their strategic planning.
The Canadian Medical Protective Association acknowledged collaborative models
of medical practice in support of practitioners who were now working
differently within these emerging initiatives.
An important milestone
was achieved when the Royal College of Physicians and Surgeons of Canada
adopted training guidelines for psychiatry residents in Collaborative mental
At this time, the
Federal government had formed the Mental Health Commission of Canada to develop
a Mental Health Strategy for the country. The establishment of CHEER in 2011 ( Collaborative Healthcare
exchange, evaluation & research) within the framework of the national
strategy heralded the widespread recognition of the merits and value of this
model of care at all levels of the system of health care. Dr. Nick Kates and
Dr. Francine Lemire from the Canadian Psychiatric Association and the College
of Family Physicians of Canada are the Co-chairs of CHEER.
The Mental Health Strategy for
Directions, Changing lives, was just released in May
2012. The six strategic directions in the strategy aim to transform the system
of health services by integrating mental health and addictions related services
from the grass roots of health promotion to management of chronic and severe
mental illness and addictions across the lifespan of humans. It extends the
expectation that the needs of families, communities and workplaces must be
considered and supported as this journey of change transforms us individually
The timing of the 12th
Collaborative Mental Health Conference held in Halifax during June of 2011 was
such that several of these major developments were incorporated into the
content and presentations at the conference. During this time, the Minister of
Health and Wellness, Maureen MacDonald, with her grass roots experience as a
social worker, was resolved to develop a provincial mental health and
addictions strategy to address the complex myriad of difficulties in providing
and receiving mental health and addictions care in Nova Scotia.
She selected an advisory committee of
diverse members to develop recommendations for the provincial strategy. The
committee held consultations across the province, studied existing literature
and commissioned reports to better understand and identify gaps in the current
system. "Come Together", was the culmination of over two
years of work and had 61 recommendations intended to snap together to address
the complex gaps identified. It called for a cross jurisdictional approach
within government and the districts within the province, reducing
inefficiencies and waste of resources, strategic investment of new funds to
develop early detection and management of issues within primary care, within
families, school, communities and workplaces.
Collaborative care was presented as
a means by which meaningful partnerships and working relationships could be
forged in addressing system wide, deep seated issues that urgently needed
change. The response from the government was to accept all the committee's recommendations . In "Together We Can”,
Nova Scotia has started its own journey towards health and wellness through
collaborative care based processes that are intended to lead to improved access
to high quality care that is sustainable for our province.
And as I write the final words of
this article, we are poised to release the recorded content from the ground
breaking Collaborative Mental Health Care conference held in Halifax in June
2011, to a global audience. You are welcome to go to www.shared-care.ca,
and follow the links to the "First Online Collaborative Mental Health care
conference”. The content is sure to inform and inspire you!
This journey started due to
necessity and as expected has met much adversity along with way. It has known
the sweetness of success as well as the bitterness of initiatives that have
gone awry. We have all continued to learn through engagement in this journey
and the evolution of Collaborative care itself has been a rewarding process to
shape and observe. And…what a ride it has been to get to the tipping point of
|Dr "AJ" Jayabarathan is a family physician in Halifax. |
She was recently awarded Nova Scotia College of Family Physicians 2012 Award of Excellence for her advocacy for "Excellence in Advocating for Accessible Quality Mental Health Care for All Nova Scotians".
AJ will present a plenary session at CFHA's October 4-6, 2012 Conference in Austin, TX. She is a regular blogger with CFHA, including posts here, here, and here.
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Posted By Benjamin Miller,
Thursday, June 7, 2012
| Comments (2)
just about any decision is possible from the Supreme Court, 1 of 3 outcomes is
Uphold the entire law,
Uphold the law except the individual mandate,
Strike the entire law.
are the collaborative care ramifications for each?
1) SCOTUS Upholds the
Entire Law. For proponents of
collaborative care, there is a lot to love about PPACA. First we have the
wondrous notion of health insurance expansion. For anyone who has worked in
primary care, one of the biggest psychosocial barriers many of our patients
face is that of not having health insurance that can help cover services
whether they are physical health or mental health. Second, we have the issue of
access that comes along with coverage. If more patients have access to
services, there is an increased likelihood that more patients can be seen in
collaborative care settings. While there are other provisions of PPACA that
address "integration” of behavioral health (section 5604 and 2703 as an
example), it is not likely that the SCOTUS decision will impact these as it
does the coverage and access issue.
2) SCOTUS Strikes the Individual
interesting is that Massachusetts,
the "canary in the coal mine" for much of what we are seeing unfold
nationally with health reform is doing quite well with healthcare. First,
residents of the Commonwealth are quite supportive of the Massachusetts individual
mandate law. Jonathan
Cohn has written extensively about Massachusetts
and the mandate before. One key point he makes is that the individual mandate
would likely have less of an impact on folks than most people are aware:
"Perhaps more important, the mandate didn’t actually change life
for most people in Massachusetts,
at least in ways they could perceive. Most people already had insurance that
satisfied the requirement. And while nationally the proportion of people with
insurance is lower than it has been in Massachusetts,
overall the same basic truth holds: The majority of people already have
insurance that would satisfy the mandate."
"The vast majority of Americans already gets insurance from their
employers, Medicaid, Medicare, the individual market, or other sources of
coverage, and will essentially automatically comply with the mandate once it
goes into effect in 2014. The Congressional Budget Office (CBO)projects
that about 80% of the 272 million non-elderly people in 2014 would be insured
even in the absence of the ACA and would therefore already fulfill the
much of what we hear in the media about the individual mandate is noise. Since
this is the most "controversial" piece of the legislation before
SCOTUS, let's just pretend that this piece of the legislation is "struck
down," what will we do? What will this mean? I would encourage those
interested to read the brilliant post by Sarah
Kliff and Ezra Klein from the Washington Post on this topic.
3) SCOTUS Strikes the
Entire Law. Let
me be somewhat controversial for a second and posit that even without PPACA,
the good work happening on the ground, the innovation, will continue
regardless. Let's be honest, even with a fully supported (financially and
politically) PPACA (including the mandate), there are still major hurdles that
must be addresses in healthcare. Does PPACA truly defragment healthcare and
make it the system we all want? Not really, but it does help.
demonstrate my point, let me offer a case study on behavioral health.
written about extensively before, the separation
of behavioral health from the larger healthcare system is an inefficient and often
ineffective model of comprehensive healthcare. Despite decades worth of research highlighting this
inseparability, we still have a bifurcated system (mental/physical) that has a
tough time taking care of the whole person. Policy barriers, primarily
financial policies, make sustaining integration efforts a challenging
proposition; however, integration efforts do not stop just because policy has
not changed to accommodate their innovation.
Health's Integration Program
Behavioral Health Project
Advancing Care Together practices
Alaska's Southcentral Foundation
the list goes on and on. Despite policies that may make their integration
efforts challenging, they keep going.
we think about the implications of major policy decisions on much of our work,
sometimes these decisions help and sometimes they hurt our efforts; regardless
of the decision, practices in our communities continue to innovate.
innovation can be defined as "the intentional introduction and application
within a role, group, or organisation, of ideas, processes, products or
procedures, new to the relevant unit of adoption, designed to significantly
benefit the individual, the group, or wider society."
policies can support or hinder the adoption of these innovations, the benefits
that the community receives far outweighs whether or not it is supported by
someone, somewhere in healthcare policy land.
behavioral health and healthcare is a truly unique opportunity to demonstrate
as well as influence
such important policy issues like the "triple
let's imagine that next week SCOTUS knocks down PPACA in its entirety. What
will we do? Will we hide away worried that policy is no longer in our favor?
Will we decide that all our efforts are for naught?
answer is simple: No! We will do what we must to continue to create a high
performing and effective system we all deserve. Regardless of the ruling, you
cannot stop the innovation in our communities. We will wake up, have our
coffee, see the outcome of the decision and continue going back into the
trenches working towards a comprehensive whole person system. We will see this
ruling as just another bump in the road and keep on moving towards change.
towards change and continued innovation!
is the President of CFHA and hosts the CFHA Game On blog. He is also the founder of the Occupy Healtcare movement. He is an Assistant Professor in the
Department of Family Medicine at the University of Colorado Denver School of Medicine where
he is responsible for integrating mental health across all three of the
Department’s core mission areas: clinical, education, and research.|
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Posted By Cheryl Holt,
Thursday, May 31, 2012
| Comments (0)
Most posts on the CFHA Blog describe integration into primary care settings. Many of these services are provided through collaboration with the community behavioral health center. Or, in some communities the integration happens in reverse, by integrating primary care services into the existing community behavioral health center. This blog examines integrated care from the perspective of the community behavioral health center.
Of the many challenges in integrating primary care services into behavioral health organizations, the one that garners the most apprehension and concern is sustainability. It is also the most frequent reason for hesitation in moving forward. Healthcare is not set up to address this. Primary care and behavioral health have different billing codes with no easily decipherable means of venturing outside the confines to include payment for integrated services. The mere thought of the process required to begin to tear down the barriers separating the two worlds strikes fear in the hearts of the most courageous administrators.
Healthcare administrators are presented with conflicting demands and are struggling to reconcile the next step. They can:
- Ignore the ever increasing focus on healthcare integration and hope it is just another passing fad; or
- Place even more burden on the ever-shrinking budgets and hope for the best.
Let’s take a closer look at the options:
Ignoring healthcare integration seems like the easiest solution. Behavioral health administrators can align themselves with like-minded peers creating a support group who reinforces the notion that it will all just fade away if they merely wait it out. This group gets considerable pleasure in observing the early adopters from a distance, filled with certainty that these risk-takers are all making huge mistakes. They pat themselves on the back encouragingly as they watch their naïve peers make the occasional fumble, while attributing any successes they might have to sheer (unsustainable) luck.
Over-burdening the current budget seems to be irresponsible. Behavioral health administrators have been faced with budget cuts in unprecedented amounts over the past few years. While they have either become masters at doing more with less or have chosen to leave the field entirely, taking on a new business-line during the increasing uncertainty of their organizations’ financial states seems to be overly risky and counterintuitive.
Yet the pressure is on.
Nationally, more and more behavioral health conferences are featuring healthcare integration tracks. The same is becoming true of primary care conferences and conventions as well. With more and more research and reports being released that provide the necessary data to support the need for integration, it’s becoming more and more difficult to write it off as a passing fad. The recent report from the SAMHSA-sponsored, National Survey on Drug Use and Health, Physical Health Conditions among Adults with Mental Illnesses provides further evidence supporting earlier reports demonstrating the need for integration.
The current model of providing behavioral healthcare may be on its way to becoming obsolete. Now is the time for behavioral healthcare administrators to begin the discussion of how to address the whole-health needs of the people they serve. Whether through collaborative partnership agreements or bi-directional integration with primary care organizations, or hiring primary care staff for expanding to fully integrated services, this issue can no longer be ignored. There are many changes that can be implemented right away (focusing on billing codes and maximizing billing opportunities) while others will require advocating changes at the state and federal level. (Click here for helpful billing tools created by the SAMHSA-HRSA Center for Integrated Health Solutions.) Daunting though this may seem, the climate is right for these discussions with your state Medicaid and behavioral health offices. They are faced with the task of making the necessary changes to move into the new era of healthcare integration. Strategically, it’s far better to be a part of discussions on creating this new structure than to have it imposed on your organizations. The Georgia Association of Community Services Boards has partnered with the Carter Center to create a forum for change in Georgia via their Integrative Healthcare Learning Collaborative. Not only have they included the public behavioral health providers and their primary care partners, they also have representation from the Georgia Primary Care Association and area medical schools. They recognize that in order to develop sustainable programs everyone must be at the table.
Let’s not lose sight of the goal: we must work together to make a difference in improving health outcomes of the people we serve. We CAN ensure that the margin is there to continue the mission. Be a part of the solution!
What are your strategies for sustaining healthcare integration?
I'd love to hear from you. Please enter your comments/suggestions/ideas below or email: firstname.lastname@example.org.
Cheryl Holt, MA, NCP, BCCP
currently serves as the Director of Training and Technical Assistance
with SAMHSA-HRSA Center for Integrated Health Solutions for the National
Council for Community Behavioral Healthcare. She is moderator of the
Behavioral Health – Primary Care Integration Listserv, manages the
Behavioral Health Integration blog, and is active in social media:
Twitter, @cherylholt and @BHPCIntegration; and Facebook, Behavioral
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