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Ch-ch-ch-changes

Posted By Lisa Zak-Hunter, Thursday, August 9, 2012
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 baby, new office furniture.

An intersection of motherhood and work:

New baby, 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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Requiem for Family Medicine

Posted By Paul D. Simmons, Thursday, August 2, 2012
Family 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.

As 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 physicians.
Paul D. Simmons
Our support for the Patient-Centered Medical Home (PCMH) model, while predicated on admirable ideals, could easily be speeding our demise.

Sadly, 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.

Even 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 well?

The 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).

Our 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, simplifying fact.

While 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.

REFERENCES:

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 from http://blogs.aafp.org/cfr/leadervoices/entry/changing_training_standards_for_maternity.

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.

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My Trip to the Doc

Posted By Peter Fifield, Thursday, July 26, 2012

My 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 return.

I 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.

After "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.

After "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 wahwah wah”

 

It 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?

I 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!

Please 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?

Then 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.

This 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 different, experiences.

Using 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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Build Your Cathedral

Posted By Randall Reitz, Thursday, July 19, 2012

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 cathedral.

Devil's Kitchen in Grand Junction, CO
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 countries.

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.

To build!

 

Randall Reitz
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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Ten strategic considerations of the Supreme Court upholding PPACA

Posted By Invited Blog Post from Milliman Inc., Thursday, July 12, 2012

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 so.

In this article, we outline 10 strategic considerations for insurers, employers, providers, taxpayers, and the government.

Background

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.

As 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

  1. 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.
  2. 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 Consideration #2...

  3. 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.
  4. 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 and 2014?

    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.

  5. 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.
  6. 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?

  7. 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 coverage.
  8. 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.
  9. 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 already proceeding?
  10. 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.

  11. 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.
  12. 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.

  13. 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.
  14. 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 factors.

  15. 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
  16. 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

  17. 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.
  18. 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.

6See http://www.healthcaretownhall.com/?p=3060.

7See http://www.healthcaretownhall.com/?tag=risk-adjustment.

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.

11Proebsting, D. (June 2010). Why Hospital Cost Shifting Is No Longer a Viable Strategy. Milliman Healthcare Reform Briefing Paper. Retrieved June 20, 2012, from http://publications.milliman.com/publications/healthreform/pdfs/why-hospital-cost-shifting.pdf.

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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Kavita Patel Answers 5 Questions on the Supreme Court Decision and Collaborative Care

Posted By Kavita Patel, Thursday, June 28, 2012

Collaborative Care Policy Month

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 national summit?

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 and efforts?

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:

  1. Think of all the changes you would need to deliver collaborative care (change in payment, health IT changes, etc).
  2. Now think of which policy elements are the LEAST difficult - what would not cost a lot or take an act of congress.
  3. Write down in 2 pages or less what you need a policymaker to do and if possible, add in some cost measure.
  4. Get some of your fellow practitioners to support your efforts.
  5. 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.
  6. 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
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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The Big Books of Unhappiness

Posted By Randall Reitz and Alicia Hardy, Thursday, June 21, 2012
Updated: Monday, June 25, 2012

Collaborative Care Policy Month

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

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: Gawande's Cost Conundrum
 

"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.


DSM

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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Changing Directions, Changing Lives: Canada Launches a National Mental Health Strategy

Posted By Ajantha Jayabarathan, Thursday, June 14, 2012

Collaborative Care Policy Month

"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 daunting.

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

  • "Declaration of Alma-Ata" in 1978,
  • "Health 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 Initiative (http://www.ccmhi.ca/) . 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.

Provincial 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 health care

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 Canada, Changing 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 and collectively.

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 this transformation!

 

 


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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Potential Ramifications of the Supreme Court’s Ruling on the Accountable Care Act

Posted By Benjamin Miller, Thursday, June 7, 2012

Collaborative Care Policy Month

It's impossible to avoid all the politics in the news surrounding the Patient-Protection and Affordable Care Act. Since its 2010 passage, we have had political parties fighting to maintain and to repeal the law. And now, we have the Supreme Court of the United States (SCOTUS) currently deliberating whether the entire law or the individual mandate are constitutional.

While just about any decision is possible from the Supreme Court, 1 of 3 outcomes is likely:

   1. Uphold the entire law,

   2. Uphold the law except the individual mandate,

   3. Strike the entire law.

What 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 Mandate. What's 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."

From the Kaiser Family Foundation:

"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 mandate’s requirement."

So 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.

To demonstrate my point, let me offer a case study on behavioral health.

As we have 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.

Take for example:

Cherokee Health Systems

Maine Health's Integration Program

California's Integrated Behavioral Health Project

Colorado's Advancing Care Together practices

Alaska's Southcentral Foundation

And the list goes on and on. Despite policies that may make their integration efforts challenging, they keep going.

When 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.

According to West et al. 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."

While 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.

Integrating behavioral health and healthcare is a truly unique opportunity to demonstrate the power of teams as well as influence such important policy issues like the "triple aim."

So 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?

The 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.

Onward, towards change and continued innovation!

 

Ben Miller
Ben Miller 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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No Margin No Mission: Sustainability in Behavioral Health – Primary Care Integration

Posted By Cheryl Holt, Thursday, May 31, 2012
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:

  1. Ignore the ever increasing focus on healthcare integration and hope it is just another passing fad; or
  2. 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: behavioralhealthintegration@gmail.com.

 

Cheryl Holt

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 Health Integration

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What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.