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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.


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 and

1Snook, T. & Harris, R. (October 2009). Adverse Selection and the Individual Mandate. Milliman Health Reform Briefing Paper. Retrieved May 24, 2012, from

2Houchens, P. (March 2012). Measuring the Strength of the Individual Mandate. Milliman Research Report. Retrieved May 24, 2012, from

3Ge, J. (June 2012). Health insurance exchanges and early retiree health coverage. Milliman Benefits Perspectives. Retrieved June 16, 2012, from

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

5Burke, J. & Pipich, R. (April 2008). Consumer-Driven Impact Study. Milliman Research Report. Retrieved May 24, 2012, from



8Families USA (2009). Hidden Health Tax: Americans Pay a Premium. Retrieved June 16, 2012, from

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

10Pyenson, B. et al. (March 18, 2010). High Value for Hospital Care: High Value for All? Milliman Client Report. Retrieved June 20, 2012, from

11Proebsting, D. (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

13Parke, R. & Fitch, K. (October 13, 2009). Accountable care organizations: The new provider model? Milliman Insight. Retrieved May 24, 2012, from

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

15Boyarsky, V. et al. (April 22, 2011). ACOs Beyond Medicare. Milliman Healthcare Reform Briefing Paper. Retrieved May 24, 2012, from


 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

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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 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.


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 ( . 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, 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:


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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Changing our Thinking about Changing our Patients

Posted By Suzanne Bailey, Thursday, May 24, 2012
Poor treatment adherence is a systemic problem. It impedes treatment outcomes, complicates treatment planning, and frustrates providers. I have yet to meet a healthcare provider who entered the field to argue with their patients, but I have met many passionate providers who are frustrated with the seemingly apathetic responses of seriously ill patients. A primary care colleague recently commented regarding a mutual patient with a history of nonadherence with his diabetic treatment regimen, "I have told him a thousand times. He just doesn’t care.”

The management of most chronic conditions requires behavior change. However, patients often underestimate their ability to modify their lifestyle and positively impact their health status. Instead, they expect their visit to the doctor to result in a prescribed treatment or medication that will cure their condition or at least alleviate their symptoms. Thus, when the prescribed treatment involves behavior change, resistance is often created. "I have pain every day and you are telling me to exercise and eat healthily?”

Prochaska and DiClemente (1984) described a model of assessing patients’ readiness to change and tailoring interventions to enhance patients’ willingness and ability to engage in behavior change. As healthcare providers, we are always in the "action” stage. We assess and diagnosis conditions and prescribe behavior change interventions to improve health status.

Suzanne Bailey
Viewing ambivalence as a normal part of the chronic disease process allows us to treat ambivalence as a component of the disease.
 However, our focus on overall health may not be patients’ priority and patients are often not in the "action” stage. Many of us can relate to the patient with an A1C of 13 who wants the focus of their primary care visit to be their back pain. It is difficult to focus this patient on their diabetes in the context of the medical visit, much less encourage them to leave our office and make meaningful lifestyle changes to improve their A1C.

Too often these patients become labeled "difficult patients,” as if something were inherently wrong with the patients. However, viewing ambivalence as a normal part of the chronic disease process allows us to treat ambivalence as a component of the disease. We must accept that we cannot force our patients to change. Rather, we must help our patients decide to engage in behavior change. Motivational Interviewing, a style of interacting with patients developed by Miller and Rollnick (1991), addresses this ambivalence by eliciting motivation to change from the patient through guided conversation.

At Cherokee Health Systems, a FQHC and CMHC with an integrated care model that blends behavioral health and primary care where I work as a Behavioral Health Consultant, we’ve learned that we must change our thinking about changing our patients. We serve a population of largely indigent patients with multifaceted behavioral health, primary care, and social needs who present across the continuum of readiness to change. Thus, we have instituted brief, basic trainings in Motivational Interviewing for our primary care providers. They are, in fact, the gateway to behavior change in an integrated model, either through direct conversation with patients or by "closing the sale” and facilitating a warm hand-off to a Behavioral Health Consultant. In implementing this training, we have learned that brief training can be effective in equipping providers with the skills to motivate patients’ behavior change and reducing provider frustration with "difficult patients.”

As we continue to address ambivalence as part of the chronic disease process and work to motivate behavior change, I am continually reminded that motivation truly is elicited and developed collaboratively in the context of the patient-provider relationship. I recently had a patient explain, "I don’t want to change, I just want to feel better.” There is perhaps no better foundation on which to begin a guided conversation about behavior change.


Suzanne Bailey, Psy.D. is a Licensed Clinical Psychologist and Behavioral Health Consultant at Cherokee Health Systems. She earned her doctorate in Clinical Psychology at Xavier University in Cincinnati, Ohio. Dr. Bailey practices in an integrated primary care clinic at Cherokee Health Systems’ Center City office in downtown Knoxville, TN, which serves a population of primarily indigent, homeless patients. She is the Director of Cherokee Health System’s Intensive Outpatient alcohol and drug Program and Supervisor for Case Management Services.

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Mother's Day Edition: The PHQ-9-Inch Circular Saw

Posted By Randall Reitz, Thursday, May 10, 2012

This Sunday marks my tenth Mother’s Day married to the dynamic Ana Reitz. Thus, it is also the tenth anniversary of when I gave her a 9-inch circular saw as a Mother’s Day gift. Now, please save your maternalistic eye rolls for another blog post. She asked for the saw and even picked out the model for purchase.

Unfortunately, as men and their tools go, I am a disorganized wuss. My ownings are scant and strewn amongst a number of broken-down cardboard boxes in the garage. I don’t value them enough to invest in them. I tend to buy them at garage sales and in bargain bins because my children break and lose them along with the rest of their playthings.

As a result, I am often required to make suboptimal usage of the tools I do have accessible at any one time. For example, during spring clean-up this year, I was forced to use my wife’s 9-inch saw to prune trees. As sap smeared the blade and sawdust sprayed my face, I reflected on the PHQ-9. A syllogism quickly formed in my mind:

     9-inch saw : Household cutting :: PHQ-9 : Clinical screening.

If you recently took the GRE, introduced yourself to an integrated care referral, or pruned a tree, I’m sure this logic is readily apparent to you. To the skilled craftsman or contractor, the 9-inch saw is of limited use. It is only helpful for shortening lumber with quick, imprecise cuts. A professional would cry inside to see me use it for pruning, ripping, demolishing, splitting, or chopping (all of which I have done with my wife’s saw).

Rather than investing in a table saw, chain saw, miter saw, hack saw, or ax, I grab the 9.

Such is the PHQ-9 in the integrated care setting. A clinician in a traditional private practice would maintain a fully-stocked tool box of clinical assessments: Becks, GAD-7s, Vanderbilts, Edinburghs, MDQs, OQ45s, Family Environment Scales, genograms, and an assortment of positive psychology screens. Each tool would be closely fit to a specific condition or patient. The tools would provide precise diagnosis and symptom management.

Despite the myriad advantages, I rarely use the other assessment tools. I grab the 9.

Don’t hate me because I’m undutiful.

The PHQ-9 presents numerous advantages in primary care and teaching settings:

  • It is unbeatably easy to take and score—especially when paired with the PHQ-2.
  • Many EMR systems have built-in smart forms that calculate the score, interpret the result, auto-populate the HPI, and track the levels across time like a lab value.
  • Health systems work most efficiently when the operations are kept simple. While I’d love to have nurses giving GAD-7s for patients with anxiety and MDQs for bipolar, that level of sophistication is a fantasy.
  • Integrated care charting is mostly a means of communicating with other members of the primary care team. I prefer to use tools that are familiar to my medical/nursing colleagues.

Our clinic’s experience with the Edinburgh Postnatal Depression Scale and the "PHQ-12” provide compelling reasons for the PHQ-9 hegemony in primary care. The Edinburgh is an excellent depression screen that is more reliable in the pre- and post-partum periods because it teases out the symptom overlap between pregnancy and depression. Before going live on our EMR it was our clinical standard to administer the Edinburgh to OB patients. However, our EMR isn’t hard-wired to easily track and communicate the Edinburgh, so we reverted to using the PHQ-9 instead.

Regarding the "PHQ-12”, I invented it about 10 years ago while at Marillac Clinic.  We were 1 of the first clinics to widely adopt the PHQ-9. Back in the day I noticed that the PHQ-9 and the GAD-7 had an overlap of 4 items and that by adding the extra 3 GAD-7 items to the PHQ-9 we could create a brief screen that gave scores for both depression and anxiety. Many other clinics have adopted it and loved it. I loved it, too, until we adopted the EMR. Because of the way we needed to move the items around on the PHQ-9 to have them line up with GAD-7, it made it much more difficult to enter the scores into the EMR’s PHQ-9 form. So, we reverted to the traditional PHQ-9.

Who knows, maybe in a few years (after we haven’t adopted a new EMR 2 times within 1 residency cycle) I’ll up the bar and re-institute the Edinburgh and PHQ-12 as first steps in reversing the trend of trading precision for convenience. But, for this Mother’s Day, I’m giving all my depressed (and anxious, grieving, and relationally conflicted) patients the PHQ-9-Inch Circular Saw.

Shhh…don’t tell Ana, but I’ve wrapped up a miter saw for Sunday.

9-inch saw 1


9-inch saw 2


9-inch saw 3









Randall Reitz , PhD, LMFT is the Director of Social Media of CFHA and the Director of  Behavioral Science at St Mary’s Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have 3 children: Gabriela, Paolo, and Sofia.  He posts his ideas at CFHA's Collaboblog and tweets at @reitzrandall.

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Welcoming Patients

Posted By Margaret Peterson, Thursday, May 3, 2012

A month or two ago I was accompanied into a consult by a young woman who was training for a new job as a behavioral health consultant at a clinic elsewhere in the city of Philadelphia. The consult was an integrated care visit, which meant that we entered the exam room knowing nothing but the patient’s name and date of birth, and with the agenda being to explore behavioral and psychological factors that might be affecting the patient’s health: diet, exercise, substance use, depression, anxiety, trauma.


The patient was a middle-aged man who turned out to be a rather colorful character—flamboyantly gay, with a long history of polysubstance abuse and a range of other health issues including infection with HIV. He and I were quickly absorbed in conversation about his concerns and his goals for his health, some of which were more conventional (adherence to his medication routine) and some of which were less so (getting back in touch with a "hormone doctor” who had been helpful to him in the past).


Eventually the provider arrived and the consult was over. I left the room with the woman who had been observing me, whose presence I had more or less forgotten about in my focus on the patient. "Well, that was interesting,” I remarked. "It certainly was,” she agreed, fervently. Something in her tone of voice made me realize: she had been a little startled by this patient. Her reaction shed a sudden light upon my own: I had responded to this patient as if he were an old friend.

Margaret Peterson
Every patient needs and deserves welcome and safety, even—perhaps especially—the ones for whom empathy might not come automatically.
Where did this come from? It came, I realized, from my experiences at the Duke University Infectious Diseases Clinic in the early 1990s. My late husband was a patient there, and practically every other patient was a flamboyantly gay man. This was back in the day when there wasn’t much of a welcome mat anywhere for people who were gay or HIV-positive, and one of the things that distinguished the Duke ID clinic was the absolutely unconditional welcome extended to people who were either or both of these.


I was extraordinarily grateful for the care that my husband and I received at the ID clinic. At the same time, it was unnerving to find myself surrounded by the clinic’s other patients, many of whom were (like my recent patient) very colorful characters with complex psychosocial histories, and (superficially, at least) not at all like me. "What on earth am I doing here?” I would think. "How is it that I belong here, in this place, with these people?” It felt like I was normal and they weren’t, and I wanted out.


What I grasped only dimly at the time was that I was no more or less unique an individual than anyone else at the clinic, and the same unconditional welcome that was extended to everyone else was extended to me. There was no comment and no criticism; only curiosity and empathy and a desire to be of help. And it changed me; and one specific way it changed me was to create in me a deep sense of kinship with individuals who (like my recent patient) remind me of the clinic and its patients.


In a broader sense, I find that experience at the Duke ID clinic informing every aspect of my new work in behavioral health. Behavioral health is all about welcoming; it is about creating a safe space in which the patient feels confident that he or she is cared for, and thus feels free to explore issues that may feel overwhelming or scary, whether those have to do with symptoms ("I’m in pain all the time”) or risk factors ("I know I need to quit smoking”) or relationships ("I’ve had so many losses in my family recently”).


Sometimes creating this safe space seems to happen very easily. The other day I entered an exam room to find a woman in her 30s who a few weeks earlier had come in complaining of severe situational stress and anxiety. The doctor had prescribed an anxiolytic and invited her to come back for a followup visit in a month. She hadn’t taken much of the medication, she reported, but she was feeling much better. "That sounds like a big change,” I said. "How has that happened?”


She wasn’t sure. Externally, things were much the same: the job, the kids, the busyness of life. "But I’m not stressing about everything,” she said. "I just let it go. And I go out with a girlfriend from work, and we go shopping.” "It sounds like the beginning of the change might have been your decision to come to the doctor,” I said. "And then the doctor responded supportively, and that was enough to help you make some different decisions about how to handle your stress.”


"Yes,” the patient said, thoughtfully. "I guess that’s exactly what happened.” As if on cue, the provider entered; I summarized our conversation and left the room. It had been a straightforward and enjoyable consult: the patient was resilient and had already reached out for and received some of what she needed and had made good use of it, she had been ready to relax into the opportunity to explore the sources of her increased well-being, and the connection between provider and patient had been enhanced.


Other times it’s not so easy. Later that same day I saw another patient, a man in his mid-twenties, at the doctor for a routine checkup. He was handsome, personable, and in apparently perfect health. He was also unemployed and uneducated beyond high school. Mostly, he just watched TV and went to the gym. "What would you identify as your primary goal for your life or health?” I asked. "Oh,” he said, "I want to have kids and grandkids, with some kind of check coming in—disability, whatever.”


"What???” I thought (but did not say). "You are smart and strong and 25 years old, and you actively aspire to be on disability? What is wrong with you?” In that moment, I was not feeling empathetic, or welcoming, either. Somehow I managed to stay with him. He wasn’t proud of his lack of ambition or accomplishment, he said; in fact, he was troubled by it. He hadn’t done anything bad with his life, but he hadn’t done anything good, either; years were going by, and he had nothing to show for them.


"If you did have an interest in something, what would it be?” I asked. His eyes lit up. "I love trains!” he said. "Not subway trains. Real trains, big ones.” And then he returned to the subject of his inertia in life. "I need a drill sergeant,” he said, fretfully. "Someone who will tell me what to do and make me do it. My mom made me work in high school, but since then I haven’t had anyone to make me do anything. I think things would be different if I had a drill sergeant.” He paused for a moment. "Or maybe if I had a father.”


All of a sudden I saw before me, not a 25-year-old man, but a six-year-old boy, a boy who loved trains, and who had no father to show him how to be a man. No wonder he had been unable to grow into adult achievements and responsibilities. No wonder he longed to be himself a father and a grandfather, yet had no idea how to integrate those roles with other aspects of an adult identity. What might help him develop into a fuller sense of himself and a greater ability to reach more of his potential?


"Have you ever had any outpatient psychotherapy?” I asked. "Do you know what psychotherapy is?” He hadn’t, and he didn’t. I offered a few words of explanation: "Children need certain things from their parents when they’re growing up, and if they don’t get those things, it can be very difficult for them to move into satisfying adult lives. Psychotherapists work with people who didn’t get what they needed when they were children, and help those individuals grow up and into more of what they want as adults. There are outpatient clinics where psychotherapy is available, and if you were ever interested in this, we would be happy to refer you.”


Before I was half done with this speech, the provider entered the room. She waited while I finished, and then I rose and took my leave. Of course I hope that this patient got some small piece of what he needed in our conversation, and that perhaps some day he will get more of what he needs in the context of some other relationship, perhaps even in therapy. What I got from our conversation, though, was a reminder: every patient needs and deserves welcome and safety, even—perhaps especially—the ones for whom empathy might not come automatically.


Margaret Kim Peterson, PhD, is a student in the master’s program in Marriage and Family Therapy at La Salle University in Philadelphia. She is doing an internship in integrated behavioral health at Fairmount Primary Care Center, under the supervision of Suzanne Daub, LCSW, Director of Behavioral Health for Delaware Valley Community Health.

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Collaborative Follies 4

Posted By Randall Reitz and Neil Korsen, Thursday, April 26, 2012


Randall Reitz

Narrative Means to Disastrous Ends

Randall Reitz, PhD, Family Therapist

St Mary's Family Medicine Residency

As a relative neophyte in family medicine education, I look back weeks, rather than years, to re-experience my foibles. A recent experience with my physician faculty colleagues is still poignant. My residency program director has tasked me with building a culture of introspection and feedback sharing among the faculty. Additionally, I have been introducing the physician faculty to the same therapy models that I teach residents. This led to a faculty development session during which I presented the basic concepts of narrative therapy to my colleagues.

 It was a complete disaster.

To demonstrate strength-based and problem-based narratives, I shared a perceived strength and weakness from my own residency teaching. I then requested that the others do the same in a small group discussion. My colleagues struggled to grasp the concepts, were uncomfortable with the requested disclosure about their teaching, and disliked sharing the problem-based narrative second (asserting that it negated the strength-based narrative). There was not an elegant way to close the discussion and the following day a dear colleague described it using an f-word combination that I was not previously aware existed.

Here are my take home lessons from the experience:


  • Behavioral science faculty are trained in environments rich in collegial feedback and self-disclosure. Because the same is not always true in medical training—tread very lightly.
  • Clearly distinguish between education and therapy, and always choose the former over the latter in collegial settings.
  • When introducing new curricular elements, test-drive it with a smaller group first.
  • Don’t give up: seek to understand what didn’t work, apologize for unintended consequences, and then recalibrate.

On a much brighter note, last weekend was our annual residency retreat. While mountain biking in Moab (a perk of living where we do) one of the residents joked that he didn’t want to hear any medical talk or offer any medical treatments during their time-off: "If you break your arm, the only person who is going to help you is Randall”. And then a chorus of jokes gave me soothing reassurance regarding the positive impact I have had:


  • Resident A: "Think about a time when your broken arm wasn’t present, how was that day different?”
  • Resident B: "Suppose that I see you 6 months from now and your arm has healed itself, what will have happened to make that possible?”
  • Faculty Member C: "On a scale of 1 to 10 how much does that arm hurt? What change could make it 1 point better?”
  • Resident D: "Let’s suppose that when you wake up in camp tomorrow you discover that a miracle has happened and the broken arm doesn’t bother you anymore…”

Their solution-focused sarcasm was healing to my heart.


Neil Korsen


I'm a Doctor, Not a Business Expert

Neil Korsen, MD, Family Physician

Maine Medical Center


MaineHealth has had a Mental Health Integration program since 2006 and has done pilot work with several dozen practices. We have learned our share of lessons over the years by making mistakes and figuring out what doesn’t work.

One early mistake we made has to do with how we start a behavioral health clinician working in a practice. Our initial thinking was that starting with a small amount of time (1/2 day per week) minimized the financial risk and therefore should lead to the service working financially. We could then gradually grow the service as the clinician got busier.


The problem with this approach is that, if a clinician is not in the practice very often, it is hard for them to become part of the team. It is also hard for primary care providers and staff to remember when the clinician is in the practice, so they are less likely to think about referring a patient for integrated services. Given that many primary care providers work less than full time, it is possible that some will never even cross paths with the integrated clinician, making it even less likely that they will refer patients. We now believe that there is a minimum of about 16-20 hours per week needed for the integrated clinician to become a member of the team and for the primary care team to develop the new habits necessary for them to make good use of the clinician and to develop and build the integrated service.

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