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Live Blog of Friday Plenary: The Great Debate

Posted By Laura Sudano, Stephanie Trudeau-Hern, and Pete Fifield, Friday, October 5, 2012
This morning's live blog is hosted by Laura Sudano, Stephanie Trudeau-Hern, and Pete Fifield. Please follow along and add your thoughts in the comments section.

8:55am: The anticipated intensity of this debate was such that it may have altered the actual "Ways” of the Universe and subsequently caused one of the debating members to be absent. Yes folks, we have already lost a presenter. Well lost necessitates a "found” and to that matter, he was found in the airport at Grand Junction, Colorado. The reason: his plane had a flat tire. A plane with a flat tire, sounds a bit like "the dog ate my homework”. We hope sabotage isn’t involved in this unfortunate event.

Dr. Randall Reitz, Dr. AJ [Ajantha Jayabarathan], and Dr. Eduardo Sanchez take the stage with music to welcome them to the great debate. Shaking hands, each take their respective podium to open up with their position statement.

9:00am: Dr. AJ opened up her position statement with a reference to the Triple Aim. The Institute of Medicines focus on access to high quality care, care that results in improved health outcomes and the care must be sustainable; all of these happening all together. Dr. AJ, an eloquently and soft yet direct spoken Canadian physician, speaks of the Canadian Rubiks Cube to demonstrate the micro, meso and macro levels of systems care. She urges for U.S.A. to adopt this as their own model.

9:07am: Dr. Reitz speaks towards the historical connections of the nascent nature of collaborative care. Relative historical physician interactions as Reitz have included, removing humors, enemas and leeching. We now are in a new phase of care, one that he would admit needs to be aligned over the Three World View:Clinical, Financial and Operational.

9:15am: A metaphor has arisen already that may represent this debate. Dr. AJ during her opening statements referenced s a graphic of what she described as a "Rubiks Cube”. Dr. Sanchez has referenced multiple times his love of baseball; perhaps his Dominican roots are showing--Yogi Berra being his favorite philosopher. Although Dr. Reitz, arrived in his red U.S.A. sweat jacket, tear-away warm-up pants, and donning boxing gloves, I can’t help but think that the Xbox version of this boxing idol may be a more accurate representation of American ways (and subsequent health level). Is it possible that these three icons represent us well? Rubik’s Cube, the Intelligent Canadians, Baseball, the athletic Dominicans and Virtual Boxing, the lazy Americans? In many ways, we need to put away the game controller and act. I might have missed on this one but you may get where I’m going.

Dr. Sanchez, focused heavily on behavioral and mental health related co-morbidities as one of the most significant players in the ill-health of America. Sooner than later, the financials of this situation will come to realization. We are headed towards collaborative care because of the financial models.

Dr. AJ disagrees and states that to make an omelet, you have to crack some eggs. If the omelet is collaborative care, you’re the egg. How are you going to feel about "being broken” if you are the egg. Currently the "Rub” comes at an individual level [PCP] and we must create. I want to be the quarterback that counts; you must change my mind at the individual level

Dr. Sanchez recommends we create an omelet without eggs? Possibly. They do agree that it needs to change. He uses the concept of a team that changes to the game; to meet the new rules. The opposite of this approach is changing the entire team to meet one player; please reference Tim Tebow’s offense to challenge to this idea.

Randall states that commercial insurance is to collaborative care as condoms are to pregnancy: They are 92% effective at prevention.

Dr. Sanchez questions what we are paying for is evidence based (EB). There are PCMHs out there that are not PCMHs but we are going to call them one. Us bloggers question, "Is that a misunderstanding of the definition or an abuse of system?” The dollars are going to drive this change more so than people gathered around a podium bantering.


The debaters 


9:28am: Barry Jacobs, audience member, states that collaborative care is not going to happen. Treatment via a care management approach, not necessarily treating the mental health illness connected to the problem.

Dr. AJ comments that Political Will and a Leadership Socialist approach are what Americans are afraid of as a possibility. Triple Aim reference to treatment being local and grass root generated. She discusses the Canadian use of office redesign; something that they created out of a grassroots collaborative care model – every person needs to make small changes and expand their own scope of practice within each professional position.

9:31am: PCMH are words that are used, doing Integrated care before it had a label.Overall, it is recognized as a team approach. Practice medicine the way football was played 50 years ago, you really can be a one person team back then. Primary care is a team, health team, driven endeavor. W

9:37am: Dr. Reitz points out that our medical system lacks a general contractor. Medical care has too many outlets in their "home” because the electrician makes a lot of money for each outlet he installs. We need a GC. Through federal CPCI initiative, clinics in nine states will earn a $20/per patient per month for collaborative care. Put BH in primary care and it will be paid for.

AJ continued to speak towards the micro level of change; the grassroot generated individual impetus for larger change. If every office, every worker made small changes, it would collectively make a more significant change. To follow the football analogy, it would be like having every player on the team be more universally trained [say simply in MI or trauma focused care] , than having "special teams”.

9:43am: If you have a safe place but people are not honest, that does not work out that well. Honesty in this case is driven by finances.

9:45am: Dr. Sanchez states that in Texas they are working on a system of payment that focuses on bundled payments. The model's first draft showed that the MH community became very nervous; fearing being "cutout” of the process. Second, when a plane comes down when the wheels just touch ground, you get the traction "we love this” but a bit of a jerk because it is scary. The pushback was around "we cannot do it” not because of the lack of unity in the idea, but there are no true systems to make or even allow it to work. We cannot get a new model without fracturing the process.

The "Culture of Shared Benefit” is it really a question of Health vs. Wealth?

Those with the money and power are not interested in collaboration.

Dr. AJ points out the Mental Health Commission: Canada--they are transition funds and incentives for treating the behavioral side

The question by moderator, Ben Miller, asks if Integrated Behavioral Health costs more - is this correct? Dr. Sanchez responds with no, it is cost-effective. Dr. Reitz states that it doesn't cost more, but does cause significant cost shifting.  Counties with a higher percent of primary care always have lowest overall healthcare costs.

AJ: You Americans put the man on the moon w/ a focus on the change, once again, we are a shining model for the rest of the world but we have to put a focus on it at an individual level.

An audience member asks if there are any Financial Benefits managers and large corporations in the room. Crickets. The member goes onto state that they are the ones who pay for care. If we are going to change this (have collaborative care carry on), we need them. They are trying to control cost; not pay more to the people and not cost more at the end. The payers need to understand we bring something to the table that helps them. We need to talk to the benefits managers.

Another take home message: If we really do want to push this forward, who is not at the table: Employers? Who else?

9:57am: One main point of this discussion around the future of collaborative care (whether we will be a mainstream healthcare model CC by 2022) is that we need to look around the table and realize who is not there. Mainly, invite those to the table who can help us move the field forward. Dr. AJ challenges people to stop being onlookers and become motivated to seek out others. She asserts her stance on changing others at the microlevel.

Dr. AJ states that for all of the eggs out there, in every end there is a new beginning. We (U.S.A.) put man on the moon, the Rubiks cube with the traffic lights, a very robust depiction of how to do this micro and meso levels; now we need to move on to the macro.

Onlookers, we pass the flame on to you: support collaborative care and disseminate the word. 2022.

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