Changing Paradigms of Changing Paradigms of Psychiatric Practice in an Era Psychiatric Practice in an Era

of Healthcare Reformof Healthcare Reform

Chair - Javeed Sukhera, MD

Co-Chair - Sarah Vinson, MD

APA Annual Meeting, New Orleans LA

May 23, 2010

A Presentation of the Council on Advocacy and Government Relations Fellow Members

Educational Objectives

1. Identify lessons learned from healthcare reform for psychiatric practice

2. Address unintended consequences of the health reform process on vulnerable populations

3. Highlight successful collaborations between psychiatry and primary care

4. Discuss the role of successful prevention programs and their importance to healthcare reform

Panel Presentations

• Beyond the Medical Home: Collaboration Between Psychiatry and Primary Care – Peter S. Martin, MD, MPH

• Mental Health Reform in North Carolina– Robin Reed, MD

• Health Insurance Reform in Massachusetts– Sarah Vinson, MD

• Mental Health Promotion & Illness Prevention in the U.S. & Canada– Margaret Balfour, MD, PhD– Catherine Krasnik, MD, PhD

Disclosures

• Javeed Sukhera, MD– Diversity Leadership Fellow - funded by AstraZeneca– APIRE/Janssen Scholar

• Peter S. Martin, MD, MPH, Margaret Balfour, MD, PhD, Catherine Krasnik, MD, PhD, Robin Reed, MD– APA/Bristol Myers-Squibb Public Psychiatry Fellows

• Sarah Vinson, MD– none

Slides available online

• https://sites.google.com/site/apacagr/

Beyond the Medical Home: Collaboration Between Psychiatry

and Primary Care

Peter S. Martin, MD, MPH

University at Buffalo

Objectives

• Explain the current state of care coordination between psychiatry and other specialties

• Define the concept of a medical home• Discuss the “mental health home”• Describe ways in which one can change

the scope of practice to include medical home concepts

Current State of Coordination

Models for Collaborative Care

• Separate physical locations for PCP and specialists without any formal collaboration

• Having a psychiatrist working within a primary care clinic

• Having a PCP working within a mental health clinic

• Medical home model that can have different physical locations for providers but has improved communication and formal collaboration initiatives

Joint Principles of the Patient-Centered Medical Home

• Personal physician

• Physician directed medical practice

• Whole person orientation

• Care is coordinated and/or integrated

• Enhanced access

• Quality and Safety

• Payment

NCQA Standards

1) Access and communication

2) Patient tracking and registry functions

3) Care management

4) Patient self-management support

5) Electronic prescribing

6) Test tracking

7) Referral tracking

8) Performance reporting and improvement

9) Advanced electronic communications

West Virginia Bureau for Public Health. Medical Home NCQA Standards.

Options for payment

• Fee-for-service to do care coordination, and provide incentives for measures that prevent ED visits, hospitalizations, readmits

• Capitation payment with P4P bonuses• Calculate payment based on diagnosis• Various algorithms that pay per episode

of illnessQuinn, K. Achieving cost control, care coordination, and quality improvement in the Medicaid program

Why do this?

• Children who receive care in settings that demonstrate elements of the medical home have better short-term outcomes than children who do not

• Practices with higher Medical Home Index scores had significantly lower hospitalization rates for children with chronic conditions

• Families of CYSHCN perceived their child to be healthier and experienced less worry when they received care in a medical home

Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today.

Is now the time to endorse the PCMH?

• Four major primary care specialties and now 18 specialty medical societies have endorsed the Joint Principles– Includes the American Academy of

Neurology

PCHM Model for Specialists

• Requirements include– Provides primary/principal care to patients

• Might require specialists’ knowledge for tx of complex disease, but also can care for most general healthcare needs

– Meets approved third-party (eg. NCQA) requirements

• Ensures structural capacity– Willingness to delivery comprehensive care

Kirschner, N and Barr, M. Specialists/subspecialists and the patient-centered medical home.

“Mental Health Home”

• Not necessarily a new service• Can take existing services and coordinate with a core

set of principles– Enhanced care and coordination of care– Integration of primary and preventative services– Use of evidence-based practices and continuous

quality improvement– Adoption of recovery principles– Family and community outreach

Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”`

Differences from existing other medical home models

• Primary coordinator may not be a physician• Psychiatry is not typically seen as a primary care

discipline– Psychiatrist in this model would not serve as the

PCP would coordinate and communicate, and help with monitoring basic health indicators (i.e. BP, BMI, smoking status, even blood work)

Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”

Potential Pitfalls

• Who is the coordinator – physician vs. NP/PA vs. another care coordinator

• Difficult for small practices to take on extra workload

• Difficulty with getting families involved (easier to do with children vs. adults)

• Is the PCP the best coordinator in all cases – maybe instead specialist

Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today.

Tips

• Define your program – purpose and population

• Find a strong leader– Work as a team, which requires support

• Have a strong, supportive staff– Link with other groups

• Know when to lead and when to delegate

Minnesota Medical Association. Building a home: Twenty tips for creating a medical home.McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way

Tips

• Have supporting documentation to show evidence why medical home beneficial

• Use templates when/if possible• Advance slowly and methodically• Involve family members from the beginning

– That includes incorporating time to acknowledge/reward their involvement

Minnesota Medical Association. Building a home: Twenty tips for creating a medical home.McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way

Tips

• Monitor (and continue to monitor) progress– Be willing to have explicit measures to see

progress – both from the practice as well as patient POV (i.e. surveys)

– Be flexible and willing to change• Do not lose emphasis on the need for care

coordination– That includes not forgetting about funding!

• Be committed to utilizing and electronic medical record system (even better if this coordinates with outside providers)– Patient registries– Patient portals

Minnesota Medical Association. Building a home: Twenty tips for creating a medical home.McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way

Take Home Points

• Not everyone needs to be a part of the medical home model

• However, principles from the overall model can help improve the care of all patients with mental illness

• Appears to bring about real cost savings

Hopeful Outcome

Resources

• National Center for Medical Home Implementation– http://www.medicalhomeinfo.org/

• NCQA– http://www.ncqa.org/tabid/631/Default.aspx

• Center for Medical Home Improvement– http://www.medicalhomeimprovement.org/

References• National Center for Medical Home Implementation

– http://www.medicalhomeinfo.org/• Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental

health home.” Psychiatric Services. 2009;60:528–533• Bazelon Center for Mental Health Law

– http://www.bazelon.org/issues/healthreform/issuepapers/MedicalHomes.pdf• Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today. Pediatric Annals. 2009;38(9): 483-

490,2009• Kirschner, N and Barr, M. Specialists/subspecialists and the patient-centered medical home. Chest. 2010;137(1):200-204• Stille, C et al. Communication and Co-Management. AAP Medical Home Implementation Teleconference Series.

– http://www.medicalhomeinfo.org/training/Call%202%20FINAL_1.pdf• West Virginia Bureau for Public Health. Medical Home NCQA Standards.

– http://www.wvdiabetes.org/Portals/12/Medical%20Home%20and%20NCQA%20Standards%20(2009-06-24).pdf• Quinn, K. Achieving cost control, care coordination, and quality improvement in the Medicaid program. J Ambulatory Care

Manage. 2010;33(1):38-49• Minnesota Medical Association. Building a home: Twenty tips for creating a medical home. Minnesota Medicine. 2010;Jan:32-

35• McMillen, M and Steward, E. The patient-centered medical home: 12 tips to help you lead the way. Family Practice

Management. 2009;July/Aug:15-18.• Images:

– http://www.spiegel.de/img/0,1020,899997,00.jpg– http://gavindo.com/images/Partnership-Program-.jpg

Unintended ConsequencesUnintended Consequences

Mental Health Reform in North Carolina Mental Health Reform in North Carolina 2001-Present 2001-Present

Robin Reed, M.D.

PGY-III General Adult Psychiatry Resident2010-2012 Community Psychiatry Fellow

Department of PsychiatryUniversity of North Carolina at Chapel Hill

Outline

• Current structure of the public mental health system in North Carolina

• Public Consulting Group Report recommendations (1998/1999)

• State Response: House Bill 381; State Mental Health Plan (2001/2002)

• Unintended consequences (Mental Health center closings, Increased admissions at State Psychiatric Hospitals, budgeting miscalculations, (lack of savings in state hospital consolidations, community support cost overruns) and poor retention of community psychiatrists.

• Press Coverage

• In Hindsight

• Where we are today (CABHA, Revised service Definitions, Antipsychotic initiative, approximating ED waits, Electronic Records,)

Current Structure of the Public Mental Health System in North Carolina

• State Operated Services: State Psychiatric Hospitals, Developmental Disability Centers, and Alcohol & Substance Abuse Centers

• Local Management Entities (LME) (~mental health centers): Organized over geographic areas, 24 total, state government accountable, additional county/city funding

• Private for-profit and nonprofit Provider groups (private practice, University-affiliated)

http://www.ncdhhs.gov/mhddsas/lme-map.pdf

= State Psychiatric Hospital

PCG Findings & Recommendations 1998/1999

• Area Programs are not accountable to state or local governments and are guided by local forces and priorities

• Reduce State Hospital bed capacity, including closure of Dorothea Dix Hospital, and transfer savings to community-based resources

• State Hospital utilization is highly variable and higher than in “peer” states

• State Hospital and Willie M. expenditures are disproportionate:

Willie M. outpatient expenditures: $37,000 / patient / yearEveryone else (MH): $337 / patient / year

1 Willie M. outpatient = 109.8 MH outpatients

• Financial data systems flawed

House Bill 381 & State Mental Health Plan (2001)

HOUSE BILL 381

• Area Programs are not accountable to state or local governments and are guided by local forces and priorities.

• Area programs, renamed, Local Management Entities (LME)

• Reduce State Hospital bed capacity, including closure of Dorothea Dix Hospital, and transfer savings to community-based resources.

• DHHS Secretary has a redefined role

Instructed to divest clinical staff and reformulate clinician contracts with ‘private’ providers

STATE PLAN

““The ideal LME provides no direct The ideal LME provides no direct services, concentrating its services, concentrating its attention on developing and attention on developing and overseeing service provision overseeing service provision throughout its entire region.”throughout its entire region.”

Eliminate state psychiatric hospital adult beds, realign funding, and continue to develop community based services for currently hospitalized persons including specialized residential services, community nursing facilities and other supports.”

State sets goal of reducing ~700 beds by 2005.

Financial Crises

• Area programs required to pay ~$75 million to the Federal Government

• State Budget Shortfalls:

$900 million in 2002

$600 million in 2003

• Governor removed $37.5 million of $47.5 million from Mental Health Trust Fund in 2002

• Medicaid overpayment to State Hospitals:

1997-2003: $658 million ($245 million by State)

Unintended Consequences

• Local Management Entities unable to remain financially viable and close (37 23)

• Increased State Psychiatric Hospital Admissions

• Budgeting Miscalculations

• Lack of providers serving patients in the public system

Local Management Entities Struggle to Survive

Local Management Entities Struggle to Survive

‘Loss’ of community psychiatrists (2003-2005):

• Per Capita LME-sector psychiatrists fell 16.1%: Rural areas hit harder (19.7%)

• In 2006, North Carolina Psychiatric Association estimated 23% more psychiatrists needed

State Psychiatric Hospital Admissions Increase

• 40% reduction in statewide capacity

(~1700 1000 beds)

• 23% increase in admissions (1999-2003/2004)

• C/A admissions doubled (7/03-12/04)

37

Average Daily Census, NC state hospitalsFY 1998 through FY 2007

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

1997-98 1998-99 1999-2000 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07

Average Daily Census

State Psychiatric Hospital Admissions Increase

Annual admissions, NC state hospitalsFY 1998 through FY 2007

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

1997-98 1998-99 1999-2000 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07

Admissions per year

State Psychiatric Hospital Admissions Increase

Bed turnover (annual admissions per bed), NC state hospitalsFY 1998 through FY 2007

0

2

4

6

8

10

12

14

16

18

1997-98 1998-99 1999-2000 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07

Annual admissions / ADC

Budgeting Miscalculations

Lack of savings in State Hospitals

• 2004 estimate:

Projected: $16.2 million

Actual Savings: $9.2 million

• Increase in bed day costs 2001-2005:

$430 $711/per patient bed day

Budgeting Miscalculations

Community Support cost overruns: $600 million

• 4/06-3/07: 245% increase in utilization

• 4/06-2/07: Adult costs/month: ↑(25x) $1.2 $30.9 million C/A costs/month: ↑(13.5x) $4.5 $61.8 million

Factors Influencing the Explosion of Community Support Services

• Delay in Service Definitions led to relaxed provider authorization requirements

• Poor transition of claims processing from LME to State-funded, private contractor: Value Options

• Lack of qualification guidelines for providing Community Support Services

• Delays in communicating the problem between government entities

Where are the Psychiatrists?

• Poor retention of Community Psychiatrists

• Difficult recruitment of private providers to serve people in the public system

• Poor utilization of funding to hire psychiatrists

Where are the Psychiatrists?

From 2003 to 2005:

• Per Capita LME-sector psychiatrists fell 16.1%: Rural areas hit harder (19.7%)

• In 2006, North Carolina Psychiatric Association estimated 23% more psychiatrists

• 24% increase in patient/psychiatrist ratio: = ~31,000 patients unable to access care.

In Hindsight • No clear organization for implementation

• Absence of data, aside from Medicaid, to monitor utilization & funding

• Absence of quality measures

• Inadequate funding

• Lack of accountability & description of leadership responsibilities

• Failure to promptly respond to system breakdowns

• Lack of transparency

Press Coverage

Fayetteville Observer editorial, 3/5/02: “It's going to be a local problem, all right: a very expensive lesson, in both fiscal and human capital, in the folly of false economy.”

Charlotte Observer series on problems in children’s group homes in January 2005

--State suspends group home licensing

Mountain Xpress (Asheville): “Nowhere to turn; state mental-health reform widens gap in crisis management” in February 2005

Hendersonville Times-News series on mental health reform: “Nurse sees jail as ‘dumping ground’ for many of the mentally ill” in February 2005

Winston-Salem Journal series: “Breakdown: A Crisis in Mental Health Care”

Asheville Citizen-Times: “NC’s mental health ‘reform’ is a train wreck right now”

Raleigh News and Observer series “--Mental Disorder” runs from 2/24 to 3/2/08

Provider Perceptions of Mental Health Reform in North Carolina*

Where we are today

• CABHA (Critical Access Behavioral Health Agency): The new mental health center

• Revised service Definitions: Preventing excessive pay for under qualified professionals

• Atypical Antipsychotic initiative: Improving utilization in psychiatry and primary care

• Approximating ED wait times and ED utilization

• Electronic Medical Records

References

“An Act to Phase in Implementation of Mental Health System Reform at the State and Local Level”. Session Law 2001-437. House Bill 381. General Assembly of North Carolina. Session 2001.

State Plan 2001: Blueprint for Change. November 30th , 2001.

State Plan 2002: Blueprint for Change. July 1st, 2002.

“Report Card on the Clinical Impact of North Carolina’s Mental Health Reform”. North Carolina Psychiatric Association. June 2005.

“An Analysis of State-Operated Hospital Downsizing in North Carolina”. Presentation by the Clinical Services Support Workgroup of the North Carolina Council of Community Programs and Approved by the Board of Directors of the North Carolina Council of Community Programs. 2005.

“There Is Not Enough Money for Mental Health”. The Second Report Card by the North Carolina Psychiatric Association. March 16th, 2006.

“Discarding Community Psychiatrists”. The Third Report Card by the North Carolina Psychiatric Association. April 18th, 2006.

References“Compromised Controls and Pace of Change Hampered Implementation of Enhanced Mental Health

Services”. Final Report to the Joint Legislative Program Evaluation Oversight Committee. Report Number 2008-05-3. July 29th, 2008.

“Caring for Previously Hospitalized Consumers: Progress and Challenges in Mental Health System Reform.” Final Report to the Joint Legislative Program Evaluation Committee. Report Number 2008-12-04. December 10, 2008.

“A History of Mental Health Reform in North Carolina”. North Carolina Center for Public Policy Research. March 1st, 2009.

“How North Carolina Compares, A Compendium of State Statistics”. North Carolina General Assembly Program Evaluation Division. June 2009.

“Proposed Report on the Continuation and Expansion of Budgets 2009-2011”. House Appropriations Subcommittee on Health and Human Services. June 4th, 2009.

“Enhanced Services Package Implementation: Costs, Administrative Decision Making, and Agency Leadership”. Final Report to the Joint Legislative Program Evaluation Committee. July 6 th, 2009.

“Lessons from Mental Health Reform in North Carolina, 2001-2008”. Harold Carmel, MD. 2009.

“Critical Access Behavioral Health Agency”. North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. March 10th , 2010.

Acknowledgements

• UNC Center for Excellence in Community Psychiatry

• Brian Sheitman, M.D., Bebe Smith, LCSW/MSW

• Harold Carmel, M.D.

• Elizabeth Reynolds, M.D.

• Elizabeth Bullard, M.D.

Health Insurance Reform in MA

A Case Study for Expanded Coverage and Individual

Mandates Sarah Y. Vinson, MD

APA/SAMHSA Minority Fellow PGY3 Adult Psychiatry Resident

Cambridge Health Alliance

Presentation Outline

• MA Health Reform– Key components– Coverage Gains

• Physician Perspectives• Employer and Employee Perspectives• Survey of MA Psychiatrists• Special Considerations

– Safety Net Hospitals– Low-income Patients– Immigrants– Mentally Ill

• Key Differences in MA Plan and National Plan

Massachusetts Health Care Reform Law

• Enacted as Chapter 58 of the Acts of 2006 of the Massachusetts General Court: “An Act Providing Access to Affordable, Quality, Accountable Health Care “

• Characteristics Unique to MA at time of passage– 10% uninsured compared to 15% national average– Higher rate of employer coverage– Broader Medicaid program– Pre-existing Uncompensated Care Pool (UCP)

• Payments made directly to hospitals and community health centers– Bi-partisan collaboration between Republican governor and Democratic

legislature– Relatively high per capita income– Existing regulation of small group & individual insurance market– State w/ highest per capita rate of physicians and psychiatrists

Sources 1-3

Medicaid Expansion

Commonwealth Care (CC)

Commonwealth Choice

Rerouting UCP Funds

Insurers

Employers

Mandated HealthInsurance Coverage or Pay Tax Penalty

Source 2

Individuals

• Individual mandate for Minimum Credible Coverage (MCC) if “affordable” *

• Pts transitioned from UCP to CC

– 150%-300% of FPL

– Sliding-scale premiums and co-payments

– Up to 150% FPL

– No premium and small medication co-payments

• Limitations to CC eligibility *

• Penalties for uninsured enforced through DOR*

*National Health Insurance bill has similar componentSource 2

Cost of H.I. Premium For Family

Source 5

Government• Medicaid expansion*

– Coverage extended to children in families with income up to 300% FPL

• Subsidized insurance plans*– “Commonwealth Care”– Sliding scale subsidies for those below 300% of FPL

• Private insurance connector*– “Commonwealth Choice”– Unsubsidized insurance plans for individuals and

small businesses employees• UCP funds reallocation to CC subsidies• Built upon pre-existing insurance regulations

Source 2

BusinessEmployers

• Expansion of Insurance Partnership Program– Subsidies/incentives for

employers/employees to participate in employer sponsored insurance

• Fees if Coverage Not Provided*– of $295 per employee

per year for employers who do not provide health insurance or

• Required Section 125 Cafeteria Plans

Insurers

• Can not deny coverage due to Pre-existing condition*

• Minimum Creditable Coverage*

• All Health Plans Required to cover essential benefits*

• Limits on Annual Deductibles*

• Merger of small group and individual markets

• Coverage under parents’ plan through age 26*

• Young Adult Plan (YAP)

Source 2

After 2 years…

• Over 400,000 Newly Insured• No evidence of crowd out• Strongest success in expanding coverage

for lower income adults (less than 300% FPL)– Uninsured rate 24% 8%

• Remainder of uninsured disproportionately young, male, single and or healthy

• Affordability a barrier for uninsured– 41% of the uninsured said they had tried to

find coverage they could afford

Source 2, 6

Sources of Coverage for Newly Insured

Commonwealth Care 178K

44%

MassHealth (Medicaid) 99K

24%

Employer Coverage 83K

20%

Nongroup 49K (including

Commonwealth Choice)

12%

Source 6

MA Physicians’ View of Reform

2,135 Practicing MA Physicians

– 70% expressed a favorable view– In 21/22 areas majority of physicians

said that law either did not have much of an effect or was having a positive effect on their practice

• Including quality, overall practice, wait time for appointments, financial situation of practice

• Administrative burden elicited the most negative response

– Negative evaluations from a majority of physicians for overall cost of care in the state

Source 8

MA Employers’ & Employees Views of Reform

Employers

• Majority viewed reform as “good for MA”

• Percentage of firms with 3 or more workers offering coverage increased from 73-79%

• Less likely than employers nationally to indicate plans to terminate coverage or restrict eligibility for health benefits

Employees

• Concerns about employers’ dropping coverage or scaling back benefits had not been realized

• Access to employer coverage increased

• Quality and scope of coverage increased

• Premiums and out-of-pocket expenses higher for employees in small firms

Sources 9, 10

MA Psychiatrists Survey• Web-based survey disseminated through the Massachusetts

Psychiatric Society listserv• Anonymous • Convenience Sample• 154 respondents• Included multiple choice, likert scale and free response questions

regarding– Reform’s effects in MA overall– Reform’s effects on respondent’s personal practice– Impressions of reform

Source 11

MA Psychiatrists Survey• 41% of respondents provided most of their

direct patient care in private practice setting• Vast majority provided direct patient care in

multiple settings• 97% in urban or suburban settings• 71% had seen patients on Medicaid w/n the

past 30 days• 56% had seen legal non U.S. citizens w/n the

past 30 days• Majority had been practicing psychiatry in MA

20+ yearsSource 11

Respondents Support of the Law

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10

No Support Full Support

Source 11

66%

MA Psychiatrists Survey

Source 11

Rate Agreement: Access Has Improved

Source 10

Reasons M.H. Service Access Has Not Improved or Gotten Worse

Source 11

Survey Free Response

• Support Limiting Issues:• administrative hassles, cost, low reimbursement rates for

Medicaid and CC, coverage gaps, insufficient providers• Many expressed support for a Single Payer Option

Concept is good. Implementation is weak based on the very low

reimbursement rates on the Commonwealth Care plans.

Access is also poor most likely due to the

reimbursement issue

Private Practice Psychiatrist

Access to treatment for co-morbid medical & substance use disorders has improved

with insurance reform & has made a huge difference for poor & previously uninsured persons with major mental

illness.

Public Sector PsychiatristSource 11

Special Considerations

• Safety Net Hospitals• Low-income Patients• Immigrants• Mentally Ill

MA’s Largest Safety Net Hospitals

BMC CHA

% Uninsured Pre-reform 20 23

% Medicaid Pre-reform 27 21

% Racial /Ethnic Minorities 70 40

Payment : Cost Ratio for Low Income Pts Pre-Reform

82:100 77:00

Payment : Cost Ratio for Low Income Pts Post-Reform

64:100 60:100

Source 12

Sources 12, 13, 14

UCP CC Patients

Source 14

More MA Residents Directly Affected Said Reform was Hurting

Them

Source 16

Immigrants• CC coverage cut abruptly for 31,00 refugees, green card

holders and others who have lived in the country <5yrs• Population’s coverage not matched by the fed. govt. • $40 million eventually restored to the $130 million program

for limited coverage through a specific provider– Disruptions in Care– Higher copayments– Limitations to Access

• Clinic Locations• Translator Services• Mental Health

• Legal immigrants and undocumented people with greater reliance on struggling SNH for culturally competent care

• Politically vulnerable population

Sources18,19

Mentally Ill• DMH cuts

– ¼ of case managers laid off as MA attempted to balance budget in wake of higher CC enrollment than anticipated and the recession

– Cuts in many services• Day Programs• Social clubs• Supported Employment (SEE)• Reduction in Jail Diversion Programs

• Lower Reimbursement for MH Services• CHA, largest MH provider and SNH, closed inpatient units and

limited outpatient services due to budget strains• Added administrative and cost-sharing requirements for those in

150-300% FPL may be particularly challenging for CMI– Limitations due to illness– Medical and psychiatric co-morbidity– Risk of missing required yearly re-enrollment

• Politically vulnerable population

Source 20

Key Differences in MA & National Plans

• National Plan – Creates dedicated funding source– Gradually increases Medicaid rates to Medicare rates

for primary care providers– Prohibits lifetime benefit limits– Requires insurers to devote at least 85% of premiums

in the large group markets and 80% in the small and individual markets to medical benefits, or provide consumer rebates if medical-benefit spending falls below this percentage

– Establishes pilot programs to test new strategies for improving quality while reducing costs

• Accountable care org.s, global payments, med. homes

Sources 2, 21

Sources1. Health Care and Affordability Conference Committee Report. http://www.mass.gov/legis/summary.pdf2. Doonan, Michael. Tull, Katharine. Health Care Reform in Massachusetts: Implementation of Coverage Expansions and a Health Insurance Mandate. The Milbank

Quarterly, Vol. 88, No. 1, 2010 (pp 54-80)3. State Health Workforce Profiles: Massachusetts. U.S. Department of Health and Human Resources: Health Resources and Services Administration.

ftp://ftp.hrsa.gov/bhpr/workforce/summaries/Massachusetts03.pdf 4. Commonwealth Connector Authority 2009. Commonwealth Health Insurance Connector Authority Affordability Information Sheet

https://www.mahealthconnector.org/portal/binary/com5. Commonwealth Connector Insurance Authority. 2009. Find Insurance: Individuals and Families, Frequently Asked Questions.

https://www.mahealthconnecotor.org/portal/site/connector6. Commonwealth Connector Health Insurance Authority. 2009. Facts and Figures. https//www.mahealthconnector.org/port/site/connector7. Long, Sharon. Stockley, Karen. Health Reform in Massachusetts: An Update on Coverage and Support for Reform as of Fall 2008. Urban Institute. 20098. Steelfisher, Gillian. Blendon, Robert et al. Physicians’ Views of the MA Health Care Reform Law – A Poll. New England Journal of Medicine. 2009; 361(19):e39.9. Long, Sharon. Stockley, Karen. Massachusetts Health Reform: Employer Coverage From Employees’ Perspective: Access to coverage has grown—even as some

workers in small firms have faced higher contributions to premiums. Health Affairs Web Exclusive. 2009;28(6):w1079–87.10. Gabel, Jon R. Whitmore, Heidi. Et al. After The Mandates: Massachusetts Employers Continue To Support Health Reform As More Firms Offer Coverage Bay State

employers have fewer reservations about the reform than they did last year, shortly after the reform took effect. Health Affairs. 2008; 27 (6) :w566–w575.11. Vinson, S. Massachusetts Psychiatrists Survey – unpublished12. Massachusetts health Reform: Lessons Learned about the Critical Role of Safety Net Health Systems. National Association of Public Hospitals and Health Systems.

Issue Brief April 2009.13. Krasner, Jeffrey. Health Provider Predicts Big Loss; Hospital alliance cites impact of reform law; Could cut 300 jobs, suffer $25m shortfall. The Boston Globe. March

17, 2008. 14. Kowalcyk, Liz. Boston Medical sues state for funds. The Boston Globe. July 16, 2009. 15. Long, Sharon. Masi, Paul. Access And Affordability: An Update On Health Reform In Massachusetts, Fall 200. Health Affairs. 2009. 28 (4): w578–w587.16. Blendon, Robert J., et al, “Massachusetts Health Reform: A Public Perspective From Debate Through Implementation,” Health Affairs. 2008. 27(6 ): w556-562.

(published online 28 August 2008; 10.1377/hlthaff.27.6.w556). 17. Long, Sharon. Masi, Paul. Access to and Affordability of Care in MA as of Fall 2008: Geographic and Racial/Ethnic Differences. Urban Institute.200918. Goodnough, Abby. Massachusetts Takes a Step Back from health Care for All. New York Times. July 15 2009.19. Lazar, Kay. Immigrants face hurdles with new care coverage: network changes, delays vex clients. November 5, 2009. 20. Goldberg, Carey. Mental health liaisons laid off: Agency loses 100 case managers; more cuts feared. The Boston Globe. January 8,2009. 21. Patient Protection and Affordable Care Act. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf,

docs.house.gov/rules/hr4872/111_hr4872_amndsub.pdf.

Mental Health Promotion & Illness Prevention:

The U.S. and Canada

Margaret Balfour, MD, PhDUniversity of Texas Southwestern Medical Center at

DallasCatherine Krasnik, MD, PhD

McMaster University Medical Centre, Hamilton, OntarioAPA/BMS Fellows in Public Psychiatry

Disclosures

• Both presenters are supported by the APA/Bristol-Myers Squibb Fellowship in Public Psychiatry

Outline

• Basic concepts of mental health prevention• Prevention resources and US health reform• The Canadian System and Mental Health

Reform• What do the U.S. and Canada have in

common?: An evidence-based, interactive case example of screening for depression.

Why prevention?

• Most mental disorders begin in adolescence or young adulthood

• Mental health linked with physical health• Results in substantial cost to individuals,

families, and society• Prevention has the potential to prevent years

of human suffering, as well as decrease costs across multiple service systems

What is mental illness prevention?Public health paradigm

• Primary prevention: preventing a disease from occurring (reducing the incidence)– Example: an intervention to discourage

adolescents from trying cigarettes to prevent nicotine dependence

• Secondary prevention: lowering the rate of established cases (reducing the prevalence)– Example: early detection and screening for

depression and suicidal ideation so that it can be treated

• Tertiary prevention: reducing disability in those that already have the disease– Example: ACT teams, supported employment, etc.

A different paradigm:Mental health intervention spectrum

Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Institute of Medicine (1994)

Preventive Interventions

• Universal: Targets general public or all members of a group (no identified risk)– Example: premarital counseling before marriage,

prenatal care, antismoking efforts• Selective: Targets individuals or groups with

increased risk for developing mental disorders– Example: preschool programs to all children in low-

income neighborhoods, support groups for elderly widows

• Indicated: Targets high-risk individuals with minimal symptoms or biological markers– Example: parent-child interaction program for children

with behavioral disorders, early treatment of prodromal SCZ

Mental health promotion

• Targets general public• To enhance appropriate development/competence, self

esteem, mastery, well-being, social inclusion, ability to cope with adversity

• Example: school programs that promote social competence through activities emphasizing self-control and problem solving

Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Institute of Medicine. (2009)

Other core concepts

• Inherently interdisciplinary – Effective tobacco

control involves law, education, community behaviors, health care,

• Coordinated community-level systems– Costs and benefits

shared across systems

Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Institute of Medicine. (2009)

Where to find evidence-based programs

• National Registry of Evidence-Based Programs and Practices http://www.nrepp.samhsa.gov/

• Preventing Drug Abuse among Children and Adolescentshttp://www.drugabuse.gov/prevention/prevopen.html

• Suicide Prevention Resource Center http://www.sprc.org/

• Center for the Study and Prevention of Violencehttp://www.colorado.edu/cspv/blueprints/

• Promising Practices Network http://www.promisingpractices.net/

• Society for Prevention Researchhttp://www.preventionresearch.org/

• SAMHSA Pocket Guide to Evidence Based Practices on the Webhttp://www.samhsa.gov/ebpwebguide/appendixB.asp#Health_Disorders

What’s in the new health care bill?

• Creation of a National Prevention, Health Promotion, and Public Health Council and Advisory Group: develop strategic plan

• Preventive Services Task Force: identify evidence-based preventive interventions

• Coverage of preventative services• Prevention and Public Health Fund:

transformation grants, education• Community health team grants• Wellness program grants for small businesses• Increasing public health workforce

Public Mental Health

PROMOTION AND PREVENTION IN THE CANADIAN CONTEXT

Canadian Health Care “Medicare”

• Universal coverage for medically necessary services provided on basis of need rather than ability to pay

• Canada Health Act (federal legislation)– "to protect, promote and restore the physical and mental well-being

of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."

• Integrated system between Federal government and 10 provinces and 3 territories– Canada Health Tax Transfers; based on Canada Health Act

Principles– Provinces/territories responsible for deciding how to use the money– Federal government is directly responsible for Native populations,

the armed forces and prisoners

The Canada Health Act (1984)5 Basic Principles

• Universal: available to all eligible residents of Canada;

• Comprehensive in coverage;

• Accessible without financial and other barriers;

• Portable within the country and during travel abroad;

• Publicly administeredOttawa Parliament

What’s included in Canadian Medicare?

• Covers physician services and hospital-based care

• Emergency care available to everyone• Wait times for specialty appointments and

procedures• Mental health care • Preventive care

– Physicians paid to do prevention counseling (this varies by province)

• *drug coverage is not included unless you have third party insurance or are on social welfare

• *allied health professionals not included (e.g. psychologists, unless part of mental health clinic)

Share of Health Budget Spent on Mental Health (2003-04)

Expenditures on Mental Health and Addictions for Canadian Provinces in 2003-2004 Canadian Journal of Psychiatry, May 2008; 54(5):306-13

Canada spent $6.6 billion on mental health = 4.8% of total health budget; $197/person

Current State of Canadian Mental Health Prevention

• Initially leader in Preventive Care• Canadian Task Force on Preventive Health Care (1976); never

in mental health though• Last of G-8 countries to develop a National Mental Health

Strategy• Several programs in place (not all of them evidence-based)• Still Reactive vs. Proactive Care• Focus on Individual vs. Community/Populations• Collaborative Mental Health

• Integrating mental health into primary care (e.g. Hamilton, Ontario)

• Screening at Schools, community centers, church communities• Patient-centered care ?

• Follow-up care left up to the patient

Key Organizations• Canadian Task Force on Preventive Health Care

– 1976-2005; recently resurrected– Adopted in 1980’s by US – US Task force

• Mental Health Commission of Canada (MHCC)(2008)– Kirby Report– Out of the shadows (2008)– Towards Recovery and Wellbeing (2009); action plan

(2011)• Canadian Mental Health Association (CMHA)

– Oldest Cdn voluntary Health Organization– Mental Health Promotion

• Public Health Agency of Canada (PHAC)

Current Framework• Developed by Mental Health Commission of Canada

– $10 million federal funding at inception; $15 million for subsequent years

– Advisory Group made up of people with lived experience of mental illness & addiction, family members, health care providers and researchers. Reflective of range of perspectives, such as children and youth, aboriginal peoples, seniors, women and adults, and in the workplace.

– Public Consultation • 15 mtgs in 12 cities; all stakeholder constituencies• electronic consultation with stakeholders & general public• 1700 individuals and >250 organizations submitted

• Linking chronic disease, social determinants, mental health– E.g. Chronic disease prevention framework includes

looking at schizophrenia & depression as risk factors for diabetes

Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)

Current Framework• Greater emphasis on addressing social determinants

of mental health– “At Home” Homelessness studies across 5 major

Canadian cities (pilot research studies) – Largest study of its kind; $110 million federal funding– Determine the value of providing housing first -- and then

following it with rehabilitation and treatment -- for those who are homeless and mentally ill.

– Altogether 1,350 people in Moncton, Montreal, Toronto, Winnipeg and Vancouver will be provided housing, and close to 1,000 other people will be provided health and social services but won't receive housing.

• Psychoeducation and supporting families & whole communities

Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)

Current Framework• Early detection and intervention• Patient-centered care

• equitable and timely access to appropriate and effective programs, treatments, services and supports that are seamlessly integrated around their needs.

• Workplace Mental Health Promotion• Preventive Health Care Task Force: Implementing

evidence-based programs• Part of a National Mental Health Strategy (2011)

Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)

What do we have in Common?

• Screening for Depression – evidence-based prevention program in both Canada and the US

• How would this take shape in your community or region?

Resources• Mental Health Commission of

Canada(MHCC)http://www.mentalhealthcommission.ca/English/Pages default.aspx

• Canadian Mental Health Association(CMHA)http://www.ontario.cmha.ca/legislation.asp

• Public Health Agency of Canada(PHAC)http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2005-hcs-sss/role-eng.php#a1

• Canadian Task Force on Preventive Health Carehttp://www.canadiantaskforce.ca/index.html

• Ministry of Health and Long Term Carehttp://www.health.gov.on.ca/transformation/fht/fht_mn.html

• Health Canada http://www.hc-sc.gc.ca/index-eng.php• Ontario Federation of Community Mental Health and Addiction

Programshttp://www.ofcmhap.on.ca/node/459

Resources on Mental Health Promotion & Mental Illness Prevention

• Towards Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada, 2009http://www.mentalhealthcommission.ca/SiteCollectionDocuments/boarddocs/15507_MHCC_EN_final.pdf

• Every Door is the Right Door, 2009http://www.health.gov.on.ca/english/public/program/mentalhealth/minister_advisgroup/pdf/discussion_paper.pdf

• Out of the Shadows Redux, 2008http://www.cmha.ca/data/1/rec_docs/1962_CMHA%20FINAL%20OutofShadows%20Redux.pdf

• Position papers on Mental Health Promotion, Stigma, and Knowledge Exchange, 2007http://www.cmha.ca/data/1/rec_docs/1961_Mental%20Health%20Promotion.pdf http://www.cmha.ca/data/1/rec_docs/1959_Stigma.pdf http://www.cmha.ca/data/1/rec_docs/1960_Knowledge%20Exchange.pdf

• A Framework for Support, third edition, 2004http://www.marketingisland.com/mi/tmm/en/cataloguemanager/CMHA/CMHA_Framework3rdEd_EN.pdf

• Mental Health Priorities of the Voluntary Sector, 2004http://www.marketingisland.com/mi/tmm/en/cataloguemanager/CMHA/CMHA_citizens_report_EN.pdf

Acknowledgements

• Dr. Nick Kates

Professor Associate Member, Department of Family MedicineDirector of Programs, Hamilton Family Health Teams

• Dr. Harriet MacMillan

Professor, Psychiatry & Behavioural Neurosciences and Pediatrics

David R. (Dan) Offord Chair in Child StudiesAssociate Member, Clinical Epidemiology & BiostatisticsAssociate Member, PsychologyMember, Offord Centre for Child StudiesMember, Child Advocacy and Assessment Program

Questions & Discussion